Screening for developmental delay among children aged 1-4 years: a systematic review

Utility of the Ages and Stages Questionnaire to Identify Developmental Delay in Children Aged 12 to 60 Months: A Systematic Review and Meta-analysis

Importance

The Ages and Stages Questionnaire (ASQ) is a commonly used developmental screening tool, but its utility is debated.

Objectives

To conduct a a systematic review and meta-analysis to evaluate ASQ's utility as a screening or diagnostic tool to identify developmental delay in children aged 12-60 months.

Data Sources

Medline, EMBASE, CINAHL, PsycINFO, and Mednar were searched from inception until December 2021.

Study Selection

Studies meeting both criteria were included. ASQ was performed at age 12 to 60 months or where the median age at ASQ was at least 12 months and formal developmental assessments were done within 2 months of ASQ.

Data Extraction and Synthesis

True positive, false positive, false negative, and true negatives from individual studies were extracted. Meta-analysis was conducted with Stata version 16.1. Risk of bias was assessed using the QUADAS-2 tool. Certainty of evidence (COE) was assessed using GRADE guidelines.

Main Outcomes and Measures

Ability of ASQ scores more than 2 SDs below the mean in more than 1 domain (ASQ-2SD) to identify any developmental delay or severe delay. Based on generally accepted interpretation of likelihood ratio (LR) values, a positive LR (PLR) more than 5 and a negative LR (NLR) of 0.2 or less were considered necessary to rule in or rule out developmental delay, respectively, with at least moderate probability.

Results

Initial search yielded 5777 citations of which 43 were included in the review. Of them, 36 were included in the meta-analysis. The pooled sensitivity, specificity, PLR, and NLR are as follows: ASQ-2SD to predict any delay in 1 or more domain (n = 16), 0.77 (95% CI, 0.64-0.86), 0.81 (95% CI, 0.75-0.86), 4.10 (95% CI, 3.17-5.30), and 0.28 (95% CI, 0.18-0.44); ASQ-2SD to predict severe delay in 1 or more domain (n = 15), 0.84 (95% CI, 0.75-0.90), 0.77 (95% CI, 0.71-0.82), 3.72 (95% CI, 2.98-4.64), and 0.20 (95% CI, 0.13-0.32); ASQ-2SD motor domain to predict motor delay (n = 7), 0.41 (95% CI, 0.26-0.57), 0.94 (95% CI, 0.87-0.97), 6.5 (95% CI, 3.8-11.1), and 0.63 (95% CI, 0.50-0.81); and ASQ-2SD cognitive domain to predict cognitive delay (n = 2), 0.44 (95% CI, 0.24-0.65), 0.93 (95% CI, 0.81-0.95), 6.4 (95% CI, 2.4-16.8), and 0.61 (95% CI, 0.43-0.86). The COE was low/very low.

Conclusions and Relevance

If a child aged 12 to 60 months passes all ASQ domains, there is a moderate probability that they do not have severe developmental delay (low COE). If a child aged 12-60 months fails the motor or cognitive domain of ASQ, there is a moderate probability that they have some motor or cognitive delay, respectively (very low COE).

Trial Registration

PROSPERO (CRD42021268543).

Standardization of a Developmental Milestone Scale Using Data From Children in Israel

IMPORTANCE

Routine developmental screening tests for children are used worldwide for early detection of developmental delays. However, assessment of developmental milestone norms lacks strong normative data, and there are inconsistencies among different screening tools.

OBJECTIVE

To establish milestone norms and build an updated developmental scale.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional, population-based study conducted between 2014 and 2020. Developmental assessments were conducted by trained public health nurses, documented in national maternal child health clinics, known as Tipat Halav, which serve all children in Israel. Participants included all children born between January 2014 and September 2020, who were followed at the maternal child health clinics from birth to age 6 years. Exclusion criteria were preterm birth, missing gestational age, low birth weight (<2.5 kg), abnormal weight measurement (<3% according to standardized child growth charts), abnormal head circumference measurement (<3% or >97% according to standardized child growth charts), and visits without developmental data or without the child's age. Data analysis was performed from September 2020 to June 2021.

EXPOSURES

In total, 59 milestones in 4 developmental domains were evaluated, and the achievement rate per child's age was calculated for each milestone.

