Profile of referrals for early childhood developmental delay to ambulatory subspecialty clinics

Disability Competent Care in Pediatric Milestones

This cross-sectional study examines how disability competencies are addressed in the Accreditation Council for Graduate Medical Education’s milestones for pediatric specialties.

Genetic Microcephaly in a Saudi Population: Unique Spectrum of Affected Genes Including a Novel One

Background: Genetic microcephaly is linked to an increased risk of developmental disabilities, epilepsy, and motor impairment. The aim of this study is to describe the spectrum of identifiable genetic etiologies, clinical characteristics, and radiologic features of genetic microcephaly in patients referred to a tertiary center in Saudi Arabia. Method: This is a retrospective chart review study of all patients with identifiable genetic microcephaly presenting to a tertiary center in Saudi Arabia. The patients' demographics, clinical, laboratory, radiologic, and molecular findings were collected. Results: Of the total 128 cases referred, 52 cases (40%) had identifiable genetic causes. Monogenic disorders were found in 48 cases (92%), whereas chromosomal disorders were found in only 4 cases (8%). Developmental disability was observed in 40 cases (84%), whereas only 8 cases (16%) had borderline IQ or mild developmental delay. Epilepsy was seen in 29 cases (56%), and motor impairment was seen in 26 cases (50%). Brain magnetic resonance imaging (MRI) revealed abnormalities in 26 (50%) of the cohort. Hereditary neurometabolic disorders were seen in 7 (15%) of the 48 cases with monogenic disorders. The most common gene defect was ASPM, which is responsible for primary microcephaly type 5 and was seen in 10 cases (19%). A novel PLK1 gene pathogenic mutation was seen in 3 cases (6%). Conclusion: Single gene defect is common in this Saudi population, with the ASPM gene being the most common. Hereditary neurometabolic disorders are a common cause of genetic microcephaly. Furthermore, we propose the PKL1 gene mutation as a possible novel cause of genetic microcephaly.

Vocal Characteristics of Infants at Risk for Speech Motor Involvement: A Scoping Review

PURPOSE

The purpose of this scoping review was to (a) summarize methodological characteristics of studies examining vocal characteristics of infants at high risk for neurological speech motor involvement and (b) report the state of the high-quality evidence on vocal characteristic trends of infants diagnosed or at high risk for cerebral palsy (CP).

METHOD

The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-Analyses) extension for scoping reviews was followed for reporting our review. Studies measured prelinguistic vocal characteristics of infants under 24 months with birth risk or genetic conditions known to commonly present with speech motor involvement. Fifty-five studies met criteria for Part 1. Eleven studies met criteria for synthesis in Part 2.

RESULTS

A smaller percentage of studies examined infants with or at risk for CP compared to studies examining genetic conditions such as Down syndrome. The median year of publication was 1999, with a median sample size of nine participants. Most studies were conducted in laboratory settings and used human coding of vocalizations produced during caregiver-child interactions. Substantial methodological differences were noted across all studies. A small number of high-quality studies of infants with or at risk for CP revealed high rates of marginal babbling, low rates of canonical babbling, and limited consonant diversity under 24 months. Mixed findings were noted across studies of general birth risk factors.

CONCLUSIONS

There is limited evidence available to support the early detection of speech motor involvement. Large methodological differences currently impact the ability to synthesize findings across studies. There is a critical need to conduct longitudinal research with larger sample sizes and advanced, modern technologies to detect vocal precursors of speech impairment to support the accurate diagnosis and prognosis of speech development in infants with CP and other clinical populations.

Profile of children assisted in a teaching outpatient clinic of developmental disabilities in São Paulo, Brazil

OBJECTIVE

To analyze the epidemiological and clinical profile of patients with developmental disabilities followed in a university clinic in Brazil.

METHODS

Descriptive, retrospective study, based on medical records. Children aged zero to 18 years with developmental problems, firstly evaluated between 2009 and 2018, were included. Patients with missing data or out of the age and time period established were excluded. There were nine losses and 374 patients constituted the final sample. Linear regression models were performed.

RESULTS

The mean age at the first assessment was 52.2±39.7 months and the age when the parents perceived the symptoms was 20.9±23.8 months. The most common impairment was motor associated with language delay (28.3%). The interval between the parents' perception and the first consultation was associated with the mothers' education and number of pregnancies. The age at first assessment was associated with the disability type. The number of pregnancies was associated with the child's age when the parents noticed the symptoms and at the first consultation.

CONCLUSIONS

Parents' recognition of the symptoms occurred early, however, there was a delay until the arrival at the clinic. Higher maternal education was associated with a shorter gap between perception of the developmental disability and consultation. A greater number of pregnancies was associated with a later perception of the developmental delay by the parents as well as a delay in the assessment and a wider interval between them. Motor problems were the most common in younger children, and language complaints in older ones.

How paediatricians investigate early developmental impairment in the UK: a qualitative descriptive study

Background

Early developmental impairment (EDI) is common and has many aetiologies and, therefore, potential investigations. There are several published guidelines recommending aetiological investigations, and paediatricians’ views of them varies. Little is known on the thought processes underlying clinical decisions in investigating EDI. This study aimed to describe the thought processes affecting clinical decisions on the investigation of EDI within a nationalised health care system.

Methods

A qualitative descriptive study using semi-structured qualitative interviews performed in person or via video link with paediatricians who see children with EDI in England. As part of the interview, a case study of a fictional disease, Cavorite deficiency, modelled on biotinidase deficiency, was given to participants with the cost of testing, incidence and likelihood it would respond to treatment. This allowed exploration of cost without encumbrance from predisposing views and training on the condition. Thematic analysis was performed by iterative approach. Where participants stated they wanted to redirect money from investigations to treatment, were that even possible, we asked which services they would like to be better funded in their area.

Results

Interviews were conducted with 14 consultant paediatricians: 9 Community / Neurodisability, 2 General paediatricians, and 3 Paediatric Neurologists. Two themes were identified: the value of an aetiological diagnosis to families and managing risk and probability when investigating EDI. The latter contained 4 subthemes: ‘circumspection’ involved blanket investigations chosen irrespective of phenotype and high regard for guidelines; ‘accepting appropriate risk’ involved participants choosing investigations based on clinical phenotype, recognising some aetiologies would be missed; consultants found they ‘transitioned between practices’ during their career; and ‘improved practice’ was thought possible with better evidence on how to stratify investigations based on phenotype. Services that were most frequently reported to need additional funding were therapy services, early community developmental services, management of behaviour, sleep and mental health, and educational support.

Conclusions

There are many factors that influence paediatricians’ choice of aetiological investigation in EDI, but clinical factors are the most important. Paediatricians want better evidence to allow them to select the right investigations for each child without a significant risk of missing an important diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03233-1.

