Indian Academy of Pediatrics Consensus Guidelines on Preconception Care

JUSTIFICATION

The preconception period is the earliest window of opportunity to ensure optimal human development.  Pregnancy and childbirth outcomes can be improved by interventions offered to support the health and well-being of women and couples prior to conception. Thus, preconception care is essential in preparing for the first thousand days of life. Adolescence, the stage of life that typically comes before the preconception stage, is characterized by various high-risk behaviors like substance abuse, sexual experimentation, injuries, obesity, and mental health issues which can adversely affect their health in adult life. Thus, a Consensus Guideline for pediatricians on providing preconception care to adolescents and young adults can go a long way in making the generations to come, healthier and more productive.

OBJECTIVES

The purpose of these recommendations is to formulate an evidence-based Consensus Statement that can serve as a guidance for medical professionals to provide preconception care for young adults and adolescents.

INTENDED USERS

All obstetric, pediatric, and adolescent health care providers.

TARGET POPULATION

Adolescents and young adults.

PROCESS

A large proportion of adolescents seek care from pediatricians and there is a lack of Consensus Guidelines on preconception care. Therefore, the Indian Academy of Pediatrics called an online National Consultative Meeting on April 03, 2023, under the chairmanship of Dr MKC Nair and the National Convenor Dr Himabindu Singh. A group of pediatricians with wide experience and expertise in adolescent health care were assigned the task of formulating evidence-based guidelines on preconception care. The group conducted a comprehensive review of existing evidence by searching resources including PubMed and Cochrane databases. Subsequently, a physical meeting was held at Amritsar on October 07, 2023 during which the consensus was reached through discussions and voting. The level of evidence (LoE) of each recommendation was graded as per the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011.

RECOMMENDATIONS

Every woman planning a pregnancy needs to attain and maintain a eumetabolic state. Prospective couples need to be counselled on the importance of a healthy lifestyle including a nutritious diet, avoidance of substance abuse, and timely screening for genetic disorders. Screening for and management of sexually transmitted diseases in males and females, appropriate vaccination and addressing mental health concerns are also recommended.

Consensus Statement of the IAP - Neurodevelopmental Chapter On Neurodevelopmental Disorders Habilitation Process: Strategic Plan for Prevention, Early Detection and Early Intervention

JUSTIFICATION

Neurodevelopmental disorders, as per DSM-V, are described as a group of conditions with onset in the development period of childhood. There is a need to distinguish the process of habilitation and rehabilitation, especially in a developing country like India, and define the roles of all stakeholders to reduce the burden of neurodevelopmental disorders.

PROCESS

Subject experts and members of Indian Academy of Pediatrics (IAP) Chapter of Neurodevelopmental Pediatrics, who reviewed the literature on the topic, developed key questions and prepared the first draft on guidelines. The guidelines were then discussed by the whole group through online meetings, and the contentious issues were discussed until a general consensus was arrived at. Following this, the final guidelines were drafted by the writing group and approved by all contributors.

OBJECTIVES

These guidelines aim to provide practical clinical guidelines for pediatricians on the prevention, early diagnosis and management of neurodevelopmental disorders (NDDs) in the Indian settings. It also defines the roles of developmental pediatricians and development nurse counselor.

STATEMENT

There is a need for nationwide studies with representative sampling on epidemiology of babies with early NDD in the first 1000 days in India. Specific learning disability (SLD) has been documented as the most common NDD after 6 years in India, and special efforts should be made to establish the epidemiology of infants and toddlers at risk for SLD, where ever measures are available. Preconception counseling as part of focusing on first 1000 days; Promoting efforts to organize systematic training programs in Newborn Resuscitation Program (NRP); Lactation management; Developmental follow-up and Early stimulation for SNCU/ NICU graduates; Risk stratification of NICU graduates, Newborn Screening; Counseling parents; Screening for developmental delay by trained professionals using simple validated Indian screening tools at 4, 8, 12, 18 and 24 months; Holistic assessment of 10 NDDs at child developmental clinics (CDCs) / district early intervention centre (DEICs) by multidisciplinary team members; Confirmation of diagnosis by developmental pediatrician/developmental neurologist/child psychiatrist using clinical/diagnostic tools; Providing parent guided low intensity multimodal therapies before 3 years age as a center-based or home-based or community-based rehabilitation; Developmental pediatrician to seek guidance of pediatric neurologist, geneticist, child psychiatrist, physiatrist, and other specialists, when necessary; and Need to promote ongoing academic programs in clinical child development for capacity building of community based therapies, are the chief recommendations.

Global prevalence of developmental disabilities in children and adolescents: A systematic umbrella review

Aim

The provisions of the United Nation's Sustainable Development Goals (SDGs) for disability-inclusive education have stimulated a growing interest in ascertaining the prevalence of children with developmental disabilities globally. We aimed to systematically summarize the prevalence estimates of developmental disabilities in children and adolescents reported in systematic reviews and meta-analyses.

Methods

For this umbrella review we searched PubMed, Scopus, Embase, PsycINFO, and Cochrane Library for systematic reviews published in English between September 2015 and August 2022. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We reported the proportion of the global prevalence estimates attributed to country income levels for specific developmental disabilities. Prevalence estimates for the selected disabilities were compared with those reported in the Global Burden of Disease (GBD) Study 2019.

Results

Based on our inclusion criteria, 10 systematic reviews reporting prevalence estimates for attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, developmental intellectual disability, epilepsy, hearing loss, vision loss and developmental dyslexia were selected from 3,456 identified articles. Global prevalence estimates were derived from cohorts in high-income countries in all cases except epilepsy and were calculated from nine to 56 countries. Sensory impairments were the most prevalent disabilities (approximately 13%) and cerebral palsy was the least prevalent disability (approximately 0.2-0.3%) based on the eligible reviews. Pooled estimates for geographical regions were available for vision loss and developmental dyslexia. All studies had a moderate to high risk of bias. GBD prevalence estimates were lower for all disabilities except cerebral palsy and intellectual disability.

Conclusion

Available estimates from systematic reviews and meta-analyses do not provide representative evidence on the global and regional prevalence of developmental disabilities among children and adolescents due to limited geographical coverage and substantial heterogeneity in methodology across studies. Population-based data for all regions using other approaches such as reported in the GBD Study are warranted to inform global health policy and intervention.

