The D-score: a metric for interpreting the early development of infants and toddlers across global settings

Stability of neurodevelopmental trajectories in moderately late and early preterm children born 15 years apart

BACKGROUND

Neurodevelopmental trajectories of preterm children may have changed due to changes in care and in society. We aimed to compare neurodevelopmental trajectories in early and moderately late preterm children, measured using the Developmental (D)-score, in two cohorts born 15 years apart.

METHODS

We included early preterm and moderately late preterm children from two Dutch cohorts (LOLLIPOP, 2002-2003 and ePREM, 2016-2017). ePREM counterparts were matched to LOLLIPOP participants by gestational age and sex. D-score trajectories were summarized by a multilevel model with random intercepts and random slopes, and multigroup analyses were used to test if the intercepts and slopes differed across cohorts.

RESULTS

We included 1686 preterm children (1071 moderately late preterm, 615 early preterm) from LOLLIPOP, and matched these with 1686 ePREM counterparts. The neurodevelopmental trajectories of the two cohorts were mostly similar. For early preterm children, we found no statistically significant differences. For moderately late preterm children, both the intercept (43.0 vs. 42.3, p < 0.001) and slope (23.5 vs. 23.9, p = 0.002) showed some, but only clinically minor, differences.

CONCLUSION

Developmental trajectories, measured using the D-score, in the first four years of life are comparable and stable across a period of 15 years for both early and moderately late preterm children.

IMPACT

Neurodevelopmental trajectories are similar for early and moderately late preterm children born 15 years apart and thus seem quite stable in time. The validated Developmental score visualizes these trajectories based on developmental milestone attainment Because of its stability over time, the Developmental score trajectory may aid clinicians in neurodevelopmental assessment of preterm children as this simplifies monitoring and interpretation, similar to a growth chart.

Computerized adaptive testing to screen pre-school children for emotional and behavioral problems

Questionnaires to detect emotional and behavioral (EB) problems in preventive child healthcare (PCH) should be short; this potentially affects their validity and reliability. Computerized adaptive testing (CAT) could overcome this weakness. The aim of this study was to (1) develop a CAT to measure EB problems among pre-school children and (2) assess the efficiency and validity of this CAT. We used a Dutch national dataset obtained from parents of pre-school children undergoing a well-child care assessment by PCH (n = 2192, response 70%). Data regarded 197 items on EB problems, based on four questionnaires, the Strengths and Difficulties Questionnaire (SDQ), the Child Behavior Checklist (CBCL), the Ages and Stages Questionnaire: Social Emotional (ASQ:SE), and the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Using 80% of the sample, we calculated item parameters necessary for a CAT and defined a cutoff for EB problems. With the remaining part of the sample, we used simulation techniques to determine the validity and efficiency of this CAT, using as criterion a total clinical score on the CBCL. Item criteria were met by 193 items. This CAT needed, on average, 16 items to identify children with EB problems. Sensitivity and specificity compared to a clinical score on the CBCL were 0.89 and 0.91, respectively, for total problems; 0.80 and 0.93 for emotional problems; and 0.94 and 0.91 for behavioral problems.    Conclusion: A CAT is very promising for the identification of EB problems in pre-school children, as it seems to yield an efficient, yet high-quality identification. This conclusion should be confirmed by real-life administration of this CAT. What is Known: • Studies indicate the validity of using computerized adaptive test (CAT) applications to identify emotional and behavioral problems in school-aged children. • Evidence is as yet limited on whether CAT applications can also be used with pre-school children. What is New: • The results of this study show that a computerized adaptive test is very promising for the identification of emotional and behavior problems in pre-school children, as it appears to yield an efficient and high-quality identification.

Health status and public health needs in a Togolese child health care centre modelled after the Dutch system

BACKGROUND

The charity foundation Association Soutien Enfants Togo started a child health care (CHC) centre in Togo that was modelled after the Dutch high-quality CHC system to improve child health.

AIM

To describe health care data of children who visited the centre.

SUBJECTS AND METHODS

Data were routinely collected between October 2010-July 2017. Outcomes were completed vaccinations, growth, development, lifestyle, physical examination, and laboratory testing results.

