When and by Whom Is Concern First Expressed for Children With Neuromotor Problems?

Clinical utility of the Structured Observation of Motor Performance in Infants within the child health services

AIM

This study aimed to evaluate the clinical utility of the Structured Observation of Motor Performance in Infants (SOMP-I) when used by nurses in routine child healthcare by analyzing the nurses' SOMP-I assessments and the actions taken when motor problems were suspected.

METHOD

Infants from three child health centers in Uppsala County, Sweden, were consecutively enrolled in a longitudinal study. The 242 infants were assessed using SOMP-I by the nurse responsible for the infant as part of the regular well-child visits at as close to 2, 4, 6 and 10 months of age as possible. The nurses noted actions taken such as giving advice, scheduling an extra follow-up or referring the infant to specialized care. The infants' motor development was reassessed at 18 months of age through review of medical records or parental report.

RESULTS

The assessments of level of motor development at 2 and 10 months showed a distribution corresponding to the percentile distribution of the SOMP-I method. Fewer infants than expected were assessed as delayed at 4 and 6 months or deficient in quality at all assessment ages. When an infant was assessed as delayed in level or deficient in quality, the likelihood of the nurse taking actions increased. This increased further if both delay and quality deficit were found at the same assessment or if one or both were found at repeated assessments. The reassessment of the motor development at 18 months did not reveal any missed infants with major motor impairments.

INTERPRETATION

The use of SOMP-I appears to demonstrate favorable clinical utility in routine child healthcare as tested here. Child health nurses can assess early motor performance using this standardized assessment method, and using the method appears to support them the clinical decision-making.

The study on achievement of motor milestones and associated factors among children in rural North India

BACKGROUND

Nearly 14% of children worldwide do not reach their developmental potential in early childhood. The early identification of delays in achieving milestones is critical. The World Health Organization (WHO) has developed normal age ranges for the achievement of motor milestones by healthy children. This study aimed to assess the gross motor developmental achievements and associated factors among children in rural India.

MATERIALS AND METHODS

A cross-sectional study was conducted with rural children in North India. A pretested questionnaire was used to collect the data. The median age at the time of the highest observed milestone was calculated and compared with the WHO windows of achievement.

RESULTS

Overall, 221 children aged 4-18 months were included in the study. The median age of motor development exhibited a 0.1-2.1-month delay compared to the WHO median age of motor milestone achievement. The prevalence of the gross motor milestone achievements for each of the six milestones ranged from 91.6% to 98.4%. Developmental delay was observed in 6.3% of the children. After adjusting for different variables, children with birth order of second or more were found to be significantly associated with the timely achievement of gross motor milestones.

CONCLUSION

The apparently healthy children of the rural area of Haryana achieved gross motor milestones with some delay with respect to the WHO windows of achievement. Although the median value of this delay was low, awareness campaigns should be implemented to promote timely identification of children with development delays.

A developmental screening tool for toddlers with multiple domains based on Rasch analysis

BACKGROUND/PURPOSE

Using multidomain developmental screening tools is a feasible method for pediatric health care professionals to identify children at risk of developmental problems in multiple domains simultaneously. The purpose of this study was to develop a Rasch-based tool for Multidimensional Screening in Child Development (MuSiC) for children aged 0-3 years.

METHODS

The MuSic was developed by constructing items bank based on three commonly used screening tools, validating with developmental status (at risk for delay or not) on five developmental domains. Parents of a convenient sample of 632 children (aged 3-35.5 months) with and without developmental delays responded to items from the three screening tools funded by health authorities in Taiwan. Item bank was determined by item fit of Rasch analysis for each of the five developmental domains (cognitive skills, language skills, gross motor skills, fine motor skills, and socioadaptive skills). Children's performance scores in logits derived in Rasch analysis were validated with developmental status for each domain using the area under receiver operating characteristic curves.

RESULTS

MuSiC, a 75-item developmental screening tool for five domains, was derived. The diagnostic validity of all five domains was acceptable for all stages of development, except for the infant stage (≤11 months and 15 days).

CONCLUSION

MuSiC can be applied simultaneously to well-child care visits as a universal screening tool for children aged 1-3 years on multiple domains. Items with sound validity for infants need to be further developed.

