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Janus M, Brownell M, Reid-Westoby C, Pottruff M, Forer B, Guhn M, Duku E. Neighbourhood-level socioeconomic status and prevalence of teacher-reported health disorders among Canadian kindergarten children. Front Public Health 2024; 11:1295195. [PMID: 38303964 PMCID: PMC10830680 DOI: 10.3389/fpubh.2023.1295195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024] Open
Abstract
Background The evidence on the association between neighborhood-level socioeconomic status (SES) and health disorders in young children is scarce. This study examined the prevalence of health disorders in Canadian kindergarten (5-6 years old) children in relation to neighborhood SES in 12/13 Canadian jurisdictions. Methods Data on child development at school entry for an eligible 1,372,980 children out of the total population of 1,435,428 children from 2004 to 2020, collected using the Early Development Instrument (EDI), were linked with neighborhood sociodemographic data from the 2006 Canadian Census and the 2005 Taxfiler for 2,058 neighborhoods. We examined the relationship using linear regressions. Children's HD included special needs, functional impairments limiting a child's ability to participate in classroom activities, and diagnosed conditions. Results The neighborhood prevalence of health disorders across Canada ranged from 1.8 to 46.6%, with a national average of 17.3%. The combined prevalence of health disorders was 16.4%, as 225,711 children were identified as having at least one health disorder. Results of an unadjusted linear regression showed a significant association between neighborhood-level SES and prevalence of health disorders (F(1, 2051) = 433.28, p < 0.001), with an R2 of 0.17. When province was added to the model, the R2 increased to 0.40 (F(12, 2040) = 115.26, p < 0.001). The association was strongest in Newfoundland & Labrador and weakest in Ontario. Conclusion Our study demonstrated that the prevalence of health disorders among kindergarten children was higher in lower SES neighborhoods and varied by jurisdiction in Canada, which has implications for practice and resource allocation.
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Affiliation(s)
- Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Caroline Reid-Westoby
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Molly Pottruff
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Barry Forer
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Martin Guhn
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Eric Duku
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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Janus M, Reid-Westoby C, Pottruff M, Schneeweiss M, Hu G, Brownell M. Developmental health of Canadian kindergarten children with teacher-reported asthma between 2010 and 2015: A population-level cross-sectional study. Prev Med Rep 2024; 37:102525. [PMID: 38186657 PMCID: PMC10767499 DOI: 10.1016/j.pmedr.2023.102525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 01/09/2024] Open
Abstract
Asthma can impact children's quality of life. It is unclear how asthma is associated with the developmental health (i.e. a broad range of skills and abilities associated with growth and development) of young children at school entry. The goals of this cross-sectional, population-level study were to: (1) investigate the association between teacher-reported asthma and children's concurrent indicators of developmental health (developmental vulnerability); and (2) explore whether school absences and functional impairments modified this association. Participants were a Canadian population-based sample of 564 582 kindergarten children (Mage = 5.71 years, SD = 0.32, 51.3 % male) with data on the Early Development Instrument (EDI) collected between 2010 and 2015. Adjusted binary logistic regressions were conducted to address the objectives. From the sample, 958 (0.2 %) children were identified as having a diagnosis of asthma. These children were absent on average 9.4 days and 53.5 % had functional impairments (vs. 6.7 days absent and 15.9 % with functional impairments in children without asthma). After controlling for demographic characteristics, children with asthma had between 1.51 and 2.42 higher odds of being developmentally vulnerable. Only the presence of functional impairments modified this relationship and only for physical health and well-being. In this large, population-based sample of Canadian kindergarten children, few teachers reported knowledge of their students' asthma diagnosis. Among teacher-reported cases, asthma was a risk factor for developmental vulnerability in the domain of physical health and well-being only. Functional impairments may therefore be more detrimental for child development at school entry than asthma alone.