Social skills of kindergarten children with Global Developmental Delay (GDD), with and without Developmental Coordination Disorder (DCD)

AIM

A high prevalence of co-occurring Developmental Coordination Disorder (DCD) has been noted in the population of children with global developmental delays (GDD). The presence of developmental disabilities in general, and DCD in particular, constitute a risk factor for difficulties in social skills. However, to the best of our knowledge, no studies, have examined the unique contribution of DCD to social skills, over and above the effect of other general developmental impairments. The aim of this study was to compare the social skills of kindergarten children with Global Developmental Delay, with and without DCD.

METHODS

Participants included 26 kindergarten children with Global Developmental Delay and DCD (Mage = 4.92, 61 % boys), and 26 children with Global Developmental Delay without DCD (Mage = 5.09, 69.25 % boys). All participants' parents and kindergarten teachers completed the Social Skills Improvement System Questionnaire (SSIS).

RESULTS

Children with GDD only performed significantly better on social skills compared to children with GDD and DCD. Parents in general reported better social skills and less behavioral problems compared to kindergarten teachers.

CONCLUSIONS

The findings contribute to the accumulating body of knowledge regarding social abilities of children with developmental disabilities and present new information as to the unique effect of DCD in this domain. Routine evaluation of social skills should be conducted among children with GDD and DCD, taking into account the negative influence that motor dysfunction has in this domain. Furthermore, children's social performance in different environments needs to be considered by relating to both parents and kindergarten teachers' perspective. Subsequent intervention programs should then address the unique profile of this population.

Awareness screening and referral patterns among pediatricians in the United States related to early clinical features of spinal muscular atrophy (SMA)

BACKGROUND

Spinal Muscular Atrophy (SMA), a leading genetic cause of death in infants, is an autosomal recessive neuromuscular disease characterized by progressive muscle weakness and atrophy. While early diagnosis of SMA is critical to modifying disease progression and improving outcomes, serious diagnostic delays persist. There is a need to improve SMA awareness, screening, and referral patterns.

METHODS

Two online surveys, developed by Cure SMA for general pediatricians, were distributed by Medscape Education via email (September 2018, n = 300, December 2019, n = 600). The surveys asked about adherence to the American Academy of Pediatrics (AAP) developmental screening and surveillance guidelines, comfort with identification of early signs of neuromuscular disease (NMD), familiarity with SMA, and barriers to timely referral.

RESULTS

In 2018, 70.3% of survey respondents indicated comfort in identifying early signs of NMD and 67.3% noted familiarity with SMA. 52.7% correctly indicated the need for genetic testing to make a definitive diagnosis of SMA, 74.0% meet or exceed developmental screening recommendations, and 52.0% said they would immediately refer to a specialist. In 2019, with a larger sample, 73.0% adhere to developmental screening guidelines, and awareness of the genetic testing requirement for SMA was significantly lower by 7.7% (p < 0.03). Specialist wait times emerged as a barrier to referral, with 64.2% of respondents citing wait times of 1-6 months.

CONCLUSIONS

Many pediatricians underutilize developmental screening tools and lack familiarity with diagnostic requirements for SMA. Continuing efforts to expand awareness and remove barriers to timely referral to SMA specialists, including reducing appointment wait times, are needed.

Factors influencing access to early intervention for families of children with developmental disabilities: A narrative review

BACKGROUND

Early intervention (EI) can improve a range of outcomes for families of children with developmental disabilities. However, research indicates the level of access does not always match the level of need. To address disparities, it is essential to identify factors influencing access.

METHOD

We propose a framework where access to EI is conceptualised as a process that includes three main phases. A narrative review examined potential barriers, facilitators and modifiers of access for each phase.

RESULTS

The process of access to EI includes the following: 1) recognition of need, 2) identification or diagnosis and 3) EI provision or receipt. Several factors affecting access to EI for each phase were identified, related to the family, services, the intersection between family and services, and the context.

CONCLUSION

A broad range of factors appear to influence the process of access to EI for this population. Our framework can be used in future research investigating access. Broad implications for policy, practice and future research to improve access to EI are discussed.

Implementation of a Physician Incentive Program for 18-Month Developmental Screening in Ontario, Canada

OBJECTIVES

To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada.

STUDY DESIGN

Population-based cohort study using linked administrative data of children (17-24 months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics.

RESULTS

Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5 years in practice vs ≥21 years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening.

CONCLUSIONS

In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

Parents' burdens of service for children with ASD – implications for service providers

Purpose

The purpose of this investigation is to gain insight into parents' perceptions of benefits vs burdens (value) of educational and healthcare service received for their child with ASD. Parents are the main integrators of long-term educational and healthcare service for their child with ASD.

Design/methodology/approach

Design/methodology/approach included (1) a sentiment analysis of discussion forum posts from an autism message board using a rule-based sentiment analysis tool that is specifically attuned to sentiments expressed in social media and (2) a qualitative content analysis of one-on-one interviews with parents of children diagnosed with ASD, complemented with interviews with experienced educators and clinicians.

Findings

Findings reveal the link between customized service integration and long-term benefits. Both parents and service providers emphasize the need to integrate healthcare and educational service to create holistic long-term care for a child with ASD. Parents highlight the benefits of varied services, but availability or cost are burdens if the service is not publicly provided, or covered by insurance. Service providers' lack of experience with ASD and people's ignorance of the challenges of ASD are burdens.

Practical implications

Ensuring health outcomes for a child with ASD requires an integrated service system and long-term, customer-centric service process because the scope of service covers the child's entire childhood. Customized educational and healthcare service must be allocated and budgeted early in order to reach the goal of a satisfactory service output for each child.

Originality/value

This is the first service research to focus on parents' challenges with obtaining services for their child with ASD. This paper provides service researchers and managers insight into parents' perceptions of educational and healthcare service value (i.e. benefits vs. burdens) received for their child with ASD. These insights into customer-centric perceptions of value may be useful to research and may help service providers to innovate and provide integrated service directly to parents, or indirectly to service providers, who serve children with ASD.

Collaborative Home-Visit Program for Young Children With Motor Delays in Rural Taiwan: A Pilot Randomized Controlled Trial

BACKGROUND

Caregiver engagement and collaborative team early childhood intervention (ECI) services are international trends; however, relevant evidence of collaborative home-visiting ECI in rural areas is as yet undetermined.

OBJECTIVE

The study aimed to investigate the effectiveness of a collaborative ECI program in a rural area of Taiwan.

DESIGN

The study was a pilot randomized control led trial.