RESULTS

In total, 8,809 children aged 0-24 years were available. Half (47.5%) of children aged 0-4 years did not receive all eligible free vaccinations from the government. The proportions of stunted children (all) or with a developmental delay (0-4 years) were 10.1% and 9.5%, respectively. In total, 40-50% of all children did not wash their hands with soap after toilet or before eating, or did not use clean drinking water. Furthermore, 5.1-6.6% had insufficient vision, high eye pressure or hearing loss. Sickle cell disease was detected in 5.3%.

CONCLUSION

A large group of children in need of prevention and early treatment were detected, informed and treated by the centre. Further research is needed to confirm if this strategy can improve children's health in Sub-Saharan Africa. Our data are available for further research.

Psychometrics of psychosocial behavior items under age 6 years: Evidence from Nebraska, USA

Because healthy psychosocial development in the first years of life is critical to lifelong well-being, governmental, and nongovernmental organizations are increasingly interested in monitoring psychosocial behaviors among populations of children. In response, the World Health Organization is developing the Global Scales of Early Development Psychosocial Form (GSED PF) to facilitate population-level psychosocial monitoring. Once validated, the GSED PF will be an open-access, caregiver-reported measure of children's psychosocial behaviors that is appropriate for infants and young children. This study examines the psychometric validity evidence from 45 items under consideration for inclusion in the GSED PF. Using data from N = 836 Nebraskan (USA) children aged 180 days to 71 months, results indicate that scores from 44 of the 45 (98%) items exhibit positive evidence of validity and reliability. A bifactor model with one general factor and five specific factors best fit the data, exhibited strong reliability, and acceptable model fit. Criterion associations with known predictors of children's psychosocial behaviors were in the expected direction. These findings suggest that measurement of children's psychosocial behaviors may be feasible, at least in the United States. Data from more culturally and linguistically diverse settings is needed to assess these items for global monitoring.

Key developmental milestones helped to identify children with special educational needs and disabilities at an early stage

AIM

Responding to developmental delay promptly is important, as it helps children to reach their full potential. This study investigated how developmental milestones predicted primary school children with special educational needs and disabilities (SEND) at an early stage.

METHODS

We obtained data about 36 milestones between 12 and 45 months using the Dutch Development Instrument. Development, primary school classification and background characteristics were collected from the Dutch Preventive Child Healthcare system in Utrecht from 2008 to 2016. We investigated SEND classifications and the primary schools that the children attended at 4-12 years of age. The findings include area under the curve (AUC) data.

RESULTS

Data on 30 579 children in mainstream schools and 1055 children with SEND were available. Different milestones predicted SEND classifications. Fourteen milestones and parental education predicted attendance at special needs schools with smaller classes (AUC 0.913). Nine milestones, sex, migration background and parental education predicted attendance at schools for severe communication problems (AUC 0.963). Ten milestones and parental education predicted attendance at schools for severe learning difficulties (AUC 0.995). Milestones did not accurately predict attendance at schools for severe behavioural or psychiatric problems.

CONCLUSION

Milestones at 12-45 months predicted most SEND classifications at primary school age, except severe behavioural or psychiatric problems.

A Developmental Surveillance Score for Quantitative Monitoring of Early Childhood Milestone Attainment: Algorithm Development and Validation

BACKGROUND

Developmental surveillance, conducted routinely worldwide, is fundamental for timely identification of children at risk of developmental delays. It is typically executed by assessing age-appropriate milestone attainment and applying clinical judgment during health supervision visits. Unlike developmental screening and evaluation tools, surveillance typically lacks standardized quantitative measures, and consequently, its interpretation is often qualitative and subjective.

OBJECTIVE

Herein, we suggested a novel method for aggregating developmental surveillance assessments into a single score that coherently depicts and monitors child development. We described the procedure for calculating the score and demonstrated its ability to effectively capture known population-level associations. Additionally, we showed that the score can be used to describe longitudinal patterns of development that may facilitate tracking and classifying developmental trajectories of children.

METHODS

We described the Developmental Surveillance Score (DSS), a simple-to-use tool that quantifies the age-dependent severity level of a failure at attaining developmental milestones based on the recently introduced Israeli developmental surveillance program. We evaluated the DSS using a nationwide cohort of >1 million Israeli children from birth to 36 months of age, assessed between July 1, 2014, and September 1, 2021. We measured the score's ability to capture known associations between developmental delays and characteristics of the mother and child. Additionally, we computed series of the DSS in consecutive visits to describe a child's longitudinal development and applied cluster analysis to identify distinct patterns of these developmental trajectories.