Motor delays: early identification and evaluation

Pediatricians often encounter children with delays of motor development in their clinical practices. Earlier identification of motor delays allows for timely referral for developmental interventions as well as diagnostic evaluations and treatment planning. A multidisciplinary expert panel developed an algorithm for the surveillance and screening of children for motor delays within the medical home, offering guidance for the initial workup and referral of the child with possible delays in motor development. Highlights of this clinical report include suggestions for formal developmental screening at the 9-, 18-, 30-, and 48-month well-child visits; approaches to the neurologic examination, with emphasis on the assessment of muscle tone; and initial diagnostic approaches for medical home providers. Use of diagnostic tests to evaluate children with motor delays are described, including brain MRI for children with high muscle tone, and measuring serum creatine kinase concentration of those with decreased muscle tone. The importance of pursuing diagnostic tests while concurrently referring patients to early intervention programs is emphasized.

Development, implementation, and evaluation of the Apollo model of pediatric rehabilitation service delivery

This article presents the experience of a rehabilitation program that undertook the challenge to reorganize its services to address accessibility issues and improve service quality. The context in which the reorganization process occurred, along with the relevant literature justifying the need for a new service delivery model, and an historical perspective on the planning; implementation; and evaluation phases of the process are described. In the planning phase, the constitution of the working committee, the data collected, and the information found in the literature are presented. Apollo, the new service delivery model, is then described along with each of its components (e.g., community, group, and individual interventions). Actions and lessons learnt during the implementation of each component are presented. We hope by sharing our experiences that we can help others make informed decisions about service reorganization to improve the quality of services provided to children with disabilities, their families, and their communities.

Children with developmental disabilities in India: age of initial concern and referral for rehabilitation services, and reasons for delay in referral

This study aimed to identify the age at first concern and age at referral for rehabilitation services in children with developmental disabilities in India. Two hundred fifty-nine children were included and data were collected from the parents. In children with developmental disabilities (excluding autism spectrum disorders), median age at initial concern was 7 months and age at referral for rehabilitation services was 13 months. In children with autism spectrum disorders, median age at initial concern was 24 months and age at referral was 42 months. Physician's recognition of the condition, single child, institutional delivery and neonatal admission ≥4 days were associated with early referral. The common reasons cited by the parents for delay in services were reassurance by physicians or family members and nonreferral by the physicians. Thus, routine screening for developmental problems (including autism) and improving the awareness of these conditions among physicians and society would lead to early referral.

Did waiting times really decrease following a service reorganization? Results from a retrospective study in a pediatric rehabilitation program in Québec

PURPOSE

To examine changes in waiting times and types of services received before, during and after a pediatric rehabilitation service reorganization including new admission procedures; To compare waiting time data available in the program's administrative database and children's medical files.

METHOD

Waiting time was defined as the time elapsed between referral and accessing a service provided by any clinician in the program (program waiting time) or by any clinician within a discipline (discipline-specific waiting time). Services were categorized as individual, group treatment, or other. ANOVAs and χ(2) tests were used to examine changes in waiting times and type of services, respectively. Paired T-tests compared the program waiting times from the two databases.

RESULTS

Data were collected on 188 children (mean age: 4 years and 1 month). The program and occupational therapy waiting times were shorter following the service reorganization. For two disciplines, the proportion of children receiving individual treatment diminished over time, while group and other types of interventions increased. Program waiting times calculated using the two data sources did not differ significantly but differences in the available data highlighted administrative issues.

CONCLUSIONS

Service reorganization can decrease waiting times and change the type of services offered over time.

Assessment of Infant Movement With a Compact Wireless Accelerometer System

There is emerging data that patterns of motor activity early in neonatal life can predict impairments in neuromotor development. However, current techniques to monitor infant movement mainly rely on observer scoring, a technique limited by skill, fatigue, and inter-rater reliability. Consequently, we tested the use of a lightweight, wireless, accelerometer system that measures movement and can be worn by premature babies without interfering with routine care. We hypothesized that this system would be useful in assessing motor activity, in identifying abnormal movement, and in reducing the amount of video that a clinician would need to review for abnormal movements. Ten preterm infants in the NICU were monitored for 1 h using both the accelerometer system and video. A physical therapist trained to recognize cramped-synchronized general movements scored all of the video data by labeling each abnormal movement observed. The parameters of three different computer models were then optimized based on correlating features computed from accelerometer data and the observer’s annotations. The annotations were compared to the model’s prediction on unseen data. The trained observer identified cramped-synchronized general movements in 6 of the 10 infants. The computer models attained between 70% and 90% accuracy when predicting the same observer label for each data point. Our study suggests that mini-accelerometers may prove useful as a clinical tool assessing patterns of movement in preterm infants.