METHODS

Children aged 6 to 33 months experiencing motor delays and their caregivers were enrolled in Taitung, Taiwan. Using stratified randomization, 24 participants were allocated to either experimental or control groups, and both received 5 home visits within 3 months. The experimental group received ECI services based on the International Classification of Functioning, Disability and Health framework and family-centered approaches. The control group received regular home visits by local social workers. Child outcomes included Pediatric Evaluation of Disability Inventory Chinese Version and Peabody Developmental Motor Scale, 2nd edition. Family outcomes included the Disability-Adapted Infant-Toddler version of Home Observation for Measurement, and Chinese versions of the Knowledge of Infant Development Inventory and Parental Stress Index-Short Form. A tester blinded to the study conducted assessments at baseline, postintervention, and 3-month follow-up. Two-way mixed analysis of variance was used with α = .05 (2-tailed).

RESULTS

The experimental group improved scores on the Disability-Adapted Infant-Toddler version of Home Observation for Measurement significantly more than the control group with an effect size of 0.64 at follow-up. In other outcomes, both groups showed no significant differences. The follow-up rate was 69%, and adherence to the ECI program was acceptable.

LIMITATIONS

A limitation of the study was the heterogeneity of the sample.

CONCLUSIONS

This pilot study revealed possible effectiveness in implementing collaborative ECI programs based on family-centered approaches and the International Classification of Functioning, Disability and Health in rural areas. Larger field studies are needed to confirm our findings.

A journey through follow-up for neurodevelopmentally at-risk infants-A qualitative study on views of parents and professionals in Liverpool

BACKGROUND

With improving neonatal intensive care, more preterm babies or those with hypoxic-ischaemic encephalopathy are surviving the newborn period. These babies are at high risk of neurodevelopmental delay. No studies to date have looked at the views of parents and professionals in relation to the processes of follow-up for these infants.

METHODS

We conducted a qualitative study in order to understand the views of parents of preterm babies or those with hypoxic-ischaemic encephalopathy as well as the views of professionals who manage and support these families. Parents were recruited through general neonatal follow-up clinics, neonatal nurse liaison services and community child health clinics and professionals through the neonatal unit and neurodevelopmental paediatrics services. We conducted in-depth interviews using an open-ended topic guide, which were audio recorded, transcribed and coded. We conducted a thematic content analysis where themes were inductively highlighted and grouped by consensus in order to conclude on major themes and subthemes.

RESULTS

Three major themes were identified for parents and professionals. These were the following: (a) What is the future, (b) What is the journey and (c) Who can help me? Parents wanted better information earlier about the prognosis and diagnoses through face to face, honest consultations with follow-up information available on the Internet. The most important requirements for follow-up clinics were honesty, reassurance, consistent pathways of follow-up and the need for a lead professional in the process. Alongside the follow-up process, there was a need for support groups and psychological support CONCLUSIONS: This study highlights the desire by parents for early information on the likely long-term outlook for their babies but the need to ensure that the information and support, which is given, is provided appropriately and with consideration in order to provide the best care of the whole family.

Differential Diagnosis of Autism Spectrum Disorder Versus Language Disorder in Children Ages 2 to 5 Years: Contributions of Parent-Reported Development and Behavior

Early diagnosis of autism spectrum disorder (ASD) has focused on differentiating children with ASD from neurotypical children. However, many children presenting with concern for ASD are ultimately diagnosed with language disorder (LD). This study aimed to identify differences in parent-rated development and behavior among children ages 2 to 5 years presenting with concern for ASD who were diagnosed with either ASD or LD. Children with ASD were rated as more socially withdrawn and more delayed in social development and self-help skills than those with LD. Parent-rated developmental delays were positively correlated with scores on an autism screening measure and with social withdrawal and pervasive developmental problems among children with ASD. Among those with LD, parent-rated social and self-help development were positively correlated with social withdrawal and attention problems. Thus, parent ratings of social withdrawal and development of social and self-help skills may facilitate differential diagnosis of ASD and LD in children ages 2 to 5 years.

Parental Action and Referral Patterns in Spatial Clusters of Childhood Autism Spectrum Disorder

Sociodemographic factors have long been associated with disparities in autism spectrum disorder (ASD) diagnosis. Studies that identified spatial clustering of cases have suggested the importance of information about ASD moving through social networks of parents. Yet there is no direct evidence of this mechanism. This study explores the help-seeking behaviors and referral pathways of parents of diagnosed children in Costa Rica, one of two countries in which spatial clusters of cases have been identified. We interviewed the parents of 54 diagnosed children and focused on social network connections that influenced parents' help seeking and referral pathways that led to assessment. Spatial clusters of cases appear to be a result of seeking private rather than public care, and private clinics are more likely to refer cases to the diagnosing hospital. The referring clinic rather than information spread appears to explain the disparities.

Empirically Identified Subgroups of Children Served in Part C Early Intervention Programs

OBJECTIVE

Early intervention (EI) programs under Part C of the Individuals with Disabilities Education Act serve a developmentally heterogeneous population of infants and toddlers with or at risk of developmental delays or disabilities. The aim of this study was to identify empirically distinct subgroups of children in EI so as to inform early prognosis and service planning.

METHODS

We applied mixture modeling to developmental assessment data from 1513 children who enrolled in a large, urban EI program between 2009 and 2013. The observed variables were children's EI-entry developmental quotients (DQs) in 5 domains (communication, cognitive, motor, adaptive, and personal-social) as assessed by the Battelle Developmental Inventory, Second Edition.

RESULTS

A 4-class model showed the best fit to the data, revealing subgroups with distinct developmental profiles. Children in the first subgroup showed a severe delay in communication with less severe delays in the other domains. Children in the second subgroup likewise showed a severe delay in communication, but with comparably severe delays in the cognitive and motor domains. Profiles for the third and fourth subgroups showed the same overall patterns as those for the first and second subgroups, respectively, but to a less severe degree. Developmental trajectories differed by subgroup.

CONCLUSION

Consideration of subgroups based on children's developmental assessment scores provides insight into underlying commonalities among children with different presenting diagnoses on entry into EI. The subgroups also have clinical relevance in terms of both practitioners' and parents' understanding of children's likely service needs and developmental trajectories.