Promoting school readiness in children with developmental disabilities in LMICs

The United Nations' Sustainable Development Goals (SDGs) explicitly acknowledge inclusive and equitable quality education as the primary goal of any global initiatives for early childhood development for children under 5 years with developmental delays and disabilities. Primary education provides the foundation for lifelong learning, vocational attainment, and economically independent living. Globally, the majority (over 90%) of children with developmental disabilities reside in low- and middle-income countries (LMICs). These children are significantly less likely to have foundational reading and numeracy skills, more likely to have never attended school and more likely to be out of primary school, compared to children without disabilities. Concerted and well-coordinated efforts to prepare these children in early childhood for inclusive education constitute a moral and ethical priority for all countries. This paper sets out to examine the concept and dimensions of school readiness for children under 5 years from an extensive narrative review of the literature. It identifies the barriers and challenges for school readiness for children with disabilities and the limitations of the available tools for evaluating school readiness. It concludes by emphasizing the critical role of inter-disciplinary engagement among pediatric caregivers in promoting school readiness in partnership with the families and community where the children reside. Overall, the paper highlights the need for appropriate policy initiatives at the global and national levels to promote school readiness specifically for children under 5 years with developmental disabilities in LMICs, if the aspirational goal of inclusive education by 2030 under the SDGs is to be realized.

Cerebral palsy and developmental intellectual disability in children younger than 5 years: Findings from the GBD-WHO Rehabilitation Database 2019

Objective

Children with developmental disabilities are associated with a high risk of poor school enrollment and educational attainment without timely and appropriate support. Epidemiological data on cerebral palsy and associated comorbidities required for policy intervention in global health are lacking. This paper set out to report the best available evidence on the global and regional prevalence of cerebral palsy (CP) and developmental intellectual disability and the associated "years lived with disability" (YLDs) among children under 5 years of age in 2019.

Methods

We analyzed the collaborative 2019 Rehabilitation Database of the Global Burden of Disease (GBD) Study and World Health Organization for neurological and mental disorders available for 204 countries and territories. Point prevalence and YLDs with 95% uncertainty intervals (UI) are presented.

Results

Globally, 8.1 million (7.1-9.2) or 1.2% of children under 5 years are estimated to have CP with 16.1 million (11.5-21.0) or 2.4% having intellectual disability. Over 98% resided in low-income and middle-income countries (LMICs). CP and intellectual disability accounted for 6.5% and 4.5% of the aggregate YLDs from all causes of adverse health outcomes respectively. African Region recorded the highest prevalence of CP (1.6%) while South-East Asia Region had the highest prevalence of intellectual disability. The top 10 countries accounted for 57.2% of the global prevalence of CP and 62.0% of the global prevalence of intellectual disability.

Conclusion

Based on this Database, CP and intellectual disability are highly prevalent and associated with substantial YLDs among children under 5 years worldwide. Universal early detection and support services are warranted, particularly in LMICs to optimize school readiness for these children toward inclusive education as envisioned by the United Nations' Sustainable Development Goals.

Indian Academy of Pediatrics Consensus Guidelines on Prevention and Management of Suicidal Behavior in Adolescents

JUSTIFICATION

Suicide is an important cause of adolescent mortality and morbidity in India. As pediatricians are often the first point of contact for adolescents and their families in the healthcare system, they need guidelines to screen, assess, manage and prevent adolescent suicidal behavior to ensure survival, health and mental well-being of this vulnerable population.

OBJECTIVES

To formulate guidelines to aid pediatricians for prevention and management of adolescent suicidal behavior.

PROCESS

Indian Academy of Pediatrics, in association with Adolescent Health Academy, formed a multidisciplinary committee of subject experts in June, 2019 to formulate guidelines for adolescent suicide prevention and management. After a review of current scientific literature and preparation of draft guidelines, a national consultative meeting was organized on 16 August, 2019 for detailed discussions and deliberations. This was followed by refining of draft guidelines, and discussions over e-mail where suggestions were incorporated and the final document was approved.

GUIDELINES

Pediatricians should screen for mental distress, mental disorders and suicidal and para-suicidal (non-suicidal self-injury) behavior during adolescent health visits. Those with suicidal behavior should be referred to a psychiatrist after providing emergency healthcare, risk assessment, immediate counselling and formulation of a safety plan. Pediatricians should partner with the community and policymakers for primary and secondary prevention of adolescent suicide.

Diagnosis and Management of Global Development Delay: Consensus Guidelines of Growth, Development and Behavioral Pediatrics Chapter, Neurology Chapter and Neurodevelopment Pediatrics Chapter of the Indian Academy of Pediatrics

JUSTIFICATION

Global developmental delay (GDD) is a relatively common neurodevelopmental disorder; however, paucity of published literature and absence of uniform guidelines increases the complexity of clinical management of this condition. Hence, there is a need of practical guidelines for the pediatrician on the diagnosis and management of GDD, summarizing the available evidence, and filling in the gaps in existing knowledge and practices.

PROCESS

Seven subcommittees of subject experts comprising of writing and expert group from among members of Indian Academy of Pediatrics (IAP) and its chapters of Neurology, Neurodevelopment Pediatrics and Growth Development and Behavioral Pediatrics were constituted, who reviewed literature, developed key questions and prepared the first draft on guidelines after multiple rounds of discussion. The guidelines were then discussed by the whole group in an online meeting. The points of contention were discussed and a general consensus was arrived at, after which final guidelines were drafted by the writing group and approved by all contributors. The guidelines were then approved by the Executive Board of IAP.

Guidelines

GDD is defined as significant delay (at least 2 standard deviations below the mean with standardized developmental tests) in at least two developmental domains in children under 5 years of age; however, children whose delay can be explained primarily by motor issues or severe uncorrected visual/hearing impairment are excluded. Severity of GDD can be classified as mild, moderate, severe and profound on adaptive functioning. For all children, in addition to routine surveillance, developmental screening using standardized tools should be done at 9-12 months,18-24 months, and at school entry; whereas, for high risk infants, it should be done 6-monthly till 24 months and yearly till 5 years of age; in addition to once at school entry. All children, especially those diagnosed with GDD, should be screened for ASD at 18-24 months, and if screen negative, again at 3 years of age. It is recommended that investigations should always follow a careful history and examination to plan targeted testing and, vision and hearing screening should be done in all cases prior to standardized tests of development. Neuro-imaging, preferably magnetic resonance imaging of the brain, should be obtained when specific clinical indicators are present. Biochemical and metabolic investigations should be targeted towards identifying treatable conditions and genetic tests are recommended in presence of clinical suspicion of a genetic syndrome and/or in the absence of a clear etiology. Multidisciplinary intervention should be initiated soon after the delay is recognized even before a formal diagnosis is made, and early intervention for high risk infants should start in the nursery with developmentally supportive care. Detailed structured counselling of family regarding the diagnosis, etiology, comorbidities, investigations, management, prognosis and follow-up is recommended. Regular targeted follow-up should be done, preferably in consultation with a team of experts led by a developmental pediatrician/ pediatric neurologist.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India

BACKGROUND

Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden.

