The assessment of preschool children with ESSENCE symptoms: concordance between parents, preschool teachers and child psychologists

BACKGROUND

It is important to detect children with Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE) in order to implement early intervention and support for the child and family. Standardized instruments for assessment in different contexts of behaviour problems, engagement and psychosocial health obtain an objective picture of the preschool child's mental health.

AIM

To explore and compare parents', preschool teachers' and child health care psychologists' assessment of behaviour, everyday function, engagement, social interaction and psychosocial health in children with ESSENCE symptoms.

METHOD

Parents of 152 children (114 boys and 38 girls, 4.5 ± 1 years) with ESSENCE symptoms, 155 preschool teachers and 8 child psychologists participated. Parents and preschool teachers assessed externalizing and internalizing behavioural problems using the Strengths and Difficulties Questionnaire (SDQ), including the SDQ supplement for assessing the impact of behavioral problems on daily function. Preschool teachers also assessed engagement and social interaction using the Children's Engagement Questionnaire (CEQ), and the child psychologists assessed psychosocial health with the Child Psychosocial Health Assessment (LillaLAPS) and template in conversations with parents of children with neurodevelopmental problems.

RESULTS

Parents', preschool teachers' and child psychologists' assessment of the child's ESSENCE symptoms overall agreed. Both parents and preschool teachers see a strength in the child's social abilities. Differences in mean values show that parents assess more conduct, emotional symptoms and problems in daily life and more social skills, compared to the preschool teachers rating more peer problems.

CONCLUSION

It is important to consider different contexts to identify the child's need for support in everyday life. Expanded use of validated screening instruments in clinical practice would promote detection of children not already identified as exhibiting neurodevelopmental problems.

A randomized controlled trial of a new intervention in early symptomatic syndromes eliciting neurodevelopmental clinical examinations: PR-ESSENCE

The need for effective intervention programs for youth with neurodevelopmental problems (ESSENCE) and challenging behaviour is great. This study examines Problem Resolution in ESSENCE (PR-ESSENCE), a newly developed model in which children and parents develop mutual problem resolution strategies. Ten-week randomized controlled trial of PR-ESSENCE for children and adolescents aged 5-18 years, compared to treatment as usual. Outcomes were assessed at baseline and randomized period endpoint. Primary outcome was the Clinical Global Impression-Improvement scale (CGI-I) rated by blinded assessors. Secondary outcomes were rated by parents-SNAP-IV, Eyberg Child Behavior Inventory (ECBI), Relationship Problems Questionnaire, Family Burden of Illness Module, and children-Beck Youth Inventories (BYI). ClinicalTrials.gov identifier: NCT03780413. The study enrolled 108 participants (active n = 72; controls n = 36, randomized 2:1), of whom 95 completed the randomized period. No clinically significant group differences were found in baseline characteristics. More than half had autism and 80% had ADD or ADHD. Large treatment effects were seen on CGI-I (ITT analysis, Effect Size 1.48). Treatment responders, much/very much improved on CGI-I, were 51.4% in active group and 5.6% of controls. Effect sizes were medium to large in parent ratings on SNAP-IV (ODD and ADHD symptoms), ECBI (behaviour problems), and in BYI child self-ratings of disruptive behaviour. PR-ESSENCE treatment improved global symptoms and functioning (CGI-I), behaviour problems, ADHD and ODD symptoms, and disruptive behaviour. Treatment effects were at least equivalent to those in previous studies of well-established Parent Management Training and Collaborative Problem Solving programs.

Neurodevelopmental problems in children with febrile seizures followed to young school age: A prospective longitudinal community-based study in Sweden

AIM

To estimate the accumulated prevalence of neurodevelopmental problems from preschool to school age in children with a history of febrile seizures (FS).

METHODS

In a community-based cohort of children with previous FS, 25/73 clinically assessed children met diagnostic criteria for neurodevelopmental disorders or had major indications of such problems at the age of 4-5 years. Parents of 54 of the 73 children accepted to take part in an interview according to the Autism-Tics, ADHD and other Comorbidities (A-TAC) inventory, when the children were 9-10 years.