Age at Autism Spectrum Disorder (ASD) Diagnosis by Race, Ethnicity, and Primary Household Language Among Children with Special Health Care Needs, United States, 2009-2010

We examined prevalence of diagnosed autism spectrum disorder (ASD) and age at diagnosis according to child's race/ethnicity and primary household language. From the 2009-2010 National Survey of Children with Special Health Care Needs, we identified 2729 3-17-year-old US children whose parent reported a current ASD diagnosis. We compared ASD prevalence, mean diagnosis age, and percentage with later diagnoses (≥5 years) across racial/ethnic/primary household language groups: non-Hispanic-white, any language (NHW); non-Hispanic-black, any language (NHB); Hispanic-any-race, English (Hispanic-English); and Hispanic-any-race, other language (Hispanic-Other). We assessed findings by parent-reported ASD severity level and adjusted for family sociodemographics. ASD prevalence estimates were 15.3 (NHW), 10.4 (NHB), 14.1 (Hispanic-English), and 5.2 (Hispanic-Other) per 1000 children. Mean diagnosis age was comparable across racial/ethnic/language groups for 3-4-year-olds. For 5-17-year-olds, diagnosis age varied by race/ethnicity/language and also by ASD severity. In this group, NHW children with mild/moderate ASD had a significantly higher proportion (50.8 %) of later diagnoses than NHB (33.5 %) or Hispanic-Other children (18.0 %). However, NHW children with severe ASD had a comparable or lower (albeit non-significant) proportion (16.4 %) of later diagnoses than NHB (37.8 %), Hispanic-English (30.8 %), and Hispanic-Other children (12.0 %). While NHW children have comparable ASD prevalence and diagnosis age distributions as Hispanic-English children, they have both higher prevalence and proportion of later diagnoses than NHB and Hispanic-Other children. The diagnosis age findings were limited to mild/moderate cases only. Thus, the prevalence disparity might be primarily driven by under-representation (potentially under-identification) of older children with mild/moderate ASD in the two minority groups.

Healthcare costs associated with language difficulties up to 9 years of age: Australian population-based study

PURPOSE

This study aimed to quantify the non-hospital healthcare costs associated with language difficulties within two nationally representative samples of children.

METHOD

Data were from three biennial waves (2004-2008) of the Longitudinal Study of Australian Children (B cohort: 0-5 years; K cohort: 4-9 years). Language difficulties were defined as scores ≤ 1.25 SD below the mean on measures of parent-reported communication (0-3 years) and directly assessed vocabulary (4-9 years). Participant data were linked to administrative data on non-hospital healthcare attendances and prescription medications from the universal Australian Medicare subsidized healthcare scheme.

RESULT

It was found that healthcare costs over each 2-year age band were higher for children with than without language difficulties at 0-1, 2-3, and 4-5 years, notably 36% higher (mean difference = $AU206, 95% CI = $90, $321) at 4-5 years (B cohort). The slightly higher 2-year healthcare costs for children with language difficulties at 6-7 and 8-9 years were not statistically different from those without language difficulties. Modelled to the corresponding Australian child population, 2-year government costs ranged from $AU1.2-$AU12.1 million (depending on age examined). Six-year healthcare costs increased with the persistence of language difficulties in the K cohort, with total Medicare costs increasing by $192 (95% CI = $74, $311; p = .002) for each additional wave of language difficulties.

CONCLUSION

Language difficulties (whether transient or persistent) were associated with substantial excess population healthcare costs in childhood, which are in addition to the known broader costs incurred through the education system. It is unclear whether healthcare costs were specifically due to the assessment and/or treatment of language difficulties, as opposed to conditions that may be co-morbid with or may cause language difficulties.

Indian children with developmental disabilities: early versus late referral for intervention

OBJECTIVE

To study the age at referral, of children with neurodevelopmental disabilities to Child Development and Early Intervention Clinic and compare the neuromorbidity and socio-economic profile of the early and late presenters.

METHODS

This retrospective observational study was conducted at Child Development and Early Intervention Clinic (CDEIC) located in Northern India. Case records of children enroled at CDEIC in last 5 y; with neurodevelopmental disabilities namely Mental Retardation/Global Developmental Delay, Cerebral Palsy, hearing and vision impairment were separated and studied.

RESULTS

Two thousand and twenty cases were included in this study. 62.8 % presented before 3 y of age (early presenters) and 37.1 % presented at 3 y or more (late presenters). There was no difference in the overall rates and severity of mental retardation in early and late presenters. The proportion of children with quadriparetic cerebral palsy, hearing impairment, vision impairment and multiple disabilities was significantly more in early presenters. The early presenters had better parental education status, less number of siblings, better immunization status and more were delivered at a hospital and residing in urban areas.

CONCLUSIONS

Large numbers of children with neurodevelopmental disabilities are referred late for intervention services, leading to loss of opportunity for early intervention. Children with purely mental disability are the ones, most likely to be referred late. Socio-economic differences are significantly contributing to these delayed referrals.

Linkage of ICF-CY codes with environmental factors in studies of developmental outcomes of infants and toddlers with or at risk for motor delays

PURPOSE

Environmental variables have been explored in studies of the development of young children with motor delays. Linking environmental variables to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY), environmental factors (EFs) categories can provide a common language for documenting their contribution to developmental outcomes. This review of studies aimed to (1) link EFs for developmental outcomes in infants with or at risk for motor delays to ICF-CY categories and (2) synthesize the influences of EFs (with ICF-CY linkage) on developmental outcomes.

METHOD

A systematic literature search was performed of multiple databases. After applying selection criteria, environmental variables in 28 articles were linked to ICF-CY categories and underwent qualitative synthesis.

RESULTS

Results indicated that physical environmental variables could be linked successfully to ICF-CY EFs categories, but not social environmental variables. Multiple environmental variables were associated with motor and other developmental outcomes.

CONCLUSION

Difficulties in linking social factors to ICF-CY categories indicate that additional EFs codes may need to be considered in the ICF-CY revision processes. The review provides empirical data on relationships between EFs and developmental outcomes in children with or at risk for motor delay.

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.

Doing the "talk": disclosure of a diagnosis of cerebral palsy

The disclosure to a family of a child's cerebral palsy is an important transformative event that has potential lasting implications. This article highlights specific challenges, the results of research into the disclosure process and what attributes should be sought for in this encounter by health care providers. Illustrative case vignettes are presented to concretely demonstrate the "dos and don'ts" of the disclosure. Suggestions will also be provided to improve the disclosure process.

Effectiveness of developmental screening in an urban setting

OBJECTIVE

To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.

METHODS

This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were <30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.

RESULTS

A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.

CONCLUSIONS

Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

Global perspective on early diagnosis and intervention for children with developmental delays and disabilities

Low- and middle-income countries are experiencing a significant reduction in mortality of children under 5 years of age. This reduction is bringing in its wake large numbers of surviving children with developmental delays and disabilities. Very little attention has been paid to these children, most of whom receive minimal or no support. Thus, there is an urgent need to recognize that improving the quality of life of the survivors must complement mortality reduction in healthcare practice and programs. The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention.

