Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps

Tasks performed by parents to enable telepractice for children with communication disorders: an interview study with clinicians and parents

PURPOSE

Current service models in childhood rehabilitation promote the active participation of parents/caregivers in their children's therapies. The existing literature provides a limited understanding of the tasks and responsibilities parents undertake in their children's therapies, especially over telepractice. This study describes the tasks undertaken by parents in their children's speech therapy delivered virtually during the COVID-19 pandemic.

METHODS

A qualitative descriptive study was conducted with parents and speech-language pathologists, using open-ended interviews. Interviews were analyzed using a combination qualitative content analysis and thematic analysis.

RESULTS

Parents performed many tasks to enable telepractice. These tasks happened before (e.g., setting up both physical and virtual space for therapy), during (e.g., managing child's behavior), and after the virtual therapy session (e.g., carrying out home practice). While parents were willing to perform these tasks in order to help their children, some expressed the toll that it can take on them.

CONCLUSIONS

Compared to what is known from in-person visits, some of these tasks were novel and unique to telepractice. We recommend that clinicians and parents collaboratively decide on tasks and responsibilities to avoid burdening parents, and that they weigh the costs associated with performing these tasks against the benefits of teletherapy.IMPLICATIONS FOR REHABILITATIONParents perform many tasks to support their children's therapies, both during and outside of therapy sessionsTherapies delivered virtually require parents to assume additional tasks to support their childrenFor services to be Family-Centered, tasks and responsibilities need to be decided collaboratively between parents and clinicians.

Impact of "early intervention" parent workshops on outcomes for caregivers of children with neurodisabilities: a mixed-methods study

PURPOSE

This study explored the feasibility, impact and parent experiences of ENVISAGE (ENabling VISions And Growing Expectations)-Families, a parent-researcher co-designed and co-led program for parents/caregivers raising children with early-onset neurodisabilities.

METHODS

Parents/caregivers of a child with a neurodisability aged ≤6 years, recruited in Australia and Canada, participated in five weekly online workshops with other parents. Self-report measures were collected at baseline, immediately after, and 3 months post-ENVISAGE-Families; interviews were done following program completion. Quantitative data were analyzed with generalized estimating equations and qualitative data using interpretive description methodology.

RESULTS

Sixty-five parents (86% mothers) were recruited and 60 (92%) completed the program. Strong evidence was found of effects on family empowerment and parent confidence (all p ≤ 0.05 after the program and maintained at 3-month follow-up). The ENVISAGE-Families program was relevant to parents' needs for: information, connection, support, wellbeing, and preparing for the future. Participants experienced opportunities to reflect on and/or validate their perspectives of disability and development, and how these perspectives related to themselves, their children and family, and their service providers.

CONCLUSIONS

ENVISAGE was feasible and acceptable for parent/caregivers. The program inspired parents to think, feel and do things differently with their child, family and the people who work with them.Implications for rehabilitationENVISAGE (ENabling VISions And Growing Expectations)-Families is a co-designed, validated parent/researcher "early intervention and orientation" program for caregivers raising a child with neurodevelopmental disabilities (NDDs).ENVISAGE-Families empowered parents' strengths-based approaches to their child, family, disability, and parenting.ENVISAGE-Families increased caregivers' confidence in parenting children with NDD's and provided them tools to support connection, collaboration, and wellbeing.Raising children with NDD can have a profound impact on caregivers, who can benefit from strengths-based, future focused supports early in their parenting experience.

Development of an App for Tracking Family Engagement With Early Intervention Services: Focus Groups and Pilot Evaluation Study

BACKGROUND

Expedient access to early intervention (EI) systems has been identified as a priority for children with developmental delays, identified disabilities, and other special health care needs. Despite the mandated availability of EI, it remains challenging for families to navigate referral processes and establish appropriate services. Such challenges disproportionately affect families from traditionally underserved communities. Mobile health apps can improve clinical outcomes, increase accessibility to health services, and promote adherence to health-related interventions. Though promising, the implementation of apps within routine care is in its infancy, with limited research examining the components of what makes an effective app or how to reach families most impacted by inequities in health care delivery.

OBJECTIVE

In study 1, we conducted focus groups to access a broad range of perspectives on the process of navigating the EI system, with the dual goals of identifying ways in which a patient-facing app might facilitate this process and identifying barriers to use with traditionally underrepresented and underserved groups. In study 2, focus group findings informed the development of a patient-facing app, which was subsequently tested with a pilot sample of 5 families.