METHODS AND FINDINGS

We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population.

CONCLUSIONS

The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.

Depression and Anxiety Disorders among Schoolgoing Adolescents in an Urban Area of South India

Context:

Adolescence is a period of turmoil, leading to several mental health challenges including anxiety and/or depression.

Aims:

To study the prevalence of depression and anxiety among higher school going adolescents and their sociodemographic correlates.

Settings and Design:

This cross-sectional study included 201 schoolgoing adolescents.

Subjects and Methods:

Depression and anxiety were measured using Beck Depression Inventory and Screen for Child Anxiety Related Disorders.

Statistical Analysis Used:

Chi-square test and binary logistic Regression with Hosmer–Lemeshow goodness-of-fit model.

Results:

Overall, 82 (40.8%) showed depression (from mild mood disturbance to severe and extreme depression). Among females, it was 49.3% (vs. 35.9% among males, odds ratio [OR] 2.00; 95% confidence interval [CI]: 1.02–03.97, P = 0.046). Overall, 110 (54.7%) participants had one or the other type of anxiety. Depression among the participants having one or other type of anxiety was 60% (vs. 17.6% without anxiety, OR 7.34; 95% CI: 3.68–14.64, P < 0.0001).

Conclusions:

Depression and anxiety were high among the study participants. Co-existing anxiety and female gender are significantly associated with depression among them. Increasing age, socioeconomic factors, and parental education are other factors influencing depression and anxiety but were statistically not significant.

Consensus Statement of the Indian Academy of Pediatrics on Evaluation and Management of Attention Deficit Hyperactivity Disorder

JUSTIFICATION

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent in children worldwide. Management of ADHD requires a systematic, multidisciplinary approach and therefore evidence-based, standardized national guidelines are essential.

PROCESS

A meeting for formulation of national consensus guidelines on neurodevelopmental disorders was organized by Indian Academy of Pediatrics in Mumbai, on 18th and 19th December, 2015. The invited experts included Pediatricians, Developmental Pediatricians, Pediatric Neurologists, Psychiatrists, Remedial Educators and Clinical Psychologists. The participants framed guidelines after extensive discussions.

OBJECTIVE

To provide consensus guidelines on evaluation and management of ADHD in children in India.

RECOMMENDATIONS

ADHD is a chronic condition and thus education of patients, families, and teachers regarding the diagnosis is an integral part of management. Involvement of patient the and the family in the management program is extremely vital. Management of ADHD centers on the achievement of target outcomes, which are chosen in collaboration with the child, parents, and school personnel. Coexisting conditions must be treated concurrently with ADHD. Modalities of management of ADHD include behavioral interventions, medications, and educational interventions. These modalities can be implemented individually or in combination.

Consensus Statement of the Indian Academy of Pediatrics on Newborn Hearing Screening

JUSTIFICATION

Hearing impairment is one of the most critical sensory impairments with significant social and psychological consequences. Evidence-based, standardized national guidelines are needed for professionals to screen for hearing impairment during the neonatal period.

PROCESS

The meeting on formulation of national consensus guidelines on developmental disorders was organized by Indian Academy of Pediatrics in Mumbai, on 18th and 19th December, 2015. The invited experts included Pediatricians, Developmental Pediatricians, Pediatric Neurologists and Clinical Psychologists. The participants framed guidelines after extensive discussions.

OBJECTIVE

To provide guidelines on newborn hearing screening in India.

RECOMMENDATIONS

The first screening should be conducted before the neonate's discharge from the hospital - if it 'fails', then it should be repeated after four weeks, or at first immunization visit. If it 'fails' again, then Auditory Brainstem Response (ABR) audiometry should be conducted. All babies admitted to intensive care unit should be screened via ABR. All babies with abnormal ABR should undergo detailed evaluation, hearing aid fitting and auditory rehabilitation, before six months of age. The goal is to screen newborn babies before one month of age, diagnose hearing loss before three months of age and start intervention before six months of age.

CDC Kerala--The Untold Story

This article is our life time experience in conceptualizing and systematically developing Child Development Centre (CDC) Kerala in the last 25 years, from a research project to a national training centre in child and adolescent development and premarital counseling. CDC Kerala's major contribution was in creating a 'conceptual framework' of a valid link between childhood disability, low birth weight, adolescent girls' nutrition and fetal onset adult lifestyle diseases. It all started with a randomized controlled trial (RCT) proving beyond doubt that early stimulation is effective in improving the neurodevelopmental status of high risk babies at one and two years and the same cohort was followed-up in detail at 5, 13, 16, 19 and 24 completed years. The process of establishing CDC Kerala is being presented under (i) clinical child development, (ii) adolescent care counseling, (iii) young adults and premarital counseling and (iv) institution building.

Language Evaluation Scale Trivandrum (LEST 3-6 years) Development and Validation

Language Evaluation Scale Trivandrum (LEST:3-6 years) with 31-items, was validated against extended REELS with a community sample-606 children (3-6yrs). One item and two item delay as LEST delay showed a sensitivity of (81%, 47%); specificity (68%, 94%), PPV (12%, 31%); NPV (98%, 97%) and accuracy (68.5%, 92%), respectively. LEST (3-6years) is a simple, valid, community screening tool.

INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD): development and validation

OBJECTIVE

To develop and validate INCLEN Diagnostic Tool for Autism Spectrum Disorder (INDT-ASD).

DESIGN

Diagnostic test evaluation by cross sectional design.

SETTING

Four tertiary pediatric neurology centers in Delhi and Thiruvanthapuram, India.