Practitioner's guide to assessment of autism spectrum disorders in infants and toddlers

Recent advances in clinical research have made it possible to diagnosis autism spectrum disorders (ASD) as early as the second year of life. The diagnostic process early in development is often complex, and thus, familiarity with the most recent findings in clinical assessment instruments, early symptoms, and developmental trajectories of young children with autism is essential. This paper provides an empirically based practitioner's guide to issues and concerns related to early diagnosis of ASD in very young children, documentation of the course and patterns of ASD symptomatology in infants and toddlers, and current understanding in the field of diagnostic outcomes of children identified in the first and second year of life.

Referral profile of a child development clinic in northern India

OBJECTIVE

To delineate the demographic and clinical profile of children referred to a Child Development Clinic (CDC) of a tertiary care public hospital in India.

METHODS

A retrospective review of medical records of all the cases referred to CDC in the year 2009 was conducted.

RESULTS

Out of the 792 children referred to CDC, complete medical records were available in 641 cases, which comprised the study population. 66% were males and mean age at referral was 54.06 ± 44.4 months. 68.64% children had global developmental delay or mental retardation, majority (51.1%) of them having severe or profound retardation. 168 (26.2%) patients had various forms of cerebral palsy, with 39.3% being quadriplegics and 121 (18.9%) patients had pervasive developmental disorders. Only, 1.2% of cases had isolated motor delay and 2.9% had developmental language disorder.

CONCLUSIONS

This study shows that in developing countries the proportion of children referred to CDC with severe disabling conditions is high and a significant proportion of these children have pervasive developmental disorders. This study provides baseline data for further planning of services for these children in the authors' region.

Other impairment associated with developmental language delay in preschool-aged children

The aim of this study was to investigate developmental impairment in several domains that might be associated with developmental language delay. The records of 56 preschool children with developmental language delay and 31 nonimpaired children were reviewed. Children with language delay were more likely than those in the nonimpaired group to have cognitive developmental delay (Mental Development Index < 70) (P < .001) and gross and fine motor delay (gross: 28 [50%] versus 5 [16%], P = .002; fine: 34 [62%] versus 11 [35%], P = .02). Children with language delay were significantly more likely to have impairment than were nonimpaired children in gross motor, fine motor, comprehension-conceptual and personal-social (P = .01, P = .02, P = .01, P = .02, respectively) functional domains. Our findings indicate that preschool children with language delay have wide-ranging difficulties in development and function.

A longitudinal study of outcome measures for children receiving early intervention services

PURPOSE

The purpose of this study was to compare the Pediatric Evaluation of Disability Inventory (PEDI) and the Mullen Scales of Early Learning (MSEL) as measures of change in children who received early intervention services.

METHODS

Thirty-four children were stratified into 2 groups according to the presence of gross motor delay. The PEDI and MSEL were administered 3 times: at an average age of 18, 31, and 53 months of age. Data were analyzed using a repeated-measures multivariate analysis of variance.

RESULTS

The findings suggest that PEDI Functional Skills Scaled Scores were capable of measuring change in both groups of children. The standard scores on the PEDI Functional Skills Social Scale were found to be more sensitive to change than the MSEL Receptive and Expressive Language scores for children with motor delays.

CONCLUSION

Using PEDI scaled scores may be an effective strategy for measuring change in children receiving early intervention services.

A longitudinal study of developmental and behavioral screening and referral in North Carolina's Assuring Better Child Health and Development participating practices

Screening children for developmental and behavioral delays is an important part of primary care practice. Well-child visits provide an ideal opportunity to engage parents and to do periodic screening. Screening identifies children who may be at risk and need further evaluation. In North Carolina's Assuring Better Child Health and Development project best-practices process, screening was incorporated as a routine part of well-child visits regardless of payor. The schedule of screenings, using the Ages and Stages Questionnaire, was 6, 12, 18 or 24, 36, 48, and 60 months. From the practices' population, a cohort of 526 children, screened from the age of 6 months during August 2001 through November 2003, was retrospectively reviewed. The main objectives of this descriptive study were to determine the number of children who were screened and whether this rate improved with time, observe patterns and trajectories for children identified at risk in 1 or more of the 5 developmental domains, and examine referral rates and physician referral patterns.

Global developmental delay and its relationship to cognitive skills

Global developmental delay (GDD) is defined as evidence of significant delays in two or more developmental domains. Our study determined the cognitive skills of a cohort of young children with GDD. A retrospective chart review of all children diagnosed with GDD within a single developmental clinic was carried out. Scores on fine motor (Peabody Developmental Motor Scale 2), expressive language (Expressive One Word Picture Vocabulary Test) and receptive language (Reynell Developmental Language Scales or Clinical Evaluation of Language Fundamentals - Preschool 2) testing, and cognitive performance (Wechsler Preschool and Primary Scale of Intelligence, Third Edition) were obtained. A multiple regression analysis was performed and correlations obtained. Results from a total of 93 patients (86 males, seven females) were retained for analysis. Mean age was 3 years 8 months (SD 10mo, range 2.5-4.75y). Cognitive scores were widely distributed, with 73% of participants displaying a global IQ score of 70 or more, despite concurrent global delay. Significant correlation was present for fine motor and expressive language scores, when isolated and compared with cognitive performance (p values of 0.04 and 0.05 respectively). The conclusion was made that an initial diagnosis of GDD is not necessarily associated with objective cognitive impairment.

Racial/ethnic disparities in the identification of children with autism spectrum disorders

OBJECTIVES

We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs).

METHODS

Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education.

RESULTS

Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70.

CONCLUSIONS

Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.

Communication about child development during well-child visits: impact of parents' evaluation of developmental status screener with or without an informational video

BACKGROUND

The American Academy of Pediatrics recommends periodic administration of standardized developmental screening instruments during well-child visits to facilitate timely identification of developmental delay. However, little is known about how parents and physicians communicate about child development or how screening impacts communication.

OBJECTIVE

Our goal was to examine whether parent-physician communication about child development is affected by (1) administration of a developmental screen or (2) video presentation on child development before well-child visits.

METHODS

Six primary care pediatricians in a practice serving predominantly Medicaid-insured children participated. Fifteen parents of children 9 to 31 months of age per pediatrician were assigned to 1 of 3 previsit conditions (n = 89): (1) usual care; (2) parent completed the Parents' Evaluation of Developmental Status screen; or (3) parent viewed 5-minute "activation" video before completing the Parents' Evaluation of Developmental Status. Visits were audiorecorded and coded by blinded raters using a classification system that assesses communication content. Outcomes included visit length, physicians' questions, information giving, reassurance or counseling about development, and parents' concerns and requests for developmentally related services.