MAIN OUTCOMES AND MEASURES

A contemporary developmental scale, the Tipat Halav Israel Screening (THIS) Developmental Scale, was built, presenting the 75%, 90%, and 95% achievement rates for each milestone. The THIS scale was compared with other commonly used screening tests, including the Denver Developmental Screening Test II (Denver II), the Alberta Infant Motor Scale (AIMS), and the Centers for Disease Control and Prevention (CDC) Developmental Assessment.

RESULTS

A total of 839 574 children were followed in the maternal child health clinics between January 2014 and September 2020 in Israel, and 195 616 children were excluded. A total of 3 774 517 developmental assessments were performed for the remaining 643 958 children aged 0 to 6 years (319 562 female children [49.6%]), resulting in the establishment of new developmental norms. In terms of the comparable milestones, THIS milestones had a match of 18 of 27 (67%) with the Denver II, 7 of 7 (100%) with AIMS, and 10 of 19 (53%) with the CDC Developmental Assessment. The remaining unmatched milestones were achieved earlier in the THIS scale compared with other screening tools.

CONCLUSIONS AND RELEVANCE

The THIS developmental scale is based on the largest population evaluated to date for developmental performance, representing the heterogeneous, multicultural population comprising this cohort. It is recommended for further evaluation worldwide.

2020 edition of the Rourke Baby Record: What is new in preventive care of children up to 5 years of age?

OBJECTIVE

To update primary care providers practising well-child and well-baby clinical care on the evidence that contributed to the recommendations of the 2020 edition of the Rourke Baby Record (RBR).

QUALITY OF EVIDENCE

Pediatric preventive care literature was searched from June 2016 to May 2019, primary research studies were reviewed and critically appraised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and recommendations were updated where there was support from the literature.

MAIN MESSAGE

Notable changes in the 2020 edition of the RBR include the recommendations to limit or avoid consumption of highly processed foods high in dietary sodium, to ensure safe sleep (healthy infants should sleep on their backs and on a firm surface for every sleep, and should sleep in a crib, cradle, or bassinette in the parents' room for the first 6 months of life), to not swaddle infants after they attempt to roll, to inquire about food insecurity, to encourage parents to read and sing to infants and children, to limit screen time for children younger than 2 years of age (although it is accepted for videocalling), to educate parents on risks and harms associated with e-cigarettes and cannabis, to avoid pesticide use, to wash all fruits and vegetables that cannot be peeled, to be aware of the new Canadian Caries Risk Assessment Tool, to note new red flags for cerebral palsy and neurodevelopmental problems, and to pay attention to updated high-risk groups for lead and anemia screening.

CONCLUSION

The RBR endeavours to guide clinicians in providing evidence-informed primary care to Canadian children. The revisions are rigorously considered and are based on appraisal of a growing, albeit still limited, evidence base for pediatric preventive care.

Édition 2020 du Relevé postnatal Rourke

Objectif

Renseigner les fournisseurs de soins de première ligne qui dispensent des soins de médecine préventive durant l’enfance quant aux données ayant servi de fondement aux recommandations de l’édition 2020 du Relevé postnatal Rourke (RBR).

Qualité des données

Une recherche a effectuée parmi les publications sur les soins préventifs en pédiatrie entre les mois de juin 2016 et mai 2019, les principales études de recherche ont été revues et rigoureusement évaluées à l’aide de la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) et les recommandations ont été actualisées là où les publications étayaient des changements.

Message principal

Les changements notables de l’édition 2020 du RBR sont les recommandations de limiter ou d’éviter les aliments très transformés et riches en sodium alimentaire, de veiller au sommeil sécuritaire (les nourrissons en bonne santé doivent dormir sur le dos et sur une surface rigide à tous les dodos, et ils doivent dormir dans un moïse, un berceau ou une couchette dans la chambre des parents pendant les 6 premiers mois de vie), de ne pas emmailloter les nourrissons après qu’ils aient tenté de se retourner, de s’informer de l’insécurité alimentaire, d’encourager les parents à lire et à chanter aux nourrissons et aux enfants, de limiter le temps que les enfants de moins de 2 ans passent devant un écran (bien que ce soit accepté pour les appels vidéo), de renseigner les parents sur les risques et les torts associés aux cigarettes électroniques et au cannabis, d’éviter les pesticides, de laver tous les fruits et légumes ne pouvant être pelés, de connaître l’existence du nouvel Outil national d’évaluation du risque de caries, de noter les nouveaux symptômes alarmants de paralysie cérébrale et de problèmes neurodéveloppementaux et de porter attention aux nouveaux groupes à risque élevé pour le dépistage du plomb et de l’anémie.