METHODS

Children aged 2-9 years were enrolled in the study. INDT-ASD and Childhood Autism Rating Scale (CARS) were administered in a randomly decided sequence by trained psychologist, followed by an expert evaluation by DSM-IV TR diagnostic criteria (gold standard).

MAIN OUTCOME MEASURES

Psychometric parameters of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency.

RESULTS

154 children (110 boys, mean age 64.2 mo) were enrolled. The overall diagnostic accuracy (AUC=0.97, 95% CI 0.93, 0.99; P<0.001) and validity (sensitivity 98%, specificity 95%, positive predictive value 91%, negative predictive value 99%) of INDT-ASD for Autism spectrum disorder were high, taking expert diagnosis using DSM-IV-TR as gold standard. The concordance rate between the INDT-ASD and expert diagnosis for 'ASD group' was 82.52% [Cohen's k=0.89; 95% CI (0.82, 0.97); P=0.001]. The internal consistency of INDT-ASD was 0.96. The convergent validity with CARS (r = 0.73, P= 0.001) and divergent validity with Binet-Kamat Test of intelligence (r = -0.37; P=0.004) were significantly high. INDT-ASD has a 4-factor structure explaining 85.3% of the variance.

CONCLUSIONS

INDT-ASD has high diagnostic accuracy, adequate content validity, good internal consistency high criterion validity and high to moderate convergent validity and 4-factor construct validity for diagnosis of Autistm spectrum disorder.

Comparison of the Diagnostic Accuracy and Validity of a Short Version of Teen Screen Questionnaire-Mental Health (TSQ -M-Short) for Use in Community

BACKGROUND

A few self-administered questionnaires are available for assessing mental health among adolescents in primary-care settings. Brief measures are desirable for use in big-data, epidemiological studies.

OBJECTIVES

To evaluate a 7-item version, of the Teen Screen Questionnaire-Mental Health (TSQ-M), the TSQ-M-Short.

MATERIALS AND METHODS

In this prospective cross-sectional study of 140 adolescents, recruited from 6 rural or urban schools, the newly developed TSQ-M-Short as the measure for validation and General Health Questionnaire-12 item (GHQ-12) as the gold standard measure were administered by independent trained raters. Tests for diagnostic accuracy and validity were conducted.

RESULTS

A total TSQ-M-Short score of ≥ 6 had a sensitivity of 76%, specificity of 74%, positive likelihood ratio of 2.99, negative likelihood ratio of 0.33, positive predictive value of 6% and a negative predictive value of 82.1%. The area under curve (AUC) in the Receiver Operating Characteristic (ROC) for the TSQ-M-Short version was 0.84 (95% cumulative incidence (CI) = 0.76-0.89). The AUC for the TSQ-M-Short version was higher than the AUC for the original version, and the difference between the areas was 0.10 (95% CI = 0.02-0.19), which was statistically significant (z = 2.49; P = 0.01). The internal consistency of TSQ-M-Short, as measured by chronbach's α, was 0.34 (95% CI = 0.15-0.48). The construct validity demonstrated a 3-factor structure, which explained 55% of the variance.

CONCLUSION

The TSQ-M-Short has an overall diagnostic accuracy which is better than the original TSQ-M. Although the original version includes symptoms for more mental health disorders, providing a wider screen. This short version will prove useful in big-data studies.

Feeding problems among children with autism in a clinical population in India

OBJECTIVES

To compare the prevalence and profile of feeding problems (FP) and their relationship with sensory processing in children with autism and intellectual disability (ID).

METHODS

Children between ages 3 to 10 y with autism (N = 41) and ID (N = 56) were recruited and assessed with Brief Autism Mealtime Behavior Inventory, Sensory Profile Questionnaire, Childhood Autism Rating Scale and Binet-Kamat Scale of Intelligence or Gesell's Developmental Schedule. Assessments were done by independent raters. Bivariate and multivariate analyses were used appropriately.

RESULTS

The prevalence of FP were 61 and 46.4% among children with autism and ID respectively. Feeding problems were severe among children with autism (P 0.001), especially in young children with autism (P 0.05), and gender was not related to FP. Disruptive meal-time behaviors (P 0.001) and food over-selectivity (P 0.02) were significantly more among children with autism in the bivariate and multivariate analysis. Feeding problems and various dimensions of sensory processing were significantly associated after controlling the confounders.

CONCLUSIONS

These findings underscore the need for mandatory assessment of FP in children with developmental disabilities, and if present, they need to be addressed with multimodal-multidisciplinary interventions.

CDC Kerala 17: Early detection of developmental delay/disability among children below 3 y in Kerala--a cross sectional survey

OBJECTIVE

To conduct a community survey to understand the prevalence and type of developmental delay/disability among a representative state wide community sample of children below 3 y.

METHODS

A state wide community based cross sectional survey was done with the help of the Integrated Child Development Services (ICDS) network in Kerala after giving one day training program at Child Development Centre (CDC), for one randomly selected anganwadi worker in each of the panchayath/municipal ward, from all districts of Kerala, to equip them to screen all children below 3 y in their anganwadi areas, using simple community screening tools like Trivandrum Developmental Screening Chart (TDSC) 0-3 and Language Evaluation Scale Trivandrum (LEST) 0-3. Those children with one or more item delay in TDSC or LEST were called to the developmental evaluation camps held at ICDS block level and trained pediatrician/medical officer re-evaluated the children with developmental delay.

RESULTS

A total of 32,664 children below 3 y were screened across the state and overall 2.5% prevalence of developmental delay was observed using TDSC and 2.8% using LEST 0-3 y and 3.4% using TDSC and/or LEST positive. Out of the total 1,110 children clinically evaluated by a trained pediatrician, 69.3% children had developmental delay, 14.3% speech delay, 5.7% global delay, 5.3% gross motor delay and 3.6% suspected of hearing impairment.

CONCLUSIONS

The study results showing 3.4% prevalence of developmental delay using TDSC and/or LEST by trained anganwadi workers or ASHA workers could be replicated in other states in India, under Rashtria Bal Swasthya Kariyakram.

CDC Kerala 2: Developmental intervention package for babies <1,800 g--outcome at 6 mo using DASII

OBJECTIVES

To describe the experience of using developmental intervention package among low birth weight babies less than 1,800 g and developmental outcome at the end of 6 mo monthly intervention.