RESULTS

Mean visit duration was similar for the 3 groups (22.5 minutes). Physicians made more information-giving and counseling statements about development and raised more developmental concerns in group 3 (video plus the Parents' Evaluation of Developmental Status) than in group 1 (usual care) visits. A trend toward increased use of such communication was also seen in group 2 (Parents' Evaluation of Developmental Status only). Parents were more likely to raise a developmental concern in group 3 than in group 1. No parent requested early intervention, therapy, or other related services.

CONCLUSIONS

Use of a validated screening test did not increase average visit duration, an important consideration in primary care. Although use of the Parents' Evaluation of Developmental Status alone led to some increase in parent-physician communication about development and developmental concerns, additional increase in communication was seen with the addition of a brief parent activation video shown before the Parents' Evaluation of Developmental Status was completed.

Array comparative genomic hybridization in global developmental delay

OBJECTIVE

Array-based comparative genomic hybridization (array CGH) is an emerging technology that allows for the genome-wide detection of DNA copy number changes (CNC) such as deletions or duplications. In this study, array-based CGH was applied to a consecutive series of children with previously undiagnosed non-syndromal global developmental delay (GDD) to assess potential etiologic yield.

METHODS

The children in this study were drawn from a previously reported consecutive series of children with well-defined GDD. Almost all subjects had undergone prior karyotyping and neuroimaging studies with non-diagnostic results. Array-based CGH was undertaken using the SignatureChip(R) (1887 BACs representing 622 loci) with abnormalities verified by subsequent FISH analysis and testing of parents to distinguish between pathogenic and familial non-pathogenic variants.

RESULTS

On CGH analysis in our study, 6 of 94 children (6.4%) had a causally related pathogenic CNC. Three were sub-telomeric in location. An analysis of a variety of clinical factors revealed that only the presence of minor dysmorphic features (<3) was predictive of etiologic yield on CGH analysis (4/26 vs. 2/68, P = 0.05). Severity of delay was not found to be predictive.

INTERPRETATION

In children with non-syndromal GDD, array-based CGH has an etiologic yield of 6.4%. This suggests that this emerging technology may be of diagnostic value when applied subsequent to detailed history, physical examination, and targeted laboratory testing. Array CGH may merit consideration as a first-tier test in the context of a child with unexplained GDD.

Global developmental delay and mental retardation or intellectual disability: conceptualization, evaluation, and etiology

Global developmental delay and mental retardation or intellectual disability offer challenges to the practitioner at several different levels. Accurate recognition of these most common of subtypes of neurodevelopmental disabilities is a central precondition to their correct evaluation and management. Proper evaluation is a time- and labor-intensive process that emphasizes several different goals. Guidelines now exist to assist the practitioner in selecting the appropriate investigation path to be pursued, and these guidelines should be used to inform the selections of investigations made. Although challenging and time consuming, the evaluation of these children offers many professional rewards and is a necessary first step in a family's adaptation to their child's chronic condition.

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.

Child health and parental stress in school-age children with a preschool diagnosis of developmental delay

Chronic disorders are known to have a wide-ranging impact on overall health and family dynamics. The objective of this study was to assess child health and well-being and parental stress in a cohort of school-age children diagnosed before school entry with either global developmental delay or developmental language impairment. In total, 65 children with preschool developmental delay were assessed at school age (mean +/- SD age: 7.3 +/- 0.7 years) with the Child Health Questionnaire and Parenting Stress Index, with a mean interval between assessment of 3.9 years. Almost all children who completed testing (60/62) continued to show developmental impairments across domains. On the Child Health Questionnaire, children showed the greatest impairment on the mental health scale (median z score: -0.9). The median Child Health Questionnaire psychosocial health score (40.7) was almost 1 SD below established normative values ( P < .001). More than 40% of parents had a Parenting Stress Index above the 85th percentile (clinically significant parenting stress). Using multiple linear regression analysis, high levels of parenting stress were best predicted by a child's Child Health Questionnaire psychosocial health score (r2 = 0.49, P < .001). Thus, 4 years after a preschool-age diagnosis of developmental delay, poor psychosocial health was a common comorbidity. Almost half the parents showed clinically significant levels of parenting stress. There is a need to both recognize and provide ongoing social and emotional support for young children diagnosed with developmental disability and their families.

Subtypes of learning disabilities: neuropsychological and behavioural functioning of 495 children referred for multidisciplinary assessment

Aim of the present study was two fold: (1) to evaluate the course of referring and diagnosing Learning Disabilities (LD) and the contribution of multidisciplinary assessment and (2) to describe characteristics of three LD subtypes: Attention with or without Motor function Disabilities (AMD), Verbal Learning Disabilities (VLD) and Non-Verbal Learning Disabilities (NVLD). Diagnostics, behavioural and neuropsychological data from 495 children aged 6-17 years were described. First, AMD and VLD was the most frequent LD. Multidisciplinary assessment could contribute to the diagnostic process of LD, especially in diagnosing uncommon LD and comorbidities. Secondly, behavioural ratings, information processing, attention regularity and visual-motor integration proved to be most sensitive in discriminating between the three LD subtypes. However, diagnosing NVLD requires additional developmental information. Multiple discriminant function analysis correctly classified 61.7% of a selection of the present sample into LD subtypes as diagnosed by the multidisciplinary team. It is believed that the three subtypes are clinically relevant and suggestions are made to test the present classification functions in an independent sample, preferably diagnosed using a structured diagnostic interview.

Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder

This study estimated differences by ethnicity in the diagnoses assigned prior to the diagnosis of autism. In this sample of 406 Medicaid-eligible children, African-Americans were 2.6 times less likely than white children to receive an autism diagnosis on their first specialty care visit. Among children who did not receive an autism diagnosis on their first visit, ADHD was the most common diagnosis. African-American children were 5.1 times more likely than white children to receive a diagnosis of adjustment disorder than of ADHD, and 2.4 times more likely to receive a diagnosis of conduct disorder than of ADHD. Differences in diagnostic patterns by ethnicity suggest possible variations in parents' descriptions of symptoms, clinician interpretations and expectations, or symptom presentation.

Office evaluation of the child with developmental delay

Developmental delays are a common problem in child health and a frequent reason for referral to a pediatric subspecialist. The office evaluation of the young delayed child has a number of objectives including primarily precisely categorizing the delay subtype together with rationally selecting investigations for determining a possible underlying etiology. Counseling the affected family regarding the diagnosis and its prognosis, identifying possible coexisting conditions that merit interventions, and ensuring appropriate rehabilitation service provision are also important objectives of this office assessment. An outline of the key features of the relevant history and physical examination together with guidelines regarding investigations are provided to best meet all these objectives within existing time and practice constraints.

