Developmental screening in South Africa: comparing the national developmental checklist to a standardized tool

Neurological examination of healthy term infants at ages 6 and 10 weeks in Tshwane District

Background

Globally, there is a significant gap in detailed neurodevelopmental data for infants under 3 months, despite 6 weeks being identified a critical milestone for neuro-behavioural development. Normative values and optimal scores for healthy infants at 6 and 10 weeks postnatally are lacking in many settings. In South Africa, the statutory neurodevelopmental assessments at these ages exclude notable characteristics of central nervous system maturation and limit opportunities to collect data of early developmental progress.

Objectives

Our study aimed to assess developmental characteristics of healthy term infants aged 6 and 10 weeks using the Hammersmith Neonatal Neurological Examination (HNNE).

Method

A prospective longitudinal study was performed on 35 healthy term-born infants from low-risk pregnancies at 6 and 10 weeks' postnatal age in the Tshwane district. The statuses of infants' neurodevelopment in six domains were recorded using the HNNE. Optimality scores were derived from the raw scores of 34 items, using the 10th and 5th percentiles as cut-off points.

Results

Evidences of neurodevelopmental advancements, particularly in posture, muscle tone and visual behaviour between 6 and 10 weeks were illustrated, and total examination optimality scores of 29.5 in 91% and 31.5 in 94% of infants were recorded at 6 and 10 weeks, respectively.

Conclusion

This article provides data on the neurodevelopment characteristics of infants at and between 6- and 10-weeks post term ages.

Clinical Implications

The findings support the viewpoint to identify important milestone characteristics during early screening.

Disability Inclusion in the National Strategic Plan for HIV/AIDS: A Review on the National Response of West African Countries

Objectives

Persons with disabilities (PWD) often experience risks associated with HIV/AIDS including unmet needs and overlooked stigmatization. This could be attributed to certain misconceptions such as PWDs are asexual, and cannot enjoy sexual pleasure, among others. Therefore, this paper sought to investigate the extent of disability inclusion in recent National Strategic Plans (NSPs) for HIV/AIDS in West African countries.

Methods

This study was a policy review of NSPs in 13 African countries. Relevant indicators in the UN Convention on the Rights of Persons with Disabilities and the UNAIDS International Guidelines on HIV and Human Rights were used. Six indicators (identification of people living with disability (PLWD) as a key population, the inclusion of principles related to PWD within the NSPs on HIV/AIDS, protecting the rights of PWD, recognition of PWD as a vulnerable population at higher risk of HIV and in need of special protection, providing HIV-related support services for PWD and monitoring and evaluating the impact of HIV on PWD).

Results

Findings from this study revealed that only 30% of West African countries recognized disability as an issue of concern. Also, 38.5% of these countries recognize the vulnerability of people with disabilities to HIV. However, only a few (7.6%) provided support in the context of special needs, monitoring, and surveillance specifically for persons with disabilities.

Conclusion

Most of the West African NSPs are outdated and due for renewal. Therefore, it is necessary to integrate the needs of persons with disabilities within the context of HIV/AIDS in the NSPs. More importantly, support and services should also be prioritized among the vulnerable groups to optimize inclusion.

Assessing the need for a standardised paediatric assessment tool for podiatrists in South Africa

There is no literature to support the existence of an effective standardised assessment tool in South Africa that aids the podiatrist in the early diagnosis of developmental delay in the paediatric patient from age one to five. Podiatrists in South Africa (SA) need a suitable assessment tool to evaluate child development. A potential proforma that could be used by South African podiatrists is the Gait and Lower Limb Observation Proforma (GALLOP) Assessment Tool.

AIM

The aim of this research was to evaluate the "ease of use" and "usefulness" of the GALLOP Assessment Tool for podiatrists to effectively assess the paediatric patient from age one to age five.

METHODS

The study was of a mixed methods descriptive design type, targeting all Health Professions Council of South Africa (HPCSA) registered podiatrists in the Johannesburg Metropolitan Municipal area. After allowing the participants to use the GALLOP Assessment Tool for a period of time, a survey was conducted to establish the "ease of use" and "usefulness" of the GALLOP Assessment Tool.

RESULTS

All participants agreed that the GALLOP Assessment Tool would be beneficial to South African podiatrists and that the assessment tool does not need to be improved upon.