METHODS

In study 1, the focus groups included 29 participants from 4 shareholder groups. Targeted sampling was used to recruit participants from traditionally underrepresented groups. Focus group questions sought information about barriers families experience as they navigate the EI system, ideal features of a patient-facing app designed to track family engagement with the EI system, and potential barriers. Focus group procedures were informed by the Consolidated Framework for Implementation Research framework. In study 2, a pilot app was developed. The app was tested with a sample of 5 families of young children involved in the EI system. Families provided information on app functionality and usability.

RESULTS

Qualitative analysis revealed a desire for increased communication and information about the process of accessing EI services, potential utility of an app for communication purposes, and clear recommendations for app features. Insights from focus groups were used to inform the development of the Family on Track app and related implementation supports. App features included survey customization, timing and delivery of prompts, and questions related to barriers and service satisfaction. Implementation supports include a visual guide for app installation, resources related to common family questions, and availability of study personnel to guide families through installation and provide ongoing support. Field testing provided preliminary information about app usability, including identifying future directions.

CONCLUSIONS

The results of this study could support the development of a new way for the EI system to communicate and connect with families, provide families with a means to communicate satisfaction and frustration, and access the supports they need to be active participants in their child's care.

Exploring contextual adaptations in caregiver interventions for families raising children with developmental disabilities

There are increasing efforts to scale up services globally for families raising children with developmental disabilities (DDs). Existing interventions, often developed in high income, Western settings, need substantial adaptation before they can be implemented in different contexts. The aim of this study was to explore perspectives on the role that context plays in the adaptation and implementation of interventions targeting caregivers of children with DDs across settings. The study question was applied to the Caregiver Skills Training (CST) programme of the World Health Organization specifically, as well as to stakeholder experiences with caregiver interventions more broadly. Two focus group discussions (FGDs; n = 15 participants) and 25 individual semi-structured interviews were conducted. Participants were caregivers of children with DDs and professionals involved in adapting or implementing the CST across five continents and different income settings. Data were analysed thematically. Four main themes were developed: 1) Setting the scene for adaptations; 2) Integrating an intervention into local public services; 3) Understanding the reality of caregivers; 4) Challenges of sustaining an intervention. Informants thought that contextual adaptations were key for the intervention to fit in locally, even more so than cultural factors. The socio-economic context of caregivers, including poverty, was highlighted as heavily affecting service access and engagement with the intervention. Competing health priorities other than DDs, financial constraints, and management of long-term collaborations were identified as barriers. This study validates the notion that attention to contextual factors is an essential part of the adaptation of caregiver interventions for children with DDs, by providing perspectives from different geographical regions. We recommend a stronger policy and research focus on contextual adaptations of interventions and addressing unmet socio-economic needs of caregivers.

Technology-assisted task-sharing to bridge the treatment gap for childhood developmental disorders in rural Pakistan: an implementation science case study

Background

As in many low-income countries, the treatment gap for developmental disorders in Pakistan is nearly 100%. The World Health Organization (WHO) has developed the mental Health Gap Intervention guide (mhGAP-IG) to train non-specialists in the delivery of evidence-based mental health interventions in low-resource settings. However, a key challenge to scale-up of non-specialist-delivered interventions is designing training programs that promote fidelity at scale in low-resource settings. In this case study, we report the experience of using a tablet device-based application to train non-specialist, female family volunteers in leading a group parent skills training program, culturally adapted from the mhGAP-IG, with fidelity at scale in rural community settings of Pakistan.

Methods

The implementation evaluation was conducted as a part of the mhGAP-IG implementation in the pilot sub-district of Gujar Khan. Family volunteers used a technology-assisted approach to deliver the parent skills training in 15 rural Union Councils (UCs). We used the Proctor and RE-AIM frameworks in a mixed-methods design to evaluate the volunteers’ competency and fidelity to the intervention. The outcome was measured with the ENhancing Assessment of Common Therapeutic factors (ENACT), during training and program implementation. Data on other implementation outcomes including intervention dosage, acceptability, feasibility, appropriateness, and reach was collected from program trainers, family volunteers, and caregivers of children 6 months post-program implementation. Qualitative and quantitative data were analyzed using the framework and descriptive analysis, respectively.