Communicating a diagnosis of cerebral palsy: caregiver satisfaction and stress

As part of the implementation of a population-based registry of children with cerebral palsy, caregiver satisfaction with the process by which diagnosis was originally communicated by a professional was assessed. Satisfaction with various aspects of the diagnosis process was assessed using a five-point Likert scale and related to child, family, and situational characteristics. Measures were then correlated with current caregiver stress as measured objectively by the Parenting Stress Inventory. During the registration process, 59 consecutive caregivers (55 mothers) were questioned. Overall, 62% (35/59) were satisfied with the disclosure process, with satisfaction ranging from 69% (41/59-hopefulness) to 92% (54/59-honesty) for professional qualities, and from 61% (36/59-sufficient information provided) to 78% (46/59-understandable) for disclosure content. Satisfaction was related to the quantity and content of information given at the disclosure session. Parenting Stress Inventory scores, both total and for parental distress, correlated significantly with both the severity of the child's cerebral palsy and caregiver satisfaction with varying elements of the disclosure process. Overall caregiver satisfaction with the process by which a diagnosis of cerebral palsy is given appears to be good. Together with the severity of a child's intrinsic cerebral palsy, it appears to relate to later parental adjustment to a setting of chronic disability, suggesting a portal through which improvements in information delivery may result in better familial adaptation to disability.

ICF and ICD codes provide a standard language of disability in young children

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the utility of a hierarchical algorithm incorporating codes from the International Classification of Functioning, Disability and Health--ICF (WHO, 2001) and the International Statistical Classification of Diseases-ICD (WHO, 1994) to classify reasons for eligibility of young children in early intervention.

METHODS

The database for this study was a nationally representative enrollment sample of more than 5,500 children in a longitudinal study of early intervention. Reasons for eligibility were reviewed and matched to the closest ICF or ICD codes under one of four major categories (Body Functions/Structures, Activities/Participation, Health Conditions, and Environmental Factors).

RESULTS

The average number of reasons for eligibility provided per child was 1.5, resulting in a population summary exceeding 100%. A total of 305 ICF and ICD codes were used with most (77%) of the children having codes in the category of Body Function/Structures. Forty-one percent of the sample had codes of Health Conditions, whereas the proportions with codes in the Activities/Partipication and Environmental Categories were 10 and 5%, respectively.

CONCLUSIONS

The results demonstrate that ICD and ICF can be jointly used as a common language to document disability characteristics of children in early intervention.

Sustained withdrawal behavior in clinic-referred and nonreferred infants

To examine the relations between infants' sustained withdrawal behavior and children's mental health status and maternal and child relational behavior, 36 clinic-referred and 43 control infants were evaluated. Families were visited at home, mother-child free play and feeding interactions were videotaped, and mothers completed self-report measures. Interactions were coded for sustained withdrawal using the Alarm Distress Baby Scale (ADBB; Guedeney and Fermanian, 2001) and for global relational patterns with the Coding of Interactive Behavior (CIB; Feldman, 1998). Higher ADBB scores were found for the referred group, with many infants (38.9% ) scoring above the clinical cutoff (vs. 11.6% in the control group). More negative relational patterns were found for the withdrawn group in terms of higher maternal intrusiveness, lower reciprocity, and lower child involvement. Associations were found between maternal and child behavior during play and feeding and child sustained withdrawal behavior at play. Sustained withdrawal also was associated with unpredictable child temperament and lower sense of parental self-efficacy. Maternal depressive symptoms were higher in the referred group and correlated with maternal and child relational patterns. The findings contribute to the construct and discriminant validity of the CIB and the ADBB coding systems, and suggest that sustained withdrawal may serve as a risk indicator for early socioemotional disorders.

Factors associated with age of diagnosis among children with autism spectrum disorders

OBJECTIVE

Early diagnosis of children with autism spectrum disorders (ASD) is critical but often delayed until school age. Few studies have identified factors that may delay diagnosis. This study attempted to identify these factors among a community sample of children with ASD.

METHODS

Survey data were collected in Pennsylvania from 969 caregivers of children who had ASD and were younger than 21 years regarding their service experiences. Linear regression was used to identify clinical and demographic characteristics associated with age of diagnosis.

RESULTS

The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Asperger's disorder. The average age of diagnosis increased 0.2 years for each year of age. Rural children received a diagnosis 0.4 years later than urban children. Near-poor children received a diagnosis 0.9 years later than those with incomes >100% above the poverty level. Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase. Children who had 4 or more primary care physicians before diagnosis received a diagnosis 0.5 years later than other children, whereas those whose pediatricians referred them to a specialist received a diagnosis 0.3 years sooner.

CONCLUSION

These findings suggest improvements over time in decreasing the age at which children with ASD, especially higher functioning children, receive a diagnosis. They also suggest a lack of resources in rural areas and for near-poor families and the importance of continuous pediatric care and specialty referrals. That only certain ASD-related behaviors, some of which are not required to satisfy diagnostic criteria, decreased the age of diagnosis suggests the importance of continued physician education.

Factors associated with age of diagnosis among children with autism spectrum disorders

OBJECTIVE

Early diagnosis of children with autism spectrum disorders (ASD) is critical but often delayed until school age. Few studies have identified factors that may delay diagnosis. This study attempted to identify these factors among a community sample of children with ASD.

METHODS

Survey data were collected in Pennsylvania from 969 caregivers of children who had ASD and were younger than 21 years regarding their service experiences. Linear regression was used to identify clinical and demographic characteristics associated with age of diagnosis.

RESULTS

The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Asperger's disorder. The average age of diagnosis increased 0.2 years for each year of age. Rural children received a diagnosis 0.4 years later than urban children. Near-poor children received a diagnosis 0.9 years later than those with incomes >100% above the poverty level. Children with severe language deficits received a diagnosis an average of 1.2 years earlier than other children. Hand flapping, toe walking, and sustained odd play were associated with a decrease in the age of diagnosis, whereas oversensitivity to pain and hearing impairment were associated with an increase. Children who had 4 or more primary care physicians before diagnosis received a diagnosis 0.5 years later than other children, whereas those whose pediatricians referred them to a specialist received a diagnosis 0.3 years sooner.

CONCLUSION

These findings suggest improvements over time in decreasing the age at which children with ASD, especially higher functioning children, receive a diagnosis. They also suggest a lack of resources in rural areas and for near-poor families and the importance of continuous pediatric care and specialty referrals. That only certain ASD-related behaviors, some of which are not required to satisfy diagnostic criteria, decreased the age of diagnosis suggests the importance of continued physician education.