RESULTS

The analyzed cohort included 1,130,005 children. The evaluation of the DSS on subpopulations of the cohort, stratified by known risk factors of developmental delays, revealed expected relations between developmental delay and characteristics of the child and mother, including demographics and obstetrics-related variables. On average, the score was worse for preterm children compared to full-term children and for male children compared to female children, and it was correspondingly worse for lower levels of maternal education. The trajectories of scores in 6 consecutive visits were available for 294,000 children. The clustering of these trajectories revealed 3 main types of developmental patterns that are consistent with clinical experience: children who successfully attain milestones, children who initially tend to fail but improve over time, and children whose failures tend to increase over time.

CONCLUSIONS

The suggested score is straightforward to compute in its basic form and can be easily implemented as a web-based tool in its more elaborate form. It highlights known and novel relations between developmental delay and characteristics of the mother and child, demonstrating its potential usefulness for surveillance and research. Additionally, it can monitor the developmental trajectory of a child and characterize it. Future work is needed to calibrate the score vis-a-vis other screening tools, validate it worldwide, and integrate it into the clinical workflow of developmental surveillance.

Protocol for validation of the Global Scales for Early Development (GSED) for children under 3 years of age in seven countries

INTRODUCTION

Children's early development is affected by caregiving experiences, with lifelong health and well-being implications. Governments and civil societies need population-based measures to monitor children's early development and ensure that children receive the care needed to thrive. To this end, the WHO developed the Global Scales for Early Development (GSED) to measure children's early development up to 3 years of age. The GSED includes three measures for population and programmatic level measurement: (1) short form (SF) (caregiver report), (2) long form (LF) (direct administration) and (3) psychosocial form (PF) (caregiver report). The primary aim of this protocol is to validate the GSED SF and LF. Secondary aims are to create preliminary reference scores for the GSED SF and LF, validate an adaptive testing algorithm and assess the feasibility and preliminary validity of the GSED PF.

METHODS AND ANALYSIS

We will conduct the validation in seven countries (Bangladesh, Brazil, Côte d'Ivoire, Pakistan, The Netherlands, People's Republic of China, United Republic of Tanzania), varying in geography, language, culture and income through a 1-year prospective design, combining cross-sectional and longitudinal methods with 1248 children per site, stratified by age and sex. The GSED generates an innovative common metric (Developmental Score: D-score) using the Rasch model and a Development for Age Z-score (DAZ). We will evaluate six psychometric properties of the GSED SF and LF: concurrent validity, predictive validity at 6 months, convergent and discriminant validity, and test-retest and inter-rater reliability. We will evaluate measurement invariance by comparing differential item functioning and differential test functioning across sites.

ETHICS AND DISSEMINATION

This study has received ethical approval from the WHO (protocol GSED validation 004583 20.04.2020) and approval in each site. Study results will be disseminated through webinars and publications from WHO, international organisations, academic journals and conference proceedings.

REGISTRATION DETAILS

Open Science Framework https://osf.io/ on 19 November 2021 (DOI 10.17605/OSF.IO/KX5T7; identifier: osf-registrations-kx5t7-v1).

The creation of the Global Scales for Early Development (GSED) for children aged 0-3 years: combining subject matter expert judgements with big data

INTRODUCTION

With the ratification of the Sustainable Development Goals, there is an increased emphasis on early childhood development (ECD) and well-being. The WHO led Global Scales for Early Development (GSED) project aims to provide population and programmatic level measures of ECD for 0-3 years that are valid, reliable and have psychometrically stable performance across geographical, cultural and language contexts. This paper reports on the creation of two measures: (1) the GSED Short Form (GSED-SF)-a caregiver reported measure for population-evaluation-self-administered with no training required and (2) the GSED Long Form (GSED-LF)-a directly administered/observed measure for programmatic evaluation-administered by a trained professional.

METHODS

We selected 807 psychometrically best-performing items using a Rasch measurement model from an ECD measurement databank which comprised 66 075 children assessed on 2211 items from 18 ECD measures in 32 countries. From 766 of these items, in-depth subject matter expert judgements were gathered to inform final item selection. Specifically collected were data on (1) conceptual matches between pairs of items originating from different measures, (2) developmental domain(s) measured by each item and (3) perceptions of feasibility of administration of each item in diverse contexts. Prototypes were finalised through a combination of psychometric performance evaluation and expert consensus to optimally identify items.