Results

We trained 36 volunteers in delivering the program using technology. All volunteers were female with a mean age of 39 (± 4.38) years. The volunteers delivered the program to 270 caregivers in group sessions with good fidelity (scored 2.5 out of 4 on each domain of the fidelity measure). More than 85% of the caregivers attended 6 or more of 9 sessions. Quantitative analysis showed high levels of acceptability, feasibility, appropriateness, and reach of the program. Qualitative results indicated that the use of tablet device-based applications, and the cultural appropriateness of the adapted intervention content, contributed to the successful implementation of the program. However, barriers faced by family volunteers like community norms and family commitments potentially limited their mobility to deliver the program and impacted the program’ reach.

Conclusions

Technology can be used to train non-specialist family volunteers in delivering evidence-based intervention at scale with fidelity in low-resource settings of Pakistan. However, cultural and gender norms should be considered while involving females as volunteer lay health workers for the implementation of mental health programs in low-resource settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00343-w.

Inequities in Receipt of the North Carolina Medicaid Waiver Among Individuals with Intellectual Disability or Autism Spectrum Disorder

OBJECTIVE

We examined characteristics associated with receiving the North Carolina Home and Community-Based Services Waiver for intellectual and developmental disabilities (I/DDs) and its association with emergency department (ED) utilization.

METHOD

Through analysis of the North Carolina 2017 to 2018 Medicaid claims and enrollment data, we examined characteristics (age, sex, race and ethnicity, geography, diagnosis (intellectual disability [ID] with or without autism spectrum disorders or autism spectrum disorder without ID) associated with receiving the NC I/DD Waiver and the association of this Wavier with ED utilization. We identified patients with at least 1 International Classification of Diseases-10-CM diagnosis code for an ID or autism spectrum disorder. We excluded patients with missing county information and whose enrollment in the NC I/DD Waiver program began after October 1, 2017.

RESULTS

Only 22% of 53,531 individuals with I/DD in North Carolina received the Waiver. Non-Hispanic Blacks and Hispanic individuals were less likely to receive the Waiver than non-Hispanic White individuals. Adults (>21 years old), men, and urban residents were more likely to receive the Waiver. Individuals who received the Waiver were 31% less likely to use the ED.

CONCLUSION

Innovative strategies are needed to provide equitable access to the NC I/DD Waiver and provide services to the 14,000 people with I/DD currently waiting to receive the Waiver. Through the Waiver, those with I/DD can access preventative and therapeutic outpatient services and decrease their need for ED care. These findings highlight the need for policy reform to address inequities in access to the Waiver for individuals with I/DD.

Mental Health and Health Behaviour Changes for Mothers of Children with a Disability: Effectiveness of a Health and Wellbeing Workshop

Healthy Mothers Healthy Families (HMHF) is a program that educates and empowers mothers of children with disabilities to improve health behaviours. Outcomes were investigated in this study. A pre, post-test design was implemented using online questionnaires including the Health promoting activities scale (HPAS) and the Depressional anxiety stress scales (DASS). Mothers (N = 71) experienced improvements in HPAS scores, p < .001. Mental health symptomatology reduced: depressive symptoms (p = .005), Anxiety symptoms (p = .005) and stress (p = .002). Wellbeing improved (p < .001). Mothers also reported that their child with a disability experienced an increase in quality of life (p = .042). Mothers' lifestyles goals improved: managing stress; dietary changes; leisure; self-perception and others. HMHF is an effective intervention with improved health status and outcomes for mothers.

A comparison of the performance of normal middle social class Egyptian infants and toddlers with the reference norms of the Bayley Scales -third edition (Bayley III): A pilot study

BACKGROUND

Developmental assessment is an important facility for early detection and intervention of developmental delay in children. Objective: to assess the performance of a sample of middle social class Egyptian infants and toddlers on Bayley Scales of Infant and Toddler Development-third edition (Bayley III), and to compare their cognitive, motor, and communication scores with that of the reference norms.

METHODS

It was a cross-sectional pilot study, included 270 children aged 18-42 months. Mothers filled a questionnaire including questions about family socioeconomic background, perinatal history, and family history. Physical examination and growth assessment of children were performed. Developmental assessment of cognitive, language and motor skills was performed using the Bayley III scales and compared the American norm scores with the Egyptian mean scores.