METHODS

Babies below 1,800 g, discharged from neonatal intensive care unit (NICU) of Sree Avittom Thirunal (SAT) hospital, over the last 3 y, were followed at Child Development Centre (CDC) Kerala and offered monthly evaluation by different tools and developmental intervention using a package by trained developmental therapists and mothers were encouraged to continue the same at home. At the end of 6 mo the developmental outcome was assessed using Developmental Assessment Scale for Indian Infants (DASII).

RESULTS

Out of a total of 821 babies enrolled for early stimulation program, 740 babies successfully completed 6 mo follow up and stimulation program. Comparing the outcome at 4 and 6 mo, both grading for head holding and gross motor part of DDST showed a statistically significant reduction in abnormal findings. At 6 mo assessment on DASII, motor DQ abnormalities were a high 80% for 600-900 g, as against 17.1% abnormalities for 1,500-1,800 g birth weight group.

CONCLUSIONS

The results of this intensive early stimulation program for babies below 1,800 g have shown the importance of monthly early intervention using a mother oriented systematic developmental stimulation package.

CDC Kerala 1: Organization of clinical child development services (1987-2013)

OBJECTIVE

The main objective of establishing the Child Development Centre (CDC), Kerala for piloting comprehensive child adolescent development program in India, has been to understand the conceptualization, design and scaling up of a pro-active positive child development initiative, easily replicable all over India.

METHODS

The process of establishing the Child Development Centre (CDC) Kerala for research, clinical services, training and community extension services over the last 25 y, has been as follows; Step 1: Conceptualization--The life cycle approach to child development; Step 2: Research basis--CDC model early stimulation is effective; Step 3: Development and validation of seven simple developmental screening tools; Step 4: CDC Diagnostic services--Ultrasonology and genetic, and metabolic laboratory; Step 5: Developing seven intervention packages; Step 6: Training--Post graduate diploma in clinical child development; Step 7: CDC Clinic Services--seven major ones; Step 8: CDC Community Services--Child development referral units; Step 9: Community service delivery models--Childhood disability and for adolescent care counselling projects; Step 10: National capacity building--Four child development related courses.

RESULTS

CDC Kerala follow-up and clinic services are offered till 18 y of age and premarital counselling till 24 y of age as shown in "CDC Kerala Clinic Services Flow Chart" and 74,291 children have availed CDC clinic services in the last 10 y.

CONCLUSIONS

CDC Kerala is the first model for comprehensive child adolescent development services using a lifecycle approach in the Government sector and hence declared as the collaborative centre for Rashtriya Bal Swasthya Karyakram (RBSK), in Kerala.

CDC Kerala 13: Antenatal, natal and postnatal factors among children (2-6 y) with autism--a case control study

OBJECTIVES

To compare antenatal, natal and postnatal factors among children between 2-6 y of age with autism and a control group of normal children.

METHODS

One hundred and forty three confirmed cases of 2-6 y-old children with autism, attending autism clinic of Child Development Centre, who had a CARS score of ≥ 30 were included in the study. Two hundred normal children in the same age group were recruited from the well-baby/immunization clinic of SAT Hospital, Thiruvananthapuram. Data was collected using a structured pre-piloted questionnaire consisting of 21 antenatal, 8 natal and 6 postnatal risk factors.

RESULTS

The multivariate analysis on antenatal, natal and postnatal possible risk factors for autism showed statistically significant high odds ratios for (i) excess fetal movement (OR = 11.44; 95% CI: 2.85-45.98); (ii) maternal respiratory infection/asthma (OR = 6.11; 95% CI: 1.56-24.02; (iii) maternal vaginal infection (OR = 5.20; 95% CI: 1.72-15.73); (iv) maternal hypothyroidism (OR = 4.25; 95% CI: 1.38-13.07) and (v) family history of neuro-developmental disorders (OR = 2.90; 95% CI: 1.72-4.88).

CONCLUSIONS

This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that excess fetal movement, maternal respiratory infection/asthma, maternal vaginal infection, maternal hypothyroidism and family history of neuro-developmental disorders are possible risk factors for autism.

CDC Kerala 16: Early Detection of developmental delay/disability among children below 6 y--a district model

OBJECTIVE

To develop a district model for establishing early detection of childhood disability below 6 y of age and to develop appropriate referral linkages for confirmation of the diagnosis and establish home based early intervention therapy to all needy children.

METHODS

Trained Accredited Social Health Activist (ASHA) workers conducted the preliminary survey for identifying developmental delay/disability among children below 6 y of age using Trivandrum Developmental Screening Chart (TDSC) (0-6 y) and a team of experts assessed the screen positives in developmental evaluation camps conducted at primary health centres (PHCs).

RESULTS

Community survey was carried out and 1,01,438 children below 6 y of age in Thiruvananthapuram district were screened by ASHA workers and 2,477 (2.45%) positive cases (TDSC two or more item delay) were identified and these children were called for the developmental evaluation camps conducted at 80 PHCs in the district. Among the 1,329 children who reached the evaluation camps 43.1% were normal. 24.98% children had speech and language delay and 22.95% children had multiple disabilities. Developmental delay was observed among 49.89% children and cerebral palsy in 8.43% and intellectual disability 16.85% were confirmed. Visual impairment in 3.31% and neuromuscular disorders in 1.35 were found among children evaluated in the camp.

CONCLUSIONS

The results of this district wide early detection of disability survey by trained ASHA workers among children below 6 y of age showed a community prevalence of 3.08% observed, based on two or more item delay in TDSC and among these children, 43.1% were normal, 49.89% had developmental delay, 24.98% had speech and language delay and 22.95% had multiple disabilities.

CDC Kerala 7: Effect of early language intervention among children 0-3 y with speech and language delay

OBJECTIVE

To assess the effect of systematic clinic and home based early language intervention program in children reporting to the early language intervention clinic with full partnership of specially trained developmental therapist and the parents.

METHODS

All babies between 0 and 3 y referred to Child Development Centre (CDC) Kerala for suspected speech/language delay were assessed and those without hearing impairment were screened first using Language Evaluation Scale Trivandrum (LEST) and assessed in detail using Receptive Expressive Emergent Language Scale (REELS). Those having language delay are enrolled into the early language intervention program for a period of 6 mo, 1 h at the CDC clinic once every month followed by home stimulation for rest of the month by the mother trained at CDC.