RESULTS

We created the GSED-SF (139 items) and GSED-LF (157 items) for tablet-based and paper-based assessments, with an optimal set of items that fit the Rasch model, met subject matter expert criteria, avoided conceptual overlap, covered multiple domains of child development and were feasible to implement across diverse settings.

CONCLUSIONS

State-of-the-art quantitative and qualitative procedures were used to select of theoretically relevant and globally feasible items representing child development for children aged 0-3 years. GSED-SF and GSED-LF will be piloted and validated in children across diverse cultural, demographic, social and language contexts for global use.

Child development with the D-score: tuning instruments to unity

The chapter familiarises the reader with an intuitive yet powerful methodology to tune instruments to a common unit, presenting a fresh approach that expresses measurements made by different instruments on the D-score scale. As a result, the reader may compare D-scores between ages, children or cohorts. It shows how to exploit common developmental milestones to bridge instruments and cohorts; presents an analysis to obtain D-scores from 16 cohorts and 14 instruments; compares D-score age-distribution across populations from four continents; suggests an indicator for the United Nations Sustainable Development Goals; and defines developmentally-on-track.

Development and Validation of Prediction Models for Developmental and Intellectual Outcome Following Pediatric Epilepsy Surgery

BACKGROUND AND OBJECTIVES

To (1) identify predictors of postoperative intelligence and developmental quotients (IQ/DQ) and (2) develop and validate clinically applicable IQ/DQ prediction models.

METHODS

We retrospectively analyzed neuropsychological outcomes and their possible determinants for children treated in Bethel and Utrecht since 1990. We performed separate analyses for patients with IQ and those with only DQ available. We developed prediction models based on presurgical determinants to predict dichotomized levels of performance (IQ≥85, IQ≥70, DQ≥50).

RESULTS

IQ/DQ data before and two years after surgery were available for 492 patients (IQ n=365, DQ n=127). At a cutoff-level ±10 points, the chance of improvement was considerably higher than the chance of deterioration (IQ 37.3% vs. 6.6% and DQ 31.5% vs. 15.0%, respectively). Presurgical IQ/DQ was the strongest predictor of postoperative cognition (IQ r=0.85, p<.001, DQ: r=0.57, p<.001).Two IQ models were developed in the Bethel cohort (n=258) and externally validated in the Utrecht cohort (n=102). For DQ, we developed the model in the Bethel cohort and used 10-fold cross-validation. Models allowed good prediction at all three cutoff-levels (correct classification for IQ≥85=86%, IQ≥70=91%, DQ≥50=76%). External validation of the IQ models showed high accuracy (IQ≥85: 0.82, CI 0.75-0.91, IQ≥70: 0.84, CI 0.77-0.92) and excellent discrimination (ROC curves IQ≥85: AUC 0.90, CI 0.84-0.96; IQ≥70: AUC 0.92, CI 0.87-0.97).

DISCUSSION

After epilepsy surgery in children, the risk of cognitive deterioration is very low. Presurgical development has a strong impact on the postoperative trajectory. The presented models can improve presurgical counseling of patients and parents by reliably predicting cognitive outcomes.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for children undergoing epilepsy surgery presurgical IQ/DQ was the strongest predictor of postoperative cognition.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers

BACKGROUND

Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development.

OBJECTIVES

We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects.

METHODS

We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024).

RESULTS

In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11).

CONCLUSIONS

Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Child Development with the D-Score - Preface

The foundations of adult health and wellbeing have their origins early in life, often measured by children’s early growth and development. A valid and easily interpretable metric is needed to interpret the underlying latent construct of early childhood development that can represent change and is comparable across cultures and contexts.

Exploring the Effects of Environmental Factors on the Development of 0-4-Year Old Children in The Netherlands

Air pollution, noise, and green space are important environmental exposures, having been linked to a variety of specific health outcomes. However, there are few studies addressing overall early life development. To assess their effects, associations between developmental milestones for a large population of 0–4-year old children in The Netherlands and environmental exposures were explored. Developmental milestones and background characteristics were provided by Preventive Child Health Care (PCHC) and supplemented with data from Statistics Netherlands. Milestones were summarized and standardized into an aggregate score measuring global development. Four age groups were selected. Environmental exposures were assigned to geocoded addresses using publicly available maps for PM_2.5, PM₁₀, PM_coarse, NO₂, EC, road traffic noise, and green space. Associations were investigated using single and multiple-exposure logistic regression models. 43,916 PCHC visits by 29,524 children were available. No consistent associations were found for air pollution and road traffic noise. Green space was positively associated in single and multiple-exposure models although it was not significant in all age groups (OR 1.01 (0.95; 1.08) (1 year) to 1.07 (1.01; 1.14) (2 years)). No consistent associations were found between air pollution, road traffic noise, and global child development. A positive association of green space was indicated.