Conclusion

Le RBR s’efforce de guider les cliniciens pour leur permettre de dispenser des soins de première ligne factuels aux enfants canadiens. Les révisions sont rigoureusement étudiées, et sont basées sur l’évaluation d’une base de données probantes croissante, quoique toujours limitée, sur les soins préventifs en pédiatrie.

A Prediction Model for Detecting Developmental Disabilities in Preschool-Age Children Through Digital Biomarker-Driven Deep Learning in Serious Games: Development Study

Background

Early detection of developmental disabilities in children is essential because early intervention can improve the prognosis of children. Meanwhile, a growing body of evidence has indicated a relationship between developmental disability and motor skill, and thus, motor skill is considered in the early diagnosis of developmental disability. However, there are challenges to assessing motor skill in the diagnosis of developmental disorder, such as a lack of specialists and time constraints, and thus it is commonly conducted through informal questions or surveys to parents.

Objective

This study sought to evaluate the possibility of using drag-and-drop data as a digital biomarker and to develop a classification model based on drag-and-drop data with which to classify children with developmental disabilities.

Methods

We collected drag-and-drop data from children with typical development and developmental disabilities from May 1, 2018, to May 1, 2020, via a mobile application (DoBrain). We used touch coordinates and extracted kinetic variables from these coordinates. A deep learning algorithm was developed to predict potential development disabilities in children. For interpretability of the model results, we identified which coordinates contributed to the classification results by applying gradient-weighted class activation mapping.

Results

Of the 370 children in the study, 223 had typical development, and 147 had developmental disabilities. In all games, the number of changes in the acceleration sign based on the direction of progress both in the x- and y-axes showed significant differences between the 2 groups (P<.001; effect size >0.5). The deep learning convolutional neural network model showed that drag-and-drop data can help diagnose developmental disabilities, with an area under the receiving operating characteristics curve of 0.817. A gradient class activation map, which can interpret the results of a deep learning model, was visualized with the game results for specific children.

Conclusions

Through the results of the deep learning model, we confirmed that drag-and-drop data can be a new digital biomarker for the diagnosis of developmental disabilities.

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.

Sensitivity and specificity of a low-cost screening protocol for identifying children at risk for language disorders

OBJECTIVES

To compare the diagnostic accuracy of a low-cost screening test for identifying children at risk for language disorders with that of a specific language assessment.

METHODS

The study was conducted during a polio vaccination campaign in basic health units in western São Paulo, Brazil. The parents/guardians of 1000 children aged between 0 and 5 years were asked to answer questions of a specific screening test. The instrument consisted of a uniform set of questions about the main milestones in language development (from 0 to 5 years of age) with scaled scores to assess responses. There were no exclusion criteria. After the screening test, the children were referred to a specific language assessment by ABFW, following a determined flow of referrals. The results obtained in the screening were compared to those obtained in the specific language assessment; then, the sensitivity, specificity, accuracy, and positive and negative predictive values were determined for the screening test. Children who failed the screening test also underwent an audiological evaluation. The statistical significance was set at 5%.

RESULTS

The majority of the participants were aged between 4 and 5 years (21.82%) and were male (51.6%). The sensitivity and specificity values were 82.5% and 98.93%, respectively. The area under the curve was 0.907 (0.887-0.925), and the screening test showed 96% accuracy.

CONCLUSIONS

The screening test showed high diagnostic efficiency in determining the risk of language disorders in children aged between 0 and 5 years.