RESULTS

Out of the total 455 children between 0 and 3 y, who successfully completed 6 mo intervention, the mean pre and post intervention language quotient (LQ) were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant. The developmental diagnosis included developmental delay (62.4%), global developmental delay (18.5%), Trisomy and other chromosomal abnormalities (10.5%), microcephaly and other brain problems (9.9%), misarticulation (8.4%), autistic features (5.3%) and cleft palate and lip (3.3%) in the descending order.

CONCLUSIONS

In the present study among 455 children between 0 and 3 y without hearing impairment, who successfully completed 6 mo early language intervention, the mean pre and post intervention LQ were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant.

CDC Kerala 9: Effectiveness of low intensity home based early intervention for autism spectrum disorder in India

OBJECTIVE

To validate effectiveness of low intensity, home based early intervention (EI) models in autism for countries with low disability resources.

METHODS

Fifty-two toddlers and young children were assessed before and after intervention with Childhood Autism Rating Scale, Vineland Social Maturity Scale, and Receptive-Expressive Emergent Language Scale. Developmental and speech therapists helped mothers assemble low-cost training kits based on the developmental age of the child, gave initial training in the basic behavioral technique to address the three autism symptom clusters at home. Follow-up support was given either on a weekly, fortnightly or monthly basis. Most of the children were also placed in play-schools. Data was analyzed using appropriate bivariate and multivariate techniques.

RESULTS

There was statistical and clinical amelioration in the severity of autism, with acquisition of social skills and language skills (all P = 0.001) after intervention in children with mild to severe autism. Gender showed a trend in becoming a significant predictor for intervention response.

CONCLUSIONS

Low-intensity, home-based EI can be effectively used in situations where there is paucity of disability resources in countries like India, especially in primary-care and community settings.

CDC Kerala 10: Diagnostic accuracy of the severity scores for childhood autism rating scale in India

OBJECTIVE

To document the diagnostic accuracy of the Childhood Autism Scale (CARS) thresholds to identify mild, moderate and severe autism in India.

METHODS

The CARS scores of 623 children, with and without autism were compared against the Diagnostic and Statistical Manual for Mental Disorders 4th edition (DSM-IV-TR) for ASD diagnosis and clinical consensus between two developmental paediatricians as the reference standard for autism severity using the Receiver operating characteristics (ROC) curve analyses and contingency tables.

RESULTS

The CARS total score for mild, moderate and severe autism ranged from 30.5 to 35, 35.5-40 and ≥40.5 respectively in this study. The overall diagnostic accuracy of CARS total score in the mild range was moderate [AUC = 0.68 (95%CI = 0.62-0.88), z = 1.34; P = 0.18], moderate range was high [AUC = 0.90 (95%CI = 0.77-0.97), z = 8.62; P = 0.0001] and severe range was also high [AUC = 0.85 (95%CI = 0.77-0.90), z = 7.09; P = 0.0001].

CONCLUSIONS

There are validated severity scores for Childhood Autism Rating Scale for clinical and research use in India.

Sensory Profile Caregiver Questionnaire: a measure for sensory impairment among children with developmental disabilities in India

OBJECTIVE

There is no validated measure for assessing sensory processing among children with Developmental Disorders (DD) in India, and therefore, the authors validated the Sensory Profile Caregiver Questionnaire (SPCQ).

METHODS

Parents of 119 children with DD or typical development completed the SPCQ. The diagnosis of DD was confirmed by psychologists using standardized measures. Two experienced occupational therapists independently diagnosed sensory processing dysfunction by consensus as reference standard diagnosis. The convergent and divergent validity were assessed by another rater. The data was analyzed for diagnostic accuracy, reliability and validity appropriately.

RESULTS

A total SPCQ score of ≤ 481 (Sn = 81.58%, Sp = 85.19%; AUC = 0.90, z = 14.95; P 0.0001) is appropriate for the diagnosis of sensory processing dysfunction. The inter-rater reliability (ICC = 0.87), test- retest reliability (ICC = 0.90), internal consistency (Cronbach's α = 0.86), section-total correlation, face and content validity for the SPCQ were good. Convergent validity with the Sensory Processing Measure (r = -0.76, P 0.001), and divergent validity with the subscale scores for social skills/ oppositional behavior of ADD-H Comprehensive Teacher Rating Scale (r = 0.32; P 0.1/ r = 0.08; P 0.6) was established.

CONCLUSIONS

The SPCQ has adequate psychometric properties for use in the Indian population for identifying sensory processing dysfunction.

A meta-analysis of the diagnostic accuracy of Autism Diagnostic Observation Schedule Module-1 for autism spectrum disorders

OBJECTIVE

Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated the cumulative diagnostic accuracy of ADOS-Module 1 (ADOS(M1)) using the original diagnostic algorithm with meta-analysis and meta-regression.

METHODS

The authors, electronically and manually searched for studies from 1999 to 2013 that evaluated the accuracy of ADOS(M1) using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOS(M1) were summarized using random-effects model. Summary Receiver Operating characteristic Curves and its Area Under the Curve (SROC-AUC) were used to summarize overall diagnostic accuracy of ADOS(M1). The modifying effects of quality of study and sample size, on the diagnostic odds ratio, were investigated using meta-regression.

RESULTS

A total of 7 cross-sectional studies provided data on 4057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOS (M1) were: 0.91 (95 %CI=0.89 to 0.93), 0.73 (95 % CI=0.69 to 0.76), 44.20 (95 %CI=15.89 to 122.95) and 0.90 respectively [corrected]. Meta-regression analysis showed a non-significant relationship between ADOS(M1) and study quality as well as sample size. There were subgroup differences in the DOR.

CONCLUSIONS

It is concluded that ADOS (M1) with the original diagnostic algorithm has the overall diagnostic accuracy and pooled specificity suggesting moderate accuracy. The pooled sensitivity is high to be used as a screening test for Autism Spectrum Disorders. ADOS( M1)with the revised diagnostic algorithm should be used for diagnostic purpose [corrected] ADOS(M1) with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders.

CDC Kerala 4: TDSC items based developmental therapy package among low birth weight babies--outcome at 18 months using DASII

OBJECTIVE

To assess the effectiveness of Trivandrum Developmental Screening Chart (TDSC) items based intervention package developed at Child Development Centre, Kerala on the developmental outcome of children at 18 mo of age using Developmental Assessment Scale for Indian Infants (DASII) and compare the same in different birth weight groups.

