Can items used in 4-year-old well-child visits predict children's health and school outcomes?

The predictive value of universal preschool developmental assessment in identifying children with later educational difficulties: A systematic review

BACKGROUND

Developmental delay affects substantial proportions of children. It can generally be identified in the pre-school years and can impact on children's educational outcomes, which in turn may affect outcomes across the life span. High income countries increasingly assess children for developmental delay in the early years, as part of universal child health programmes, however there is little evidence as to which measures best predict later educational outcomes. This systematic review aims to assess results from the current literature on which measures hold the best predictive value, in order to inform the developmental surveillance aspects of universal child health programmes.

METHODS

Systematic review sources: Medline (2000 -current), Embase (2000 -current), PsycInfo (2000 -current) and ERIC (2000 -current). Additional searching of birth cohort studies was undertaken and experts consulted. Eligibility criteria: Included studies were in English from peer reviewed papers or books looking at developmental assessment of preschool children as part of universal child health surveillance programmes or birth cohort studies, with linked results of later educational success/difficulties. The study populations were limited to general populations of children aged 0-5 years in high income countries. Study selection, data extraction and risk of bias assessment were carried out by two independent authors and any disagreement discussed. PROSPERO registration number CRD42018103111.

RESULTS

Thirteen studies were identified for inclusion in the review. The studies were highly heterogeneous: age of children at first assessment ranged from 1-5 years, and at follow-up from 4-26 years. Type of initial and follow-up assessment also varied. Results indicated that, with the exception of one study, the most highly predictive initial assessments comprised combined measures of children's developmental progress, such as a screening tool alongside teacher ratings and developmental histories. Other stand-alone measures also performed adequately, the best of these being the Ages and Stages Questionnaire (ASQ). Latency between measures, age of child at initial measurement, size of studies and quality of studies all impacted on the strength of results.

CONCLUSIONS

This review was the first to systematically assess the predictive value of preschool developmental assessment at a population level on later educational outcomes. Results demonstrated consistent associations between relatively poor early child development and later educational difficulties. In general, specificity and Negative Predictive Value are high, suggesting that young children who perform well in developmental assessment are unlikely to go on to develop educational difficulties, however the sensitivity and Positive Predictive Values were generally low, indicating that these assessments would not meet the requirements for a screening test. For surveillance purposes, however, findings suggested that combined measures provided the best results, although these are resource intensive and thus difficult to implement in universal child health programmes. Health service providers may therefore wish to consider using stand-alone measures, which also were shown to provide adequate predictive value, such as the ASQ.

How well can poor child health and development be predicted by data collected in early childhood?

BACKGROUND

Identifying children at risk of poor developmental outcomes remains a challenge, but is important for better targeting children who may benefit from additional support. We explored whether data routinely collected in early life predict which children will have language disability, overweight/obesity or behavioural problems in later childhood.

METHODS

We used data on 10 262 children from the UK Millennium Cohort Study (MCS) collected at 9 months, 3, and 11 years old. Outcomes assessed at age 11 years were language disability, overweight/obesity and socioemotional behavioural problems. We compared the discriminatory capacity of three models: (1) using data currently routinely collected around the time of birth; (2) Model 1 with additional data routinely collected at 3 years; (3) a statistically selected model developed using a larger set of early year's risk factors for later child health outcomes, available in the MCS-but not all routinely collected.

RESULTS

At age 11, 6.7% of children had language disability, 26.9% overweight/obesity and 8.2% socioemotional behavioural problems. Model discrimination for language disability was moderate in all three models (area under the curve receiver-operator characteristic 0.71, 0.74 and 0.76, respectively). For overweight/obesity, it was poor in model 1 (0.66) and moderate for model 2 (0.73) and model 3 (0.73). Socioemotional behavioural problems were also identified with moderate discrimination in all models (0.71; 0.77; 0.79, respectively).

CONCLUSION

Language disability, socioemotional behavioural problems and overweight/obesity in UK children aged 11 years are common and can be predicted with moderate discrimination using data routinely collected in the first 3 years of life.

Do early life cognitive ability and self-regulation skills explain socio-economic inequalities in academic achievement? An effect decomposition analysis in UK and Australian cohorts

Socio-economic inequalities in academic achievement emerge early in life and are observed across the globe. Cognitive ability and "non-cognitive" attributes (such as self-regulation) are the focus of many early years' interventions. Despite this, little research has compared the contributions of early cognitive and self-regulation abilities as separate pathways to inequalities in academic achievement. We examined this in two nationally representative cohorts in the UK (Millennium Cohort Study, n = 11,168; 61% original cohort) and Australia (LSAC, n = 3028; 59% original cohort). An effect decomposition method was used to examine the pathways from socio-economic disadvantage (in infancy) to two academic outcomes: 'low' maths and literacy scores (based on bottom quintile) at age 7-9 years. Risk ratios (RRs, and bootstrap 95% confidence intervals) were estimated with binary regression for each pathway of interest: the 'direct effect' of socio-economic disadvantage on academic achievement (not acting through self-regulation and cognitive ability in early childhood), and the 'indirect effects' of socio-economic disadvantage acting via self-regulation and cognitive ability (separately). Analyses were adjusted for baseline and intermediate confounding. Children from less advantaged families were up to twice as likely to be in the lowest quintile of maths and literacy scores. Around two-thirds of this elevated risk was 'direct' and the majority of the remainder was mediated by early cognitive ability and not self-regulation. For example in LSAC: the RR for the direct pathway from socio-economic disadvantage to poor maths scores was 1.46 (95% CI: 1.17-1.79). The indirect effect of socio-economic disadvantage through cognitive ability (RR = 1.13 [1.06-1.22]) was larger than the indirect effect through self-regulation (1.05 [1.01-1.11]). Similar patterns were observed for both outcomes and in both cohorts. Policies to alleviate social inequality (e.g. child poverty reduction) remain important for closing the academic achievement gap. Early interventions to improve cognitive ability (rather than self-regulation) also hold potential for reducing inequalities in children's academic outcomes.