Exploring swallowing, feeding and communication characteristics of toddlers with severe acute malnutrition

BACKGROUND

 Severe acute malnutrition (SAM) is associated with cognitive and motor deficits. Little is known about the swallowing, feeding and communication characteristics of hospitalised toddlers with SAM, limiting the abilities of speech-language therapists to provide effective early intervention.

OBJECTIVE

 To explore the background, swallowing, feeding and communication characteristics of toddlers with SAM during in-patient nutritional rehabilitation.

METHOD

 An exploratory, prospective, collective case-study was conducted with three hospitalised toddlers who were 12-18 months old and independently diagnosed with SAM, at least 1 week after transitioning to oral feeding. Detailed case histories were compiled through medical file perusal and parent interviews. Cross-sectional clinical bedside assessments were completed with the Rossetti Infant-Toddler Language Scale and Schedule for Oral-Motor Assessment.

RESULTS

 All three participants had a history of feeding difficulties before admission. Despite intact pharyngeal swallows, heterogeneous oral-sensorimotor dysfunction and disruptive feeding behaviours were identified. Risk for oropharyngeal dysphagia indicates the need to modify dietary consistencies to prevent prolonging recovery or SAM relapse. Participants had mild-to-moderate language delays, particularly in interaction-attachment, play and language comprehension, with an atypical moderate receptive and mild expressive language delay profile. None of the participants were referred for speech-language therapy.

CONCLUSION

 This exploratory research showed the oral-sensorimotor skills, swallowing and communication characteristics of children with SAM. Speech-language therapists could address oral-sensorimotor functioning, feeding difficulties and communication interaction delays before discharge to community-based management for SAM. Further investigation with a larger sample size is recommended.Contribution: Novel description of the oral-sensorimotor skills for feeding and the communication development of three severely malnourished toddlers with HIV and tuberculosis co-infection was presented. The complexity of the three cases is highlighted.

Role of Pediatricians, Pediatric Associations, and Academic Departments in Ensuring Optimal Early Childhood Development Globally: Position Paper of the International Pediatric Association

ABSTRACT

Early childhood (birth-8 years), particularly the first 3 years, is the most critical time in development because of the highly sensitive developing brain. Providing appropriate developmental care (i.e., nurturing care, as defined by the World Health Organization [WHO]) during early childhood is key to ensuring a child's holistic development. Pediatricians are expected to play a critical role in supporting early childhood development (ECD) through providing developmental services such as developmental monitoring, anticipatory guidance, screening, and referral to medical and/or community-based services when delay is identified. Pediatricians are also expected to serve as advocates within their clinics and communities for improved delivery of ECD services, such as advocating for increasing funding for ECD initiatives, increasing insurance coverage of ECD services, and working to increase other pediatricians' awareness of the principles of ECD and how to deliver developmental services. However, this does not always occur. Typically, pediatricians' training and practice emphasizes treating disease rather than enhancing ECD. Pediatricians are further hindered by a lack of uniformity across nations in guidelines for developmental monitoring and screening. In this article, we present the vision of the International Pediatric Association (IPA) of the roles that pediatricians, academic departments, medical training programs, and pediatric associations should fulfill to help support ECD, including raising ECD to higher levels of priority in routine pediatric care. First, we present the challenges that face these goals in supporting ECD. We then propose, with supportive literature, strategies and resources to overcome these challenges in collaboration with local and international stakeholders, including the IPA, the WHO, UNICEF, and the World Bank.

Screening for Intellectual Disabilities and/or Autism Amongst Older Children and Young Adults: a Systematic Review of Tools for Use in Africa

There are many well-developed screening tools for both intellectual disabilities and autism, but they may not be culturally appropriate for use within Africa. Our specific aims were to complete a systematic review to (1) describe and critically appraise short screening tools for the detection of intellectual disabilities and autism for older children and young adults, (2) consider the psychometric properties of these tools, and (3) judge the cultural appropriateness of these tools for use within Africa. Six screening tools for intellectual disabilities and twelve for autism were identified and appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. We identified two screening tools which appeared appropriate for validation for use within African nations.