METHODS

Five hundred consecutive discharges from the Neonatal Intensive Care Unit (NICU), Sree Avittam Thirunal hospital, were recruited and followed up till 18 mo of age including 240 low birth weight (LBW;<2,500 g) babies and 260 normal birth weight babies. All 240 LBW babies were offered early intervention at monthly intervals till 12 mo of age, whereas the normal birth weight (NBW) group received only immunization service as per the routine of the hospital. The early intervention package for the low birth weight group was designed based on Trivandrum Developmental Screening Chart (TDSC 0-2 y) items delay. At 18 mo of age both the groups were offered developmental assessment using DASII by specially trained and experienced developmental therapists who were blind to the intervention status of the babies.

RESULTS

It was observed that the LBW (<2,500 g) group, who received intervention had a DASII mental age of 18.31 as against 18.16 in the NBW (≥2,500 g) group and mental DQ 101.84 (LBW group) and 98.65 (NBW group) and the observed differences were not statistically significant. Similarly, the LBW, who received intervention group had a DASII motor age of 18.68 as against 18.47 in the NBW group and motor DQ 139.40 (LBW group) and 135.39 (NBW group) and the observed differences were not statistically significant.

CONCLUSIONS

The results of this TDSC based intervention package among low birth weight babies showed that at 18 mo of age there was no statistically significant difference in the developmental outcome using DASII, between low birth weight babies on intervention and the normal birth weight babies without any intervention.

CDC Kerala 14: Early child care practices at home among children (2-6 y) with autism--a case control study

OBJECTIVES

To compare early child care practices at home as possible risk factors among children between 2 and 6 y of age with autism and a control group of normal children without any symptom of autism, presenting at the well-baby/immunization clinic.

METHODS

This case control study was undertaken at the autism clinic of CDC Kerala, comparing possible risk factors for autism among 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children of the same age from well-baby/immunization clinic of SAT hospital. The data was collected using a structured pre-piloted questionnaire, which included 11 questions administered by the same senior social scientist, on early child care practices at home that have been universally considered as important for child development.

RESULTS

On multivariate analysis on early child care practices at home as possible risk factors for autism, it was observed that statistically significant high odds ratios were present for (i) no outings (OR = 3.36; 95% CI: 1.39-8.16; p 0.007); (ii) child does not play with children of same age (OR = 19.57; 95% CI: 9.50-40.32); (iii) do not tell stories/sing songs to the child (OR = 3.21; 9 % CI: 1.61-6.41); and (iv) breastfeeding duration nil/ < 6 mo (OR = 3.40; 95% CI: 1.28-8.99).

CONCLUSIONS

This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that early child care practices at home, specifically breastfeeding duration nil/ < 6 mo, child does not play with children of same age, do not tell stories/sing songs to the child and no outings for the child are possible risk factors for autism.

Comparison of burden among primary care-givers of children with autism and intellectual disability against children with intellectual disability only in a hospital population in India

OBJECTIVE

To compare the burden among the primary caregivers (PCG) of children with autism and intellectual disability (ASD + ID) against intellectual disability (ID) only, and identify the factors that predict high caregiver burden.

METHODS

Children with either ASD + ID (N = 41) or ID (N = 56) and their PCG were recruited and assessed using the Family Burden Interview Schedule, Binet Kamat Scale of Intelligence or Gesell's Developmental Schedule and Vineland Social Maturity Scale, Childhood Autism Rating Scale, Sensory Profile and Brief Autism Mealtime Behavior Inventory after collecting the socio-demographic details. Appropriate bivariate and multivariate statistical test were used.

RESULTS

The total burden and level of burden was similar among PCG of children with ASD + ID and ID (P = 0.8). However, financial burden (P = 0.03) and burden due to the effects on the physical health of other family members (P = 0.03) was more among the ID group. The burden due to the effects on family interaction was more (P = 0.009) in the ASD + ID group. The socio-economic status (OR = 3.60; P = 0.03) and the kinship of the primary care-giver (OR = 0.37; P = 0.008) were significantly associated with high level of burden. In addition, the diagnosis, and gender of the child contributed to the prediction model for high level of burden.

CONCLUSIONS

The interventions for children with ASD + ID and ID should have modules to address burden among PCG. Disability specific burden alleviating strategies should be used among PCG who are at risk of having high burden.

ADD-H-Comprehensive Teacher's Rating Scale (ACTeRS): a measure for attention deficit hyperactivity disorder among children with intellectual disability in India

OBJECTIVE

There is no validated measure for assessing Attention Deficit Hyperactivity Disorder (ADHD) in India, and therefore, the authors validated the ADD-H Comprehensive Teacher's Rating Scale (ACTeRS).

METHODS

Teachers/parents/clinicians of 110 children with ADHD completed the ACTeRS. The diagnosis of ADHD was confirmed by an independent multi-disciplinary team using ICD-10 diagnosis for diagnostic accuracy and criterion validity. The convergent and divergent validity were assessed by another rater. The data was analyzed for diagnostic accuracy, reliability and validity appropriately.

RESULTS

An ACTeRS score of ≥61 [Sensitivity (Sn) =85.51%; Specificity (Sp) = 90.24%; Area under the curve (AUC) = 0.94] is appropriate for the diagnosis of ADHD. The test-re-test reliability [Intra-class correlation coefficient (ICC) = 0.87], internal consistency (Cronbach's α = 0.80; range of 0.89-0.93), section-total correlation, face and content validity for the ACTeRS were good. Convergent validity of attention deficit, hyperactivity and oppositional subscales of ACTeRS with the corresponding subscales of Swanson, Nolan & Pelham Rating Scale-Revised (SNAP-IV) was moderate (r = 0.60, P = 0.005; r = 0.49, P = 0.02; r = 0.58, P = 0.008 respectively), and negative correlation with the Childhood Autism Rating Scale (r = -0.36; P =0.1) for divergent validity was found. The criterion validity analysis showed a high concordance rate of 82.52% between ACTeRS and International Classification of Diseases, Edition10 (ICD-10) diagnosis of ADHD. A 4-factor structure was replicated.

CONCLUSIONS

The ACTeRS has adequate psychometric properties for use in the Indian population for identifying ADHD.