Effects of a family-centered workshop for children with developmental delays

This study investigated the effects of a short-term family-centered workshop for children with developmental delays.This study was conducted in a rehabilitation outpatient clinic of a teaching hospital. We recruited 30 children with developmental delays and their parents as the study group and 57 age- and sex-matched children with typical development and their parents as the control group. The workshop was conducted for the children with developmental delays and their parents in the form of one 2-hour session per week for 6 weeks by health and education professionals by using a family-centered multidisciplinary approach. The Mandarin-Chinese Communicative Developmental Inventory and Peabody Developmental Motor Scales-Second Edition were used to assess the communication and motor skills of the children with developmental delays. The parent form of the Pediatric Outcomes Data Collection Instrument, Child Health Questionnaire, Pediatric Quality of Life (PedsQL) Inventory, and PedsQL Family Impact Module were administered to the parents of both groups.On study commencement, no significant differences were noted in functional performance and family impact between the children with developmental delays and those without delays. The children with developmental delays had lower health and health-related quality of life (HRQOL) scores than the children with typical development. Following the workshop, the study group exhibited significant improvements in physical health (94.2 vs 80.2, effect size: 1.00, P = .026), global function (94.8 vs 78.7, effect size: 0.88, P = .006), impact of the child's health on parental HRQOL (85.0 vs 70.4, effect size: 0.81, P = .043), and parental HRQOL (81.3 vs 65.0, effect size: 0.81, P = .015). No significant differences were recorded in function, health, HRQOL, or family impact between the children with developmental delays and those with typical development after 6 weeks.The multidisciplinary short-term family-centered workshop for children with developmental delays improved the children's physical health and global functional skills, and it reduced the impact of the child's health on parental HRQOL while also improving parental HRQOL.

Using the ages and stages questionnaire in the general population as a measure for identifying children not at risk of a neurodevelopmental disorder

Background

Early detection of neurodevelopmental disorders (NDDs) enables access to early interventions for children. We assess the Ages and Stages Questionnaire (ASQ)’s ability to identify children with a NDD in population data.

Method

Children 4 to 5 years old in the National Longitudinal Survey of Children and Youth (NLSCY) from cycles 5 to 8 were included. The sensitivity, specificity, positive and negative predictive values were calculated for the ASQ at 24, 27, 30, 33, 36 and 42 months. Fixed effects regression analyses assessed longitudinal associations between domain scores and child age.

Results

Specificity for the ASQ was high with 1SD or 2SD cutoffs, indicating good accuracy in detecting children who will not develop a NDD, however the sensitivity varied over time points and cut-offs. Sensitivity for the 1 SD cutoff at 24 months was above the recommended value of 70% for screening. Differences in ASQ domains scores between children with and without NDD increases with age.

Conclusions

The high specificity and negative predictive values of the ASQ support its use in identifying children who are not at the risk of developing a NDD. The capacity of the ASQ to identify children with a NDD in the general population is limited except for the ASQ-24 months with 1SD and can be used to identify children at risk of NDD.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1105-z) contains supplementary material, which is available to authorized users.

Diagnostic accuracy of developmental screening in primary care at the 18-month health supervision visit: a cross-sectional study

BACKGROUND

Communication delays are often the first presenting problem in infants with a range of developmental disabilities. Our objective was to assess the validity of the 18-month Nipissing District Developmental Screen compared with the Infant Toddler Checklist, a validated tool for detecting expressive language and other communication delays.

METHODS

A cross-sectional design was used. Children aged 18-20 months were recruited during scheduled health supervision visits. Parents completed both the 18-month Nipissing District Developmental Screen and the Infant Toddler Checklist. We assessed criterion validity (diagnostic test properties, overall agreement) for 1 or more "no" responses (1+NDDS flag) and 2 or more "no" responses (2+NDDS flag) using the Infant Toddler Checklist as a criterion measure.

RESULTS

The study included 348 children (mean age 18.6 ± 0.7 mo). The 1+NDDS flag had good sensitivity (94%, 95% confidence interval [CI] 70%-100%, and 86%, 95% CI 64%-96%), poor specificity (63%, 95% CI 58%-68%, and 63%, 95% CI 58%-69%), and fair agreement (0.26) to identify expressive speech and other communication delays, respectively. The 2+NDDS flag had low to fair sensitivity (50%, 95% CI 26%-74%, and 73%, 95% CI 50%-88%), good specificity (86%, 95% CI 82%-90%, and 88%, 95% CI 84%-92%) and moderate agreement (0.45) to identify expressive speech and other communication delays, respectively.

INTERPRETATION

The low specificity of the 1+NDDS flag may lead to overdiagnosis, and the low sensitivity of the 2+NDDS flag may lead to underdiagnosis, suggesting that infants who could benefit from early intervention may not be identified. The Nipissing District Developmental Screen does not have adequate characteristics to accurately identify children with a range of communication delays.