Going beyond the identification of change facilitators to effectively implement a new model of services: lessons learned from a case example in paediatric rehabilitation

PURPOSE

To identify facilitators and barriers to service reorganization, how they evolved and interacted to influence change during the implementation of a new service delivery model of paediatric rehabilitation.

METHODS

Over 3 years, different stakeholders responded to SWOT questionnaires (n = 139) and participated in focus groups (n = 19) and telephone interviews (n = 13). A framework based on socio constructivist theories made sense of the data.

RESULTS

Facilitators related to the programme's structure (e.g. funding), the actors (e.g. willingness to test the new service model) and the change management process (e.g. participative approach). Some initial facilitators became barriers (e.g. leadership lacked at the end), while other barriers emerged (e.g. lack of tools). Understanding factor interactions requires examining the multiple actors' intentions, actions and consequences and their relations with structural elements.

CONCLUSIONS

Analysing facilitators and barriers helped better understand the change processes, but this must be followed by concrete actions to successfully implement new paediatric rehabilitation models.

Evaluation of neuromotor function in infancy-A systematic review of available methods

OBJECTIVE

Neuromotor function in infancy can be evaluated in various ways. Assessment instruments are used for early detection of children with a high risk for developmental disorders. Early detection enables clinicians to provide intervention at a young age when plasticity of the nervous system is high. The assessments may also be used to monitor intervention. The present article will review the psychometric properties of methods to assess neuromotor function in infancy.

METHOD

A literature search was performed in PubMed, Medline, and PsycINFO (1966-2007) on instruments to assess neuromotor functioning of infants.

RESULTS

Fifteen instruments were included and classified into 4 groups: (1) Comprehensive neurological examinations (n = 4). These techniques are widely used, though little is known about their reliability. Their validity in predicting major developmental disorders such as cerebral palsy is good; their predictive validity for minor motor disorders is moderate at best. (2) Procedures with standardized scoring (n = 7). These have good reliability, but only moderate predictive validity for major developmental disorders. No data available for prediction of minor developmental disorders. (3) Observation of milestones (n = 2). Its predictive validity for major developmental disorders is only moderate, whereas reliability is good. (4) Assessment of quality of motor behavior or motor patterns (n = 2). These instruments have the best predictive validity for major and minor developmental motor disorders, but current methods are only useful under the age of 4 months.

CONCLUSION

Prediction of developmental outcome at an early age is difficult. In medical evaluations of high-risk infants, the best predictions are achieved through a combination of multiple, complementary tools, that is, achieved milestones, neurological examination and assessment of the quality of motor behavior.

Is waiting for rehabilitation services associated with changes in function and quality of life in children with physical disabilities?

OBJECTIVES

To determine whether longer waiting times for rehabilitation were associated with deterioration in child functional status and/or quality of life.

METHODS

Parents of 124 children (mean age 45 months) with physical disabilities (e.g., cerebral palsy, global developmental delay, spina bifida) who were referred to pediatric rehabilitation centers were interviewed every three months, from referral until admission into the rehabilitation program. Information from parental interviews included socio-demographics, parental empowerment (Family Empowerment Scale), function (WeeFIM: Functional Independence Measure for Children), and quality of life (PedsQL). Data on date of referral, age, gender, and diagnosis were obtained from hospital databases.

RESULTS

Half of the sample waited more than 9.1 months (95% confidence interval: 6.5-16.1) for admission to a public rehabilitation program. A total of 42% paid for some private services while waiting. Over the waiting period, there was statistically significant improvement in WeeFIM cognition and total scores but not in mobility scores. PedsQL psychosocial summary score declined over the waiting period (p< .05).

CONCLUSION

Longer wait times for rehabilitation were associated with declining psychosocial quality of life. Reducing waiting times for rehabilitation services may allow rehabilitation specialists to address psychosocial problems for these children.