CDC Kerala 3: At-risk baby clinic service using different screening tools--outcome at 12 months using Developmental Assessment Scale for Indian Infants

OBJECTIVES

To describe CDC Kerala experience of establishing an at-risk baby clinic and the comparison of different developmental screening tools at 12 mo against the gold standard Developmental Assessment Scale for Indian Infants (DASII).

METHODS

At risk baby clinic of CDC, Kerala was established as a facility for follow up of NICU graduates from Sree Avittam Thirunal Hospital at 2, 4, 6, 8 and 12 mo corrected age and during each visit the mother is taught the CDC model early stimulation by developmental therapists and encouraged to continue to do the same at home. At 12 mo, assessment results of four simple developmental tools were compared with the gold standard DASII administered by a senior developmental therapist.

RESULTS

Out of a total of 800 babies, outcome measurements at 12 mo were available for 604 infants. The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and using DASII, a diagnostic tool (13.3%). Also the combination of Amiel Tison angles, CDC standing grading and DDST gross motor against DASII motor DQ had high specificity (94.15%) and negative predictive value (NPV) (70.18%) but with a very low sensitivity of 14.58% and low positive predictive value (PPV) of 53.85%. It was observed that a significant odds ratio for DASII mental deviation quotient (DQ) was seen for neonatal seizures (2.34) and low birth weight (1.49).

CONCLUSION

The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and together they had a high specificity, NPV and accuracy against DASII motor DQ as gold standard at one year assessment.

CDC Kerala 5: Developmental therapy clinic experience--use of Child Development Centre grading for motor milestones

OBJECTIVES

To document the experiences of the intervention given to children who attended the developmental therapy clinic of Child Development Centre (CDC) Kerala, a specialized clinic for providing developmental intervention/therapy for babies less than two years with developmental delay/disability.

METHODS

All the babies referred to this speciality clinic from developmental screening/evaluation clinics of CDC were registered in the clinic and re-evaluation was done using CDC grading for head holding, sitting, standing, Amiel Tison passive angles, and Trivandrum Developmental Screening Chart (TDSC) 0-2 y.

RESULTS

Out of a total of 600 consecutive babies below 2 y with developmental delay/disability referred to developmental therapy clinic, on comparing the test results at enrollment and after 6 mo of intervention, a statistically significant reduction was observed (i) in the 2-4 mo age group with regard to abnormal TDSC (25.5%), (ii) in the 4-8 mo age group with regard to abnormal head holding grade (87.1%) and abnormal TDSC (19.4%), (iii) in the 8-12 mo age group, with regard to abnormal sitting grade (71.7%) and (iv) in the above 12 mo age group with regard to abnormal sitting grade (35.3%) and abnormal standing grade (78.8%).

CONCLUSIONS

The experience of organizing the developmental intervention/therapy clinic at CDC Kerala has shown that therapy services by developmental therapists in a centre and supportive therapy by mother at home is useful in improving the developmental status of children with developmental delay.

CDC Kerala 15: Developmental Evaluation Clinic (2-10 y)--developmental diagnosis and use of home intervention package

OBJECTIVE

To describe the last 5 years' experience of Child Development Centre (CDC), Kerala Developmental Evaluation Clinic II for children between 2 and 10 y, referred for suspicion of developmental lag in the preschool years and scholastic difficulty in the primary classes with specific focus on developmental profile and the experience of the home based intervention package taught to the mothers.

METHODS

A team of evaluators including developmental therapist, preschool teacher with special training in clinical child development, speech therapist, special educator, clinical psychologist and developmental pediatrician assessed all the children referred to CDC Kerala. Denver Developmental Screening Test (DDST-II), Vineland Social Maturity Scale (VSMS) and Intelligent Quotient (IQ) tests were administered to all children below 6 y and those above 6 with apparent developmental delay.

RESULTS

Speech/delay (35.9%), behavior problem (15.4%), global delay/ intellectual disability (15.4%), learning problem (10.9%), pervasive developmental disorders (7.7%), seizure disorder (1.7%), hearing impairment (0.7%), and visual impairment (0.7%) were the clinical diagnosis by a developmental pediatrician. Each child with developmental problem was offered a home based intervention package consisting of developmental therapy and special education items, appropriate to the clinical diagnosis of the individual child and the same was taught to the mother.

CONCLUSIONS

The experience of conducting the developmental evaluation clinic for children between 2 and 10 y has shown that a team consisting of developmental therapist, speech therapist, preschool teacher, special educator, clinical child psychologist and developmental pediatrician, using appropriate test results of the child could make a clinical diagnosis good enough for providing early intervention therapy using a home based intervention package.

ICD-10 and alternative diagnostic criteria for childhood autism among children with intellectual disability

OBJECTIVES

The diagnosis of Childhood Autism (CA) among children with Intellectual Disability (ID) based on clinical criteria validated for populations with average intelligence compromises it's diagnostic accuracy in this special population. This study documents the diagnostic accuracy of ICD-10 and alternative criteria for CA in ID population.

METHODS

Consensus clinical diagnosis of autism made by a multi-disciplinary team as the reference data were extracted from the case notes and psychological tests details by two trainee psychologists, and ICD-10 based clinical diagnosis, demographics, ID, CA related data documented independently of the psychiatrist. The appropriate statistical analyses were completed.

RESULTS

Repetitive behaviors formed the most common symptom cluster. The high internal consistency (κ = 0.75) among the three groups of ICD-10 symptoms indicate their usefulness in the diagnosis of CA among children with ID, but significantly more children with ID failed to meet the ICD-10 criteria for CA. The fourth alternative criteria had the highest concordance with the reference standard (100%) and the first alternative criteria had the highest agreement with the reference standard (κ = 0.88) in identifying CA among ID. The diagnostic accuracy of all the alternative criteria was significantly better than that of ICD-10 with the first alternative criteria having the best diagnostic accuracy (Sn = 98%; Sp = 100%; PPV = 1; NPV =0.83) closest to the reference standard.

CONCLUSIONS

The symptom clusters in ICD-10 for CA should be retained, however reorganising the diagnostic criteria is required for diagnosing CA accurately among children with ID. The first alternative criteria can significantly improve the case identifying ability and diagnostic accuracy altering there by the epidemiological data on Childhood Autism among children with Intellectual Disability.