RESULTS

The mean cognitive, language and motor composite scores were 92.5+18.5, 91.76+ 15.6, and 95.67+18.9 respectively. All were lower than the American mean (100+ 15) with highly significant differences. About one-fourth of the enrolled Egyptian children had below-average composite scores according to the US cutoff point. The ranks of Egyptian children on the American versus the Egyptian percentile curves were significantly different.

CONCLUSION

Mean values of all assessed developmental domains of Egyptian children are within the norm-referenced average of Bayley III, but lower than the recorded American mean. Assessing Egyptian children according to the American norms may result in overestimating developmental delay. This pilot study raised the question about using different cutoff points suitable for the developmental trajectory of Egyptian children. Answering this question needs further studies on Bayley-III after cultural adaptation and standardization, using a larger, more diverse, and representative sample of the Egyptian population.

A comparison of the performance of normal middle social class Egyptian infants and toddlers with the reference norms of the Bayley Scales -third edition (Bayley III): A pilot study

Background

Developmental assessment is an important facility for early detection and intervention of developmental delay in children. Objective: to assess the performance of a sample of middle social class Egyptian infants and toddlers on Bayley Scales of Infant and Toddler Development-third edition (Bayley III), and to compare their cognitive, motor, and communication scores with that of the reference norms.

Methods

It was a cross-sectional pilot study, included 270 children aged 18–42 months. Mothers filled a questionnaire including questions about family socioeconomic background, perinatal history, and family history. Physical examination and growth assessment of children were performed. Developmental assessment of cognitive, language and motor skills was performed using the Bayley III scales and compared the American norm scores with the Egyptian mean scores.

Results

The mean cognitive, language and motor composite scores were 92.5+18.5, 91.76+ 15.6, and 95.67+18.9 respectively. All were lower than the American mean (100+ 15) with highly significant differences. About one-fourth of the enrolled Egyptian children had below-average composite scores according to the US cutoff point. The ranks of Egyptian children on the American versus the Egyptian percentile curves were significantly different.

Conclusion

Mean values of all assessed developmental domains of Egyptian children are within the norm-referenced average of Bayley III, but lower than the recorded American mean. Assessing Egyptian children according to the American norms may result in overestimating developmental delay. This pilot study raised the question about using different cutoff points suitable for the developmental trajectory of Egyptian children. Answering this question needs further studies on Bayley-III after cultural adaptation and standardization, using a larger, more diverse, and representative sample of the Egyptian population.

Maternal and child factors associated with the health-promoting behaviours of mothers of children with a developmental disability

BACKGROUND/AIM

Mothers caring for their child or adult with a developmental disability can experience mental health disparity. Protective factors such as healthy behaviours are under-researched. This study investigated relationships between mental health, healthy behaviours, and disability factors.

METHODS

The cross-sectional online survey included: Depression Anxiety Stress Scales (DASS); Family Empowerment Scale (FES); Health Promoting Activities Scale (HPAS); and a measure of childhood quality of life (QoL).

RESULTS

All mothers were raising offspring (aged 3-36 years) with a developmental disability. Fifty-two percent of mothers (N = 81) had a mental health diagnosis. DASS scores were elevated for depression (58 %), anxiety (52 %) and stress (68 %). Mothers participated in health promoting activities infrequently and reported low satisfaction with community health-supporting facilities. Depressive symptoms, maternal empowerment and two indicators of child-related QoL explained 29.7 % of the variance in healthy behaviours. Depressive symptoms were the most important predictor of lack of health promoting behaviours.

CONCLUSIONS

Better mental health predicted more frequent participation in health promoting behaviour. Future research might explore the extent to which health promoting behaviours protect mental health. Service changes including family health focused services, and custom designed health promotion or coaching programs may improve the health behaviours of mothers with high care responsibilities.

Profile of Mothers of Children with a Disability Who Seek Support for Mental Health and Wellbeing

This paper investigated the characteristics of mothers of children with a disability who registered for a mental health and wellbeing workshop. The questionnaire measured mental health, health-related behaviours, empowerment, family cohesion, wellbeing and child-related variables. Regression analysis identified factors associated with depressive symptoms and positive wellbeing. Fifty-seven percent of participants (N = 171) had depressive symptoms within the clinical range. Higher symptoms were associated with reduced: empowerment (r = - .39, p < .01); positive-wellbeing (r = - .66, p < .05); and healthy activity (r = - .41, p < .001). Low positive wellbeing (β = .55, p < .001) was the strongest predictor of depressive symptoms. Family cohesion (β = .25, p < .001), was the strongest predictor of positive-wellbeing. Future health and wellbeing interventions that support mothers with high care responsibilities should include psycho-education and strategies to address healthy maternal and family-related behaviour changes.