Africa is not a museum: the ethics of encouraging new parenting practices in rural communities in low-income and middle-income countries

The Nurturing Care Framework for Early Childhood Development urges stakeholders to implement strategies that help children worldwide achieve their developmental potential. Related programmes range from the WHO's and UNICEF's Care for Child Development intervention, implemented in 19 countries, to locally developed programmes, such as non-governmental organisation Tostan's Reinforcement of Parental Practices in Senegal. However, some researchers argue that these programmes are unethical as they impose caregiving practices and values from high-income countries (HICs) on low-income communities, failing to consider local culture, communities' goals for their children and generalisability of scientific findings from HICs. We explore these criticisms within a public health framework, applying principles of beneficence, autonomy and justice to the arguments. To facilitate the change communities themselves desire for their children, we recommend that practitioners codevelop programmes and cooperate with communities in implementation to harness local beliefs and customs and promote evidence-based and locally adapted practices.

Child development with the D-score: tuning instruments to unity

The chapter familiarises the reader with an intuitive yet powerful methodology to tune instruments to a common unit, presenting a fresh approach that expresses measurements made by different instruments on the D-score scale. As a result, the reader may compare D-scores between ages, children or cohorts. It shows how to exploit common developmental milestones to bridge instruments and cohorts; presents an analysis to obtain D-scores from 16 cohorts and 14 instruments; compares D-score age-distribution across populations from four continents; suggests an indicator for the United Nations Sustainable Development Goals; and defines developmentally-on-track.

Child development with the D-score: turning milestones into measurement

The chapter equips the reader with a basic understanding of robust psychometric methods that are needed to turn developmental milestones into measurements, introducing the fundamental issues in defining a unit for child development and demonstrates the relevant quantitative methodology. It reviews quantitative approaches to measuring child development;introduces the Rasch model in a non-technical way;shows how to estimate model parameters from real data;puts forth a set of principles for model evaluation and assessment of scale quality;analyses the relation between early D-scores and later intelligence;and compares the D-scores from three studies that all use the same instrument.

Predictive validity in middle childhood of short tests of early childhood development used in large scale studies compared to the Bayley-III, the Family Care Indicators, height-for-age, and stunting: A longitudinal study in Bogota, Colombia

There is increasing global commitment to establish early childhood interventions that promote the development of the millions of disadvantaged children in low- and middle-income countries not reaching their developmental potential. However, progress is hindered by the lack of valid developmental tests feasible for use at large scale. Consequently, there is an urgent need for such tests. Whilst screeners and single-domain tests ('short tests') are used as alternatives, their predictive validity in these circumstances is unknown. A longitudinal study in Bogota, Colombia began in 2011 when 1,311 children ages 6-42 months were given the Bayley Scales of Infant and Toddler Development (Bayley-III) by psychologists and randomized to receive one of two batteries of short tests under survey conditions. Concurrent validity of the short tests with the Bayley-III ('gold standard') was reported. In 2016, at 6-8 years, 940 of these children were given tests of IQ (Wechsler Intelligence Scale for Children, WISC-V) and school achievement (arithmetic, reading, and vocabulary) by psychologists. We compared the ability of the short tests, the Family Care Indicators (FCI), height-for-age, stunting (median height-for-age <-2 SD), and the Bayley-III to predict IQ and achievement in middle childhood. Predictive validity increased with age for all tests, and cognition and language were usually the highest scales. At 6-18 months, all tests had trivial predictive ability. Thereafter, the Bayley-III had the highest predictive validity, but the Denver Developmental Screening Test was the most feasible and valid short test and could be used with little validity loss compared with the Bayley-III. The MacArthur-Bates Communicative Development Inventory at 19-30 months and the FCI under 31 months predicted IQ and school achievement as well as the Bayley-III. The FCI had higher predictive validity than stunting and height-for-age, and could be added to stunting for use as a population-based indicator of child development.