Developmental and functional outcomes at school age of preschool children with global developmental delay

The later developmental trajectory of young children diagnosed early with global developmental delay was determined. Using a prospective study, preschool children diagnosed with global developmental delay were systematically reassessed during the early school years with standardized developmental and functional outcome measures (Battelle Developmental Inventory and Vineland Adaptive Behavior Scale). Of an original cohort of 99 children assessed and diagnosed at a mean age of 3.4 +/- 1.1 years, 48 were reassessed at a mean age of 7.3 +/- 0.9 years. Group performance on the Battelle Developmental Inventory overall was 66.4 +/- 4.3 (mean 100 +/- 15). Between 75% and 100% of the cohort performed at least 1.5 SD below the normative mean on the individual domains of the Battelle Developmental Inventory. Similarly, the group mean on the Vineland Adaptive Behavior Scale overall was 63.5 +/- 20.8 (mean 100 +/- 15), with between 61% and 76% of the cohort scoring more than 1.5 SD below the mean on each of the domains. Univariate and multivariate analyses on potential predictor variables identified a lack of an underlying etiology as predictive of poorer performance on the Battelle Developmental Inventory fine motor and motor domains and increasing severity of initial delay as predictive of poorer performance on the Vineland Adaptive Behavior Scale communication domain and overall score. Similarly, maternal employment and paternal postsecondary education improved Vineland Adaptive Behavior Scale communication scores, whereas paternal postsecondary education alone predicted better socialization and total scores on the Vineland Adaptive Behavior Scale. Children with early global developmental delay demonstrate persistent and consistently poor performance across all developmental and functional domains. Few variables are apparent at intake to predict later performance.

The role of nurses in screening for autistic spectrum disorder in pediatric primary care

This article addresses the issue of integration of routine screening for autism spectrum disorder (ASD) in pediatric primary care. The relationship between screening and patient outcome is discussed. The ASD screening recommendations of the American Academy of Pediatrics and practical issues associated with their application are then reviewed. Finally, data from a pilot project to prepare nurses to conduct ASD screening during routine pediatric health visits are presented. The authors discuss the role of nurses in establishing systems within pediatric primary care to identify and refer children at risk for ASD.

Outcomes at school age of preschool children with developmental language impairment

In a prospective study, preschool children diagnosed with developmental language impairment were systematically reassessed during the early school years with standardized developmental (Battelle Developmental Inventory) and functional measures (Vineland Adaptive Behavior Scale). Of an original cohort of 70 children assessed and diagnosed at a mean age of 3.6 +/- 0.7 years, 43 were reassessed at a mean age of 7.4 +/- 0.7 years. Group performance on the Battelle overall was 71.9 +/- 8.2 with the lowest sub-domain score in communication at 69.5 +/- 8.9. On the Battelle, 67% of children fell below the 1.5 standard deviation (S.D.) cutoff signifying significant developmental concerns. Between 36% (gross motor) and 83% (communication) of the cohort performed at least 1.5 S.D. below the normative mean on the individual domains of the Battelle. Seventy-four percent were impaired in two or more domains of the Battelle. The group mean on the Vineland overall was 81.1 +/- 16.9 with between 19% (socialization) to 48% (communication) of the cohort scoring more than 1.5 S.D. below the mean on each of the sub-domains. Almost half of the cohort (20/42, 48%) manifested functional impairment in at least two domains of the Vineland. Univariate and multivariate analysis of potential predictor variables identified only female sex as being predictive of significantly poorer performance on the Vineland communication sub-domain and the Vineland total score. Children with early developmental language impairment demonstrate persistent impairments in developmental and functional skills at school entry not limited to language. Deficits remain especially evident in the communication sub-domain. These results have implications with respect to later prognostication, family counseling, and devising a programmatic approach to this group of children.

School district resources and identification of children with autistic disorder

OBJECTIVES

We estimated the effect of community and school district resources on the identification of children with autistic disorder.

METHODS

Latent growth curve regression models were applied to school district-level data from one large state.

RESULTS

The rate of identification of autistic disorder increased on average by 1.0 child per 10000 per year (P<.001), with statistically significant district variation. After adjustment for district and community characteristics, each increase in decile of school revenue was associated with an increase of 0.16 per 10000 children identified with autistic disorder. The proportion of economically disadvantaged children per district was inversely associated with autistic disorder cases.

CONCLUSIONS

District revenue was associated with higher proportions of children identified with autistic disorder at baseline and increasing rates of identification when measured longitudinally. Economically disadvantaged communities may need assistance to identify children with autistic spectrum disorders and other developmental delays that require attention.

Developmental screening

An estimated 5 to 10% of the pediatric population has a developmental disability. The current strategy to identify these children is through developmental surveillance, a continuous procedure in which the health professional observes the infant, takes a developmental history, and elicits any concerns that the caregiver might have. However, identification of delayed children is ineffective when based solely on routine surveillance. A necessary adjunct is developmental screening: the process of systematically identifying children with suspected delay who need further assessment. Screening tests greatly improve the rate of identification. With the advent of intervention programs and the support of organizations such as the American Academy of Pediatrics, the topic of developmental screening is a timely and essential one. This review aims to describe the properties of screening tests, to evaluate the available tools for developmental screening while providing a representative sample of the currently available developmental tests, and, finally, to evaluate the efficacy of intervention programs, a needed prerequisite to justify screening.

Motor function at school age in children with a preschool diagnosis of developmental language impairment

OBJECTIVES

To evaluate fine motor (FM) and gross motor (GM) function shortly after school entry in children with a preschool diagnosis of developmental language impairment (DLI).

STUDY DESIGN

A cohort of children (n = 70) diagnosed at pre-school age with DLI was reevaluated in elementary school. Language, cognitive, and motor outcomes were assessed through the use of the Battelle Developmental Inventory (BDI). Language was further assessed through the use of the Vineland Adaptive Behavior Scale, Peabody Picture Vocabulary, and Expressive One Word Picture Vocabulary Tests. Performance below -1.5 SD of the normative mean on any test was considered to represent impairment.

RESULTS

Forty-three children (mean age, 7.4 +/- 0.7 years) underwent reassessment at a mean of 3.8 +/- 0.7 years after initial preschool assessment. Mean scores for BDI motor domains (FM, 78.3 +/- 11.4; GM, 84.9 +/- 13.3) fell below normative values. Twenty-two children (52%) had motor impairment (FM, 17 of 42; GM, 15 of 42); 35 of 43 (81%) continued to have language impairment. BDI communication raw scores correlated most strongly with FM (rho = 0.73, P < .001) and GM (rho = 0.58, P = .003) raw scores but showed only moderate correlations with cognitive raw scores (rho = 0.41, P = .05).

CONCLUSIONS

Impaired motor function is an important comorbidity in DLI. Factors critical to motor performance may also contribute to language deficits in DLI.