mHealth developmental screening for preschool children in low-income communities

Children are often only identified with a developmental delay when they enter primary school due to developmental delays hindering academic progress. Detection of at-risk children in low-income communities is typically unavailable due to several challenges. This study validated an mHealth-based developmental screening tool as a potential time- and cost-effective way of delivering services for preschool children. This cross-sectional within-subject study screened 276 preschool children from low-income communities using the mHealth Parents' Evaluation of Developmental Status (PEDS) tools. The mHealth PEDS tools' performance was then evaluated by comparing caregiver concerns according to the PEDS tools with results obtained using a reference standard assessment tool, the Vineland-3. The mHealth PEDS tools identified 237 (85.9%) of children at risk of developmental delay compared to 80.1% (n = 221) of children identified with a developmental delay using the Vineland-3. Sensitivity of the PEDS tools was high (92.6%) with low specificity (22.5%) using US standardised criteria. Literacy skills were found to be most delayed, according to the PEDS: DM (89.3%; n = 142) and Vineland-3 (87.1%; n = 134). Low specificity of the prescribed criteria may require the implementation of adapted referral criteria within low socio-economic status (SES) settings. The mHealth PEDS tools may still be valuable for preschool developmental surveillance of children within low SES settings. It is recommended, however, that children who are identified with a developmental concern undergo a second screen to reduce false positives.

Developmental delay in a resource-constrained environment: Screening, surveillance and diagnostic assessment

The range and severity of developmental delays vary, and a systematic approach to ensuring early detection for early intervention is essential. The formative years are considered critical for nurturing and maximising developmental potential. In this article, the authors describe a clinical approach to developmental delay within resource-constrained environments of South Africa. The article unpacks the history and examination, developmental screening, surveillance and diagnostic assessment and social determinants of health. For timely interventions to occur, early and accurate assessment is necessary. Medical officers and other health professionals such as nurses, general practitioners and therapists working in low-resourced contexts may use this information in their approach to the assessment of developmental delay.

Developmental Risks in Vulnerable Children from a Low-Income South African Community

OBJECTIVE

To describe the developmental risks, and its influence, in young children from a low-income South African community.

METHOD

An exploratory, cross-sectional research study design was employed. Developmental screening was conducted during home visits with 126 caregivers and children between 0 and 42 months of age from a low-income South African community. Children who failed the rescreen were referred for diagnostic assessment. A binomial logistic regression was used to determine the effect of developmental risks on developmental outcomes.

RESULTS

Seventy-three percent of children screened were identified with a possible developmental delay (n = 59) according to caregiver-report using the PEDS tools. The regression model was statistically significant (χ² (3) = 34.902, p < 0.001) with exposure to multiple languages (p < 0.05; odds ratio 3.810, CI 1.2-12.4) most indicative of potential developmental delay. Older children (19-42 months) were also more at risk of developmental delay (p < 0.001) than younger children (0-18 months).

CONCLUSIONS FOR PRACTICE

Healthcare professionals serving these vulnerable populations should create awareness amongst caregivers about the effect of developmental risks, in particularly multiple language exposure, on development.

Screening tools for early identification of children with developmental delay in low- and middle-income countries: a systematic review

OBJECTIVE

To systematically review, identify and report the screening tools used for early identification of developmental delay in low- and middle-income countries.

DESIGN

Systematic review.

DATA SOURCES

Four bibliographic databases: Medline (1946 to 13 July 2020), Embase (1974 to 13 July 2020), Scopus (1823 to 11 July 2020) and PsycINFO (1987 to July week 1 2020).

ELIGIBILITY CRITERIA

Peer-reviewed original articles published in English addressing validated culturally sensitive developmental screening tools among children aged <5 years were included in this review.

DATA EXTRACTION AND SYNTHESIS

One author (CK, medical librarian) developed the search strategy. Three authors conducted the database search (phase I: CK; phase II: IJ and MKI). Three authors (TF, IJ and MKI) independently screened the title and abstracts. TF, MKI and GK independently performed the full-text review of the screened articles. During each step of the study selection process, disagreements were resolved through discussion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the systematic review. Data extraction and analysis were performed using MS Excel. Meta-analysis was not possible due to heterogeneity of the study findings.

RESULTS

We identified 3349 articles, of which 18 studies from 10 countries, reporting 16 screening tools, were selected for qualitative synthesis. Six cultural contexts were explored. Twelve general, two motor and two speech-language tools were identified. Seven of them found to be parent-completed ones. Five screening tools (American Speech-Language and Hearing Association, Guide for Monitoring Child Development, Infant Neurological International Battery, New Delhi-Development Screening Questionnaire and Woodside Screening Technique) reported relatively higher sensitivity (82.5%-100%) and specificity (83%-98.93%).

CONCLUSIONS

Limited number of culturally sensitive developmental screening tools were validated for children aged <5 years in low- and middle-income countries. Revising existing screening tools in different ethnic and cultural settings and subsequent validation with normative value should be a research priority.