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Affiliation(s)
- Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario L8S 4K1, Canada
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
| | - Caroline Reid-Westoby
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Molly Pottruff
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario L8S 4K1, Canada
| | - Michelle Schneeweiss
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - George Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba R3E 3P5, Canada
| | - Canadian Children's Health in Context Study Team
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario L8S 4K1, Canada
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario L8P 1H6, Canada
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba R3E 3P5, Canada
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Abstract
INTRODUCTION Fetal alcohol spectrum disorder (FASD) is one of the most common neurodevelopmental disorders in North America. It is a complex disability, associated with challenges in cognitive, behavioural and socialemotional functioning, as well as an increased risk of physical and mental health comorbidities, and difficulties in daily living across the lifespan. Previous attempts to characterise the profile of this population have been hampered by differences in data collected across studies, regional discrepancies in terminology and definitions, and a lack of tools to integrate comprehensive datasets. METHODS AND ANALYSIS The goals of this study are to use the Canadian National FASD Database, a national repository of FASD assessment-related information, to better understand the functional profile, comorbidities, intervention needs and difficulties in daily living experienced by individuals assessed for FASD across the lifespan. We will also examine what factors may be the most sensitive predictors of receiving an FASD diagnosis. Data will be analysed from over 3500 records collected between 2010 and 2021 (ongoing) from 26 FASD diagnostic clinics in seven provinces and territories. Data collection is ongoing, and analysis will be performed on a biannual basis to continue to hone our understanding of the profiles, needs and outcomes of individuals assessed for FASD in Canada. This research is critical for refining FASD assessment and diagnostic practice, enabling accurate and early identification of individuals with FASD, and connecting individuals with FASD and their families to comprehensive and effective services and resources to support healthy developmental trajectories. ETHICS AND DISSEMINATION Ethics approval for the National FASD Database Project was obtained from the Ottawa Health Science Network Research Ethics Board. As new knowledge is gained from this project, findings will be disseminated through publications, presentations and feedback to participating clinics, with the ultimate goal of informing FASD research, practice and policy.
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Affiliation(s)
- Jocelynn Cook
- Society of Obstetricians and Gynaecologists of Canada, Ottawa, Ontario, Canada
| | - Kathy Unsworth
- The Canada FASD Research Network, Ottawa, Ontario, Canada
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Teacher-Reported Prevalence of FASD in Kindergarten in Canada: Association with Child Development and Problems at Home. J Autism Dev Disord 2021; 51:433-443. [PMID: 32472249 PMCID: PMC7835185 DOI: 10.1007/s10803-020-04545-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The prevalence of Fetal Alcohol Spectrum Disorder (FASD) may be underestimated as it can be difficult to diagnose in early childhood possibly reflecting unique developmental trajectories relative to other Neurodevelopmental Disabilities (NDDs). Using data collected via the Early Development Instrument (EDI) between 2010 and 2015, we examined the prevalence of kindergarten children with FASD and their concurrent developmental outcomes. We found that the prevalence of FASD ranged from 0.01 to 0.31%. A greater percentage of children with FASD had teacher-reported home problems that interfered with their classroom functioning. Overall children with FASD had higher mean scores on the developmental domains compared to children with NDDs. Results of the current study can inform strategies and policies for early identification and intervention.
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Siddiqua A, Duku E, Georgiades K, Mesterman R, Janus M. Association between neighbourhood socioeconomic status and developmental vulnerability of kindergarten children with Autism Spectrum Disorder: A population level study. SSM Popul Health 2020; 12:100662. [PMID: 33015307 PMCID: PMC7522116 DOI: 10.1016/j.ssmph.2020.100662] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/29/2020] [Accepted: 08/28/2020] [Indexed: 01/08/2023] Open
Abstract
There is limited knowledge about the relationship between neighbourhood socioeconomic status (SES) and development of kindergarten children with ASD. The primary objective of this study was to determine the association between neighbourhood SES and developmental vulnerability of kindergarten children with ASD while controlling for family SES across 10 provinces and territories in Canada. This study used data from a population level database of child development in kindergarten, collected with the Early Development Instrument (EDI). The EDI covers five broad domains of developmental health: physical health and well-being, social competence, emotional maturity, language and cognitive development, and communication skills and general knowledge. Neighbourhood SES was assessed with an SES index created using 10 variables from the 2011 Canadian Census and 2010 Taxfiler data. Family SES was assessed using 4 variables from the 2016 Canadian Census. Descriptive statistics and regression-based models were used in this study. Multilevel binary logistic regression analyses were used to examine the association between neighbourhood SES and child developmental vulnerability (yes/no), at the individual level, while controlling for family SES, demographic characteristics, and neighbourhood clustering. The association between neighbourhood SES and child developmental vulnerability at the individual level, while controlling for family SES and demographic characteristics was examined with binary single level logistic regression analyses. Multivariable linear regression analyses were used to examine the association between neighbourhood SES and developmental vulnerability at the neighbourhood level (% of kindergarten children with ASD demonstrating developmental vulnerability in a neighbourhood). In Ontario, British Columbia, Manitoba, and Newfoundland and Labrador, higher neighbourhood SES was associated with lower likelihood of developmental vulnerability. In Nova Scotia, higher neighbourhood SES was associated with higher likelihood of vulnerability in the social competence and communication skills and general knowledge domains. These findings emphasize the importance of addressing neighbourhood deprivation to support the development of children with ASD. Additionally, the inconsistency highlights the importance of examining the mechanisms through which neighbourhood SES impacts development of these children on a provincial basis.