Early intervention for children with developmental disabilities in low and middle-income countries - the case for action

In the last two decades, the global community has made significant progress in saving the lives of children <5 y of age. However, these advances are failing to help all children to thrive, especially children with disabilities. Most early child development research has focussed on the impact of biological and psychosocial factors on the developing brain and the effect of early intervention on child development. Yet studies typically exclude children with disabilities, so relatively little is known about which interventions are effective for this high-risk group. In this article we provide an overview of child development and developmental disabilities. We describe family-centred care interventions that aim to provide optimal stimulation for development in a safe, stable and nurturing environment. We make the case for improving opportunities for children with developmental disabilities to achieve their full potential and thrive, including through inclusive early childhood development intervention. Finally, we call for the global research community to adopt a systematic approach for better evidence for and implementation of early interventions for children with developmental disabilities in low-resource settings.

Mothers' perspectives on the influences shaping their early experiences with infants at risk of cerebral palsy in India

BACKGROUND

Accurate diagnosis of cerebral palsy (CP) high-risk status is now possible in infants less than six months corrected age. Parents play a central role in providing nurturing care and implementing early intervention approaches. To design interventions tailored to needs of parents and understand how to improve parental support, this study aimed to understand the influences shaping parent experiences with an infant at high-risk of CP in West Bengal, India.

METHODS AND PROCEDURES

This phenomenological qualitative study was conducted with parents of infants at high-risk of CP in West Bengal, India. Individual in-depth interviews explored experiences with health providers, supports for caregiving and challenges of parenting. Interviews were conducted in English with concurrent translation and analysed using thematic analysis.

OUTCOMES AND RESULTS

Main themes included: limited finances and social networks shape decisions and caregiving practices; trust in the formal health care system; views of disability including explanations for their infant's condition and expectations for the child's future, and everyday adaptations required to meet infants' needs.

CONCLUSIONS AND IMPLICATIONS

Low cost models of early intervention may alleviate the financial burden and stress on families. Dependence on health care professionals for care management is a barrier to family-delivered approaches to care.

Developmental Signs of Autism Spectrum Disorder in Iranian Pre-Schoolers

PURPOSE

Early identification and intervention is recommended for developmental disabilities such as autism spectrum disorders (ASD). Various screening tools are available, but most were developed in affluent English speaking countries.

DESIGN AND METHODS

In order to identify possible early signs of ASD within Iranian society, parents of 623 children in an age range from 3 to 7 years of age at risk of ASD, were interviewed about the signs that alerted their concerns. Also two screening instruments were developed and tested with the parents using items derived from the Gilliam Autism Rating Scale (GARS2). One focused on autistic behaviors and the second on developmental indicators.

RESULTS

Using both tools, 93% of the children who were identified as likely to have ASD based on a full GARS assessment were identified using the two screening tools.

PRACTICE IMPLICATIONS

These assessments might be used in initial screening for ASD by early year's personnel or public health professionals with Iranian parents of toddlers who have concerns about their child's development.

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.

Fathers of children with a disability: health, work, and family life issues

PURPOSE

Fathers in families raising children with disabilities are under-researched. Fathers' perspectives can be better accommodated in childhood disability services that operate on a family-centred paradigm if their perspectives are understood. This study aimed to investigate the perspectives of fathers on caring and family life, work, and health.

METHODS

A mixed-methods design with an online questionnaire included open-ended questions and three instruments: Depression Anxiety Stress Scales (DASS); Health Promoting Activities Scale (HPAS-M); Fathers of Children with Developmental Challenges (FCDC) Scale.

RESULTS

Fathers (n = 33) reported high depressive (58%), anxiety (37%), and stress symptoms (61%). Fathers reported low participation in health-promoting activity with less than weekly: planning health activities (58%); solo physical activity (26%); social activity (3%); time relaxing (16%). Sixty-four percent worked full-time, although work was reported to be challenged by family responsibilities. Fathers described directly caring for their children although service interactions were low and delegated to mothers.