Early Childhood Development Risks and Protective Factors in Vulnerable Preschool Children from Low-Income Communities in South Africa

Age-appropriate early childhood development is greatly influenced by exposure to various mediating and moderating factors. Developmental outcomes cannot be viewed in isolation, but by considering the interaction of the various risks and protective factors that influence early child development. A non-experimental, cross-sectional research design was employed. Data was collected in a low-income community in Gauteng, South Africa. Caregivers with children (n = 276) between the ages of 3 years and 6 years 11 months (mean 51.57 months; SD ± 12.4) whose children were in a preschool were invited to participate in the research study. Participants were divided into two groups, children with developmental delays and children without a developmental delay. The study sample included high risk, vulnerable preschool children, with a developmental delay prevalence of 80.1% (221/276). Families included were exposed to an average of five (SD ± 1.86) environmental and/or biological risks. According to a logistic regression model, three factors were significantly associated with increasing resilience amongst children with no developmental delay: living with both parents (p < 0.031, OR 4.5, 95% CI 1.2-17.2), caregivers having at least completed Grade 8 to 12 (p < 0.027, OR 11.9, 95% CI 1.4-10.5) and parents being married (p < 0.023, OR 5.1, 95% CI 1.3-20.9). Important protective factors in low-income communities like caregiver education, living with both parents and parental marriage can inform public health messaging and other population-based interventions to support early childhood development.

Feeding and developmental outcomes of infants in a South African community

BACKGROUND

Prevalent environmental risk factors place infants in lower-middle-income countries (LMICs) at an increased risk for feeding and developmental difficulties.

AIM

This study aimed to determine the relationship between feeding and developmental outcomes in infants, as early feeding difficulties may have a cascading effect on developmental outcomes and vice versa.

METHODS

Data on 144 infants' feeding and development [mean age (standard deviation) = 8.8 months (2.2)] from a primary health care clinic in Gauteng, South Africa were retrospectively analysed.

RESULTS

Early introduction of cup feeding was found to be a predictor of possible expressive language and articulation difficulties. Gagging, spitting, or vomiting, pocketing, the use of force feeding, and poor sucking and chewing abilities were significantly associated with behavioural and social-emotional difficulties. Breastfeeding was found to be a protective factor for language development. The results emphasise the importance of primary prevention and early identification of risks in late infancy in LMIC.

Diagnostic accuracy of the Molteno Adapted Scale for developmental delay in South African toddlers

Background: There is currently a great need in South Africa for culturally appropriate neurodevelopmental screening measures in order to facilitate early identification of neurodevelopmental problems in children. Neurodevelopmental screening has the potential to decrease the burden at health-care facilities as it is time, resource and cost effective. Aim: To assess the use of the Molteno Adapted Scale (MAS), a locally developed screening measure, to suggest an optimal cut-off score and investigate its accuracy in detecting developmental delays. Method: The MAS was assessed by evaluating three components: accuracy, efficacy and usefulness. For each of 136 participants, MAS scores were compared with dichotomised scores from the Griffiths Mental Development Scales (GMDS). Receiver operating characteristic (ROC) curves were generated to determine the accuracy of the MAS in identifying developmental delay defined by the GMDS. Sensitivity, specificity and predictive values were calculated for potential MAS cut-off scores. Results: The MAS had an excellent area under the ROC curve, indicating good test accuracy. A developmental quotient of 83 was identified as optimal for screening purposes, with acceptable sensitivity (71.4%) and specificity (90.7%) as well as predictive values (29.4% positive predictive value and 98.3% negative predictive value) for developmental delay on the GMDS. Conclusion: The present study provides preliminary evidence supporting the use of the MAS for screening.

Evaluation of a Zulu translation of the Parents' Evaluation of Developmental Status

BACKGROUND

One of the greatest challenges in early communication intervention in South Africa is developing and implementing successful identification strategies in primary health care (PHC). A shortage of trained PHC personnel is one of the barriers to providing adequate health services in South Africa. This dearth of services creates the need to substitute clinician-administered developmental screening tools with parent-administered tools.

AIM

To determine the accuracy of the Zulu Parents' Evaluation of Developmental Status (PEDS) in comparison with the outcome of the English PEDS.

SETTING

The data were collected in a clinical, non-contrived environment at Stanza Bopape Community Health Clinic in Mamelodi, City of Tshwane.