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Affiliation(s)
- Ayesha Siddiqua
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West – MIP Suite 201A, Hamilton, ON L8S 4K1, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8, Canada
| | - Eric Duku
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West – MIP Suite 201A, Hamilton, ON L8S 4K1, Canada
| | - Kathy Georgiades
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West – MIP Suite 201A, Hamilton, ON L8S 4K1, Canada
| | - Ronit Mesterman
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8, Canada
| | - Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West – MIP Suite 201A, Hamilton, ON L8S 4K1, Canada
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Zeraatkar D, Duku E, Bennett T, Guhn M, Forer B, Brownell M, Janus M. Socioeconomic gradient in the developmental health of Canadian children with disabilities at school entry: a cross-sectional study. BMJ Open 2020; 10:e032396. [PMID: 32350007 PMCID: PMC7213855 DOI: 10.1136/bmjopen-2019-032396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 02/27/2020] [Accepted: 04/07/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To examine the relationship between developmental health and neighbourhood socioeconomic status (SES) in kindergarten children with disabilities. DESIGN Cross-sectional study using population-level database of children's developmental health at school entry (2002-2014). SETTING 12 of 13 Canadian provinces/territories. MEASURES Taxfiler and Census data between 2005 and 2006, respectively, were aggregated according to custom-created neighbourhood boundaries and used to create an index of neighbourhood-level SES. Developmental health outcomes were measured for 29 520 children with disabilities using the Early Development Instrument (EDI), a teacher-completed measure of developmental health across five domains. ANALYSIS Hierarchical generalised linear models were used to test the association between neighbourhood-level SES and developmental health. RESULTS All EDI domains were positively correlated with the neighbourhood-level SES index. The strongest association was observed for the language and cognitive development domain (β (SE): 0.29 (0.02)) and the weakest association was observed for the emotional maturity domain (β (SE): 0.12 (0.01)). CONCLUSIONS The magnitude of differences observed in EDI scores across neighbourhoods at the 5th and 95th percentiles are similar to the effects of more established predictors of development, such as sex. The association of SES with developmental outcomes in this population may present a potential opportunity for policy interventions to improve immediate and long-term outcomes.
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Affiliation(s)
- Dena Zeraatkar
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Duku
- Offord Centre for Child Studies, Department of Psychiatry and Behvioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Teresa Bennett
- Offord Centre for Child Studies, Department of Psychiatry and Behvioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Martin Guhn
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Barry Forer
- Human Early Learning Partnership, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behvioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
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Janus M, Reid-Westoby C, Lee C, Brownell M, Maguire JL. Association between severe unaddressed dental needs and developmental health at school entry in Canada: a cross-sectional study. BMC Pediatr 2019; 19:481. [PMID: 31810457 PMCID: PMC6898915 DOI: 10.1186/s12887-019-1868-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/02/2019] [Indexed: 11/24/2022] Open
Abstract
Background Dental problems are the most prevalent chronic disease worldwide, with up to half of all kindergarten children having tooth decay. However, there is a lack of evidence of whether unaddressed dental needs (UDNs) are associated with children’s developmental health, a concept reflecting holistic child development - encompassing physical, emotional, and cognitive development. The objective of the current study was to evaluate the relationship between UDNs and developmental health among kindergarten children using the Early Development Instrument (EDI). Methods We examined associations between teacher reported UDNs and developmental vulnerability on the EDI. Children were included in the study if they were enrolled in kindergarten in publicly-funded schools in Canada between 2010 and 2015, had been in the classroom for at least one month, and had no more than 25% of missing items on the questionnaire. Results Among 576,264 children who met inclusion criteria (95.4% of eligible children), 2465 (0.4%) were identified as having UDNs by their teachers. Children with UDNs had 4.58 to 8.27 times higher odds of being vulnerable on any of the five developmental domains (physical health and well-being, social competence, emotional maturity, language and cognitive development, communication skills and general knowledge), compared to children without UDNs. Conclusion In this study, teacher-reported UDNs were associated with developmental vulnerability in kindergarten children. Teacher reported unmet dental needs in kindergarten children may be a proxy for poor developmental health at school entry, and thus a marker for supporting both children’s oral health and early developmental needs.