CONCLUSIONS

Fathers in this study reported stress, mental health issues, and low participation in healthy activity. Fathers experienced challenges related to career progression and job choices due to family responsibilities. Providing individualised and responsive support to fathers of a child with a disability would better support the family unit.IMPLICATIONS FOR REHABILITATIONFathers of children with a disability in this study experienced high mental health symptoms.Fathers were involved with their child's care at home but had low service interactions suggesting that service providers need to discover new ways to better engage fathers.Fathers experienced challenges to participation in paid work secondary to care responsibilities for their child with a disability and resulting needs of their family.Services that better support fathers are important to promote better health and wellbeing and support families.

Early-onset developmental impairments among infants attending the routine immunization clinic at the University College Hospital, Ibadan, Nigeria

Developmental disorders are frequently overlooked in the developing countries, particularly in sub-Saharan Africa. Early identification of developmental delays (DDs) is critical to optimal outcomes. This study set out to determine the proportion of children who are at risk of DDs among infants attending immunization clinics at the University College Hospital, Ibadan, Nigeria. Infants 6 weeks to 12 months of age (median age 6 months) who presented for routine immunization were screened for DDs using the Ages and Stages Questionnaire. A total of 587 infants [312 (53.2%) males] were enrolled. A total of 198 (33.7%) children showed signs of DDs. For the domains of communication skills, fine motor skills, gross motor skills, problem solving/cognition skills and personal/social skills, the prevalences of DDs were 7.5%, 15.0%, 10.7%, 14.1% and 14.8%, respectively, and 14.3% had global DDs. Factors that significantly predicted DDs included prematurity (odds ratio [OR] 2.64 [95% confidence interval {CI} 1.45 to 2.05]) and a history of perinatal asphyxia (OR 1.74 [95% CI 1.77 to 2.49]). There is a need to incorporate routine developmental screening into the Nigerian healthcare system for timely recognition of DDs and prompt interventions.

Mental Health and Health Behaviour Changes for Mothers of Children with a Disability: Effectiveness of a Health and Wellbeing Workshop

Healthy Mothers Healthy Families (HMHF) is a program that educates and empowers mothers of children with disabilities to improve health behaviours. Outcomes were investigated in this study. A pre, post-test design was implemented using online questionnaires including the Health promoting activities scale (HPAS) and the Depressional anxiety stress scales (DASS). Mothers (N = 71) experienced improvements in HPAS scores, p < .001. Mental health symptomatology reduced: depressive symptoms (p = .005), Anxiety symptoms (p = .005) and stress (p = .002). Wellbeing improved (p < .001). Mothers also reported that their child with a disability experienced an increase in quality of life (p = .042). Mothers’ lifestyles goals improved: managing stress; dietary changes; leisure; self-perception and others. HMHF is an effective intervention with improved health status and outcomes for mothers.

Commentary: Challenges and opportunities in autism assessment - a commentary on Kanne and Bishop (2020)

Kanne and Bishop's (2020) Editorial Perspective 'The Autism waitlist crisis and remembering what families need' offers a strong argument to provide greater access to high-quality assessments for Autism Spectrum Disorder (ASD). They note, correctly, that due to increasing numbers of referrals practitioners are under increasing pressure to provide quicker or abbreviated evaluations, that some cases are extremely complex and require considerable expertise to assess, and that a good assessment is a good investment in effective intervention. I agree with these points but also want to highlight some difficulties and dilemmas associated with the assessment of ASD; and to argue that improving access to assessments and interventions through the use of nonspecialists and new technologies may be a promising direction.

Fostering Inter-Professional Education through Service Learning: The Belize Experience

Service-learning and interprofessional education are forms of experiential learning that instill confidence in students. This pilot study used a post-service learning survey to explore the benefits of interprofessional education in a service-learning experience with students. Findings indicated that this service-learning experience contributed to the development of cultural awareness, and professional skills, as well as increased team attitudes and perceptions related to the respective roles of occupational and physical therapy students. The following report describes students' perspectives and satisfaction concerning professional development, interprofessional education, and cultural awareness utilizing quantitative and qualitative descriptors.