METHODS

The PEDS is a standardised, parent-completed questionnaire regarding the child's general development. The English PEDS was translated into Zulu by a Zulu linguist. There were 99 potential participants in the study of whom 83 met the necessary prerequisites.

RESULTS

Of the participants whose home language is Zulu, 54% preferred the PEDS in English over the PEDS in Zulu. This indicates a skewed preference towards English, with only slight associations between language preference and age, education and home language.

CONCLUSION

The Zulu PEDS displayed high positive and negative correspondences, representative of an accurate translation of the English PEDS. It is recommended that this study should be repeated in a community where the majority are Zulu home language speakers.

Developmental screening: predictors of follow-up adherence in primary health care

BACKGROUND

The importance of early identification for infants and young children with developmental delays is well established. Poor follow-up on referrals, however, undermines the effectiveness of early intervention programmes.

OBJECTIVES

To identify factors, including text message reminders, that influence follow-up adherence for early intervention after developmental screening in primary health care. A secondary objective surveyed reasons for follow-up default.

METHODS

The PEDS tools were used to screen 247 high-risk children. A risk assessment questionnaire was completed with caregivers whose children were referred for speech-language and/or occupational therapy (n=106, 43%). A quasi-experimental correlational study was employed to identify risk factors for defaulting on appointments. A thematic analysis of telephonic interviews was also employed to determine reasons for follow-up defaults.

RESULTS

Follow-up adherence was 17%. Participants who were never married, divorced or widowed were 2.88 times more likely to attend a follow-up appointment than those who were married or living together (95%, CI 0.97-8.63). Text message reminders did not improve follow-up. More than half (58%) of participants who defaulted on appontments could be reached for telephonic interviews. Interviews showed that 87% of participants were unconcerned about their child's development. Other reasons for defaulting were employment, logistical issues, other responsibilities and forgetfulness.

CONCLUSION

Follow-up adherence for early intervention services following a positive primary health care screen was poor. Increased awareness and education regarding the importance of development for educational success is needed.

The Utility of Developmental Checklists in Parent-held Health Records in Singapore

OBJECTIVE

The aim of this study was to investigate parents' perceptions of developmental checklists and the child development monitoring schedule in the Singapore health booklet.

METHOD

Parents of children aged 2 years 6 months to 3 years 11 months with or without developmental concerns (n = 450) completed a structured interview, and their child's health booklets were reviewed.

RESULTS

Most parents reported reading and using the developmental checklists. However, only about half of them attempted the checklists with minimal help from professionals. Approximately 7 in 10 parents of children with developmental concerns found the checklists useful for identifying concerns about their child. Despite positive feedback from parents about the checklists, only about 1 in 4 parents brought their child for a 2 to 3 years developmental monitoring visit at the time of the survey, and the completion rates of the checklists were less than desirable.

CONCLUSIONS

Further revisions to the checklists can include simplifying the words and sentences and providing relevant pictures to aid understanding. If the checklists are to be used for screening, standardization of how the checklists are to be completed and how children at risk of developmental delays can be identified on the checklists need to be provided. Parents' awareness of the importance of evaluating their child's development at 9 months, 18 months, and particularly at 2.5 years, needs to be raised. Developmental screening for children at these critical ages can be made mandatory. An electronic version of the health booklet is likely to facilitate implementation of developmental screening in the health care system.

Early detection of communication delays with the PEDS tools in at-risk South African infants

Background

Prevalence of communication delays or disorders is increasing, possibly because of various environmental risk factors. Selection and implementation of effective screening tools are important to detect at-risk infants as early as possible. This study aimed to evaluate the accuracy of the Parents’ Evaluation of Developmental Status (PEDS), PEDS-Developmental Milestones and PEDS tools to detect communication delays in infants (6–12 months) in a South African primary healthcare context.

Method

A comparative study design evaluated the accuracy of the PEDS tools to detect communication delays, using an internationally accepted diagnostic assessment tool, the Rossetti Infant-Toddler Language Scale (RITLS). A convenience sample of 201 infants was selected at primary healthcare clinics.

Results

Expressive and receptive language sensitivity scores were low across all three screens (ranging between 14% and 44%). The PEDS tools had high sensitivity (71%) and specificity (73%) ratings for the receptive and expressive language and socio-emotional domain in combination.

Conclusion

In the sample population, the PEDS tools did not accurately detect receptive and expressive language delays; however, communication delays in general were identified. Future research determining accuracy of the PEDS, PEDS-Developmental Milestones and PEDS tools for children aged 2–5 years in detecting communication delays should be prioritised.