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Affiliation(s)
- Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, McMaster Innovation Park, 175 Longwood Rd South, Suite 201A, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.
| | - Caroline Reid-Westoby
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, McMaster Innovation Park, 175 Longwood Rd South, Suite 201A, 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Catherine Lee
- Bachelor of Health Sciences (Honours), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathon L Maguire
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, Faculty of Medicine, Universtiy of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Paediatrics, St. Michael's Hospital, Toronto, ON, Canada
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Siddiqua A, Duku E, Georgiades K, Mesterman R, Janus M. Neighbourhood-level prevalence of teacher-reported Autism Spectrum Disorder among kindergarten children in Canada: A population level study. SSM Popul Health 2019; 10:100520. [PMID: 31872037 PMCID: PMC6909034 DOI: 10.1016/j.ssmph.2019.100520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/03/2019] [Accepted: 11/18/2019] [Indexed: 12/17/2022] Open
Abstract
Number of children with ASD per neighbourhood varies from none to as high as 21. Developmental vulnerabilities were not associated with levels of clustering. Highest level of clustering of children with ASD was found in Nova Scotia.
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Affiliation(s)
- Ayesha Siddiqua
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP Suite 201A, Hamilton, ON, L8S 4K1, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Eric Duku
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP Suite 201A, Hamilton, ON, L8S 4K1, Canada
| | - Kathy Georgiades
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP Suite 201A, Hamilton, ON, L8S 4K1, Canada
| | - Ronit Mesterman
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Magdalena Janus
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, MIP Suite 201A, Hamilton, ON, L8S 4K1, Canada
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Janus M, Zeraatkar D, Duku E, Bennett T. Validation of the Early Development Instrument for children with special health needs. J Paediatr Child Health 2019; 55:659-665. [PMID: 30302861 DOI: 10.1111/jpc.14264] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/06/2018] [Accepted: 09/16/2018] [Indexed: 12/01/2022]
Abstract
AIM Population-level data on the development of children with special health needs attending primary school can assist special education, health and service delivery strategies. This study aims to determine whether results of the Early Development Instrument (EDI) can be interpreted and used with the same confidence for children with special health needs as for those who are typically developing. Psychometric properties of the EDI for kindergarteners with identified special health needs are examined. METHODS Data for children with a special health need designation come from a database of all Canadian provincial implementations of the EDI between 2004 and 2014. Item and domain characteristics (distributions of scores and measures of internal consistency) of the EDI were examined. Construct validation was assessed by correlating EDI scores with gender and age. The fit of the original factor structure of the EDI was evaluated using confirmatory factor analysis. RESULTS Data for 29 692 children (69.8% male) were analysed. The performance of items and domains was similar to that of typically developing children. As expected, boys scored lower on all EDI domains (Cohen's d: 0.03-0.46) and a general, but non-significant, positive trend was observed between age and EDI scores. The factor structure of the EDI in this population yielded similar goodness-of-fit statistics as those reported in studies with typically developing children. CONCLUSION Results of this investigation support the validity of the EDI in children with special health needs, paving the way for a more extensive use of EDI data for this vulnerable, yet often neglected, population.
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Affiliation(s)
- Magdalena Janus
- Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada.,Health Research Methodology Program, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Eric Duku
- Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
| | - Teresa Bennett
- Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
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