Identification of developmental disorders including autism spectrum disorder using salivary miRNAs in children from Bosnia and Herzegovina

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by major social, communication and behavioural challenges. The cause of ASD is still unclear and it is assumed that environmental, genetic and epigenetic factors influence the risk of ASD occurrence. MicroRNAs (miRNAs) are short 21-25 nucleotide long RNA molecules which post-transcriptionally regulate gene expression. MiRNAs play an important role in central nervous system development; therefore, dysregulation of miRNAs is connected to changes in behaviour and cognition observed in many disorders including ASD. Based on previously published work, on diagnosing ASD using miRNAs, we hypothesized that miRNAs can be used as biomarkers in children with suspected developmental disorders (DD) including ASD within Bosnian-Herzegovinian (B&H) population. 14 selected miRNAs were tested on saliva of children with suspected developmental disorders including ASD. The method of choice was qRT-PCR as a relatively cheap method available in most diagnostic laboratories in low to mid-income countries (LMIC). Out of 14 analysed miRNAs, 6 were differentially expressed between typically developing children and children with some type of developmental disorder including autism spectrum disorder. Using the most optimal logistic regression, we were able to distinguish between ASD and typically developing (TD) children. We have found 5 miRNAs as potential biomarkers. From those, 3 were differentially expressed within the ASD cohort. All 5 miRNAs had shown good chi-square statistics within the logistic regression performed on all 14 analysed miRNAs. The accuracy of 5-miRNAs model training set was 90.2%, while the validation set had a 90% accuracy. This study has shown that miRNAs may be considered as biomarkers for ASD detection and may be used to identify children with ASD along with standard developmental screening tests. By combining these methods we may be able to reach a reliable and accessible diagnostic model for children with ASD in LMIC such as B&H.

Strengthening Health Systems to Support Children with Neurodevelopmental Disabilities in Fiji-A Commentary

Supporting children with neurodevelopmental disabilities (NDDs) is recognized as an increasing priority in Fiji, a middle-income Pacific Island country. Our objective was to describe our approach to developing a model of care and strengthening local leadership in developmental paediatrics in Fiji to ensure high-quality identification, assessment and management of children with NDDs. Paediatric staff at Colonial War Memorial (CWM) Hospital in Suva have worked in partnership with Australian paediatricians to develop the model of care. The platform of continuing medical education during biannual 3 to 4 days of clinic-based teaching with visiting developmental paediatricians from Australia has been used. Since 2010, there have been 15 local and regional paediatric trainees trained. Since 2015, our two local lead paediatric trainees have run a weekly local developmental clinic. In total, 370 children aged 0 to 18 with NDDs have been comprehensively assessed with a detailed history and standardised tools. The model is extending to two divisional hospitals. Research engagement with the team is resulting in the development of a local evidence base. Local, regional and international leadership and collaboration has resulted in increased capacity in the Fijian health system to support children with NDDs.

Anxiety and depression among caregivers of young children with Congenital Zika Syndrome in Brazil

PURPOSE

To examine the psychological well-being of primary caregivers of infants and toddlers with Congenital Zika Syndrome (CZS), and the roles of family resources, parenting stress, and coping strategies in caregivers' adaptation.

MATERIALS AND METHODS

Family caregivers (N = 50) of children with CZS who were receiving treatment at a rehabilitation hospital in Recife, Brazil participated a cross-sectional survey study. Caregivers completed measures of anxiety and depression, coping strategies, family resources, and parenting stress.

RESULTS

Mild to severe symptoms of depression were identified in 40% of caregivers and were a more prominent concern than symptoms of anxiety. Fewer family resources and high levels of parenting stress were significantly associated with both anxiety and depression. The association between parenting stress and depression was moderated by coping, such that parenting stress was associated with higher caregiver depression at low but not high levels of coping strategy use.

CONCLUSIONS

Practitioners in Brazil should consider the role of family coping and resources as important resilience promoting factors in the development of new programs designed to promote psychological adaptation in caregivers to children with CZS. It is recommended that caregiver mental health support services be integrated into existing early intervention programs targeting children with CZS.Implications for RehabilitationParents and other primary caregivers are encouraged to take an active role in the care and developmental monitoring of children born with CZS, but their ability to provide care may be compromised by difficulties in psychological adaptation.Moderate and severe symptoms of depression were more prominent in caregivers than moderate and severe symptoms of anxiety (20% versus 6%, respectively).Practitioners should include assessment of coping strategies, parenting stress and family resources conjointly with evaluation of symptoms of depression and anxiety as part of routine CZS family evaluations.A useful approach for caregivers in Brazil may be to more fully integrate caregiver mental health support services into existing early intervention programs for children with CZS.

Nurturing care framework for inclusive early childhood development: opportunities and challenges

The nurturing care framework (NCF) for early childhood development (ECD) launched at the 2018 World Health Assembly opens a range of opportunities and challenges for child neurodisability professionals. The United Nations Convention on the Rights of the Child and Convention on the Rights of People with Disabilities frame these pathways for collaboration and progress. This overview of the NCF and its contexts in inclusive ECD identifies avenues for innovation and collaboration in harmony with the field's clinical, scientific, and advocacy agendas. One avenue involves enhancing the alignment between health systems and human rights. A second avenue involves neurodisability professionals engaging with nurturing care as leaders, partners, and implementers. WHAT THIS PAPER ADDS: Participation and leadership by neurodisability professionals can enhance quality and impact. A rights-based framework that includes young children with disabilities and their families is widely encouraged.

Awareness and Knowledge Associated with Autism Spectrum Disorders Among University Students in Zambia

Experiences with Autism Spectrum Disorders (ASDs) in sub-Saharan Africa are characterized with lots of uncertainty, including lack of awareness and knowledge. This study examined ASD awareness and knowledge among 488 University of Zambia undergraduate students using an autism awareness and knowledge survey. Study findings on awareness revealed a high proportion of students-seventy-nine percent (79%) had never heard of ASD before the survey. Significant variation in aspects of ASD knowledge was explained by gender, having children, internet use and school of study. Implications of low levels of ASD awareness and knowledge is a call to invest in ASD awareness campaigns through different platforms in order to promote ASD knowledge that translates into increased ASD understanding for better service provision in Zambia.

"A child who is hidden has no rights": Responses to violence against children with disabilities

BACKGROUND

There is an urgent need to understand how best to prevent and respond to violence against children with disabilities as they are at a high risk for violence because they are marginalized, isolated, and targeted and have little power within their communities.

OBJECTIVE

Guided by social-ecological theory, this study explores responses to violence against children with disabilities, including preventative measures and treatment of victims in the West African countries of Guinea, Niger, Sierra Leone, and Togo.

PARTICIPANTS

Participants were recruited using purposive and snowball sampling from the following three groups: disability stakeholders including representatives from local, national, and international organizations and governments; community members including parents, teachers, and leaders; and children with disabilities.

METHODS

A qualitative study design guided data generation, that included document analysis, semi-structured interviews, and focus groups across the four countries. In total, 419 people participated. Of those participants, 191 took part in an interview and the rest participated in one of 55 focus groups.

FINDINGS

Responses to disability-based violence are driven at the mesosystem and exosystem levels. Prevailing views indicated that national level policies and laws are not always considered part of solutions, communities are leading responses to violence, and children with disabilities are hidden at home or in institutions for both their own and their family's safety. Conclusions The findings can inform development of prevention and intervention programs that will protect children with disabilities from violence in contexts with high levels of disability stigma, social conflict, violence, and poverty.

Reflections on Health Promotion and Disability in Low and Middle-Income Countries: Case Study of Parent-Support Programmes for Children with Congenital Zika Syndrome

Universal health coverage (UHC) has been adopted by many countries as a national target for 2030. People with disabilities need to be included within efforts towards UHC, as they are a large group making up 15% of the world's population and are more vulnerable to poor health. UHC focuses both on covering the whole population as well as providing all the services needed and must include an emphasis on health promotion, as well as disease treatment and cure. Health promotion often focusses on tackling individual behaviours, such as encouraging exercise or good nutrition. However, these activities are insufficient to improve health without additional efforts to address poverty and inequality, which are the underlying drivers of poor health. In this article, we identify common challenges, opportunities and examples for health promotion for people with disabilities, looking at both individual behaviour change as well as addressing the drivers of poor health. We present a case study of a carer support programme for parents of children with Congenital Zika Syndrome in Brazil as an example of a holistic programme for health promotion. This programme operates both through improving skills of caregivers to address the health needs of their child and tackling poverty and exclusion.

Thailand's national universal developmental screening programme for young children: action research for improved follow-up

Introduction

In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening.

Methods

Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers.

Results

The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments.

Conclusion

Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.