RESULTS

There was a trend for ADHD symptom scores to be higher in the FS group. Non-participants at age 9-10 years had had much higher rates of neurodevelopmental problems at 4-5 years, and the total number of such problems at either 4-5 or age 9-10 was 41% (30/73).

CONCLUSION

High rates of neurodevelopmental problems (41%) were found at either age 4-5 or 9-10 years or both in this group of 73 children with FS. Non-participants at 9-10 years had had much higher rates of neurodevelopmental problems at 4-5 years. Further follow-up of this cohort is needed before definite conclusions can be drawn about whether FS should be considered a marker for more complex neurodevelopmental problems.

The ESSENCE-Questionnaire in Medical Records Screening for Neurodevelopmental Symptoms/Problems: Utility and Clinical Validity

PURPOSE

Determine the prevalence of symptoms of neurodevelopmental problems (NDPs) with a semi-structured review of fourth grade students' medical records, its interrater agreement and validity as compared with clinical assessment.

METHODS

A school-based sample of 11-year-old children provided child health care (CHC) records and school health care (SHC) records. A pediatric neurologist, child psychiatrist and an adult psychiatrist scored the records, with the "Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations-Questionnaire" (ESSENCE-Q, 12 items scored 0-2, summary score range 0-24). Agreement was measured with model-based kappa and intraclass correlation coefficient (ICC). Ratings were validated against a multidisciplinary assessment involving a physician, psychologist, teacher- and parental behavioral rating scales rendering a clinical global impression severity rating (CGI-S, range 1-7) of NDPs.

RESULTS

Out of 223 participants, medical charts were available from 201, of whom 169 were rated by all three raters. Kappa agreement was moderate/strong (~0.8) for 7 of the 12 questionnaire items. Measured with the ICC, concordance in the summary score was good for agreement (~0.8) and excellent (~0.9) for consistency. Test-retest reliability was excellent (ICC = ~0.9). Area under the curve for the ESSENCE-Q in predicting clinical-level problems (CGI ≥4) was ~80% for all three raters, albeit with differing optimal cutoffs.

CONCLUSION

Using the ESSENCE-Q as a template, NDPs appear to be common in medical records, are identified reliably, and predict clinical-level concern. Medical records screening may facilitate a structured review of medical records in work-ups or be applied in conjunction with other screening measures for neurodevelopmental disorders. However, differences in calibration currently preclude defining a universal cutoff for using the ESSENCE-Q for medical records screening.

Orofacial function in children with Speech Sound Disorders persisting after the age of six years

Purpose: The aim was to investigate, describe and analyse speech characteristics, intelligibility, orofacial function and co-existing neurodevelopmental symptoms in children with SSD of unknown origin, persisting after six years of age.Method: The study included 61 children with SSD (6-17 years) of unknown origin, referred for a speech and oral motor examination. The severity of SSD was estimated using Percentage Consonants Correct (PCC) and Percentage Vowels Correct (PVC) and assessments of resonance based on Swedish Articulation and Nasality Test (SVANTE). Orofacial function was screened using the Nordic Orofacial Test-Screening (NOT-S). Parents completed the Intelligibility in Context Scale (ICS) and a questionnaire including questions about heredity, medical and neurodevelopmental conditions, and speech development.Result: SSD varied according to PCC (8-95%) and PVC (55-100%) measurements. Percentages of co-occurring disorders included: 51% resonance deviations, 90% intelligibility issues, and 87% orofacial difficulties. The most affected orofacial domains were "Chewing and swallowing" (41%), "Masticatory muscles and jaw function" (38%) and "Sensory function" (38%). The majority (64%) had co-existing dysfunctions relating to general motor and neurodevelopmental disorders.Conclusion: Children with persistent SSD are at risk for orofacial dysfunction, general motor difficulties and other neurodevelopmental disorders and therefore should be screened for co-occurring disorders.

Borderline intellectual functioning

Borderline intellectual functioning (BIF), that is to say, tested IQ levels in the range of 70-84/85, is prevalent, affecting about 12%-14% of the population depending on the exact level for "diagnostic" cutoff. In the current Diagnostic and Statistical Manual of Mental Disorders, BIF does not have a separate diagnostic category but can be categorized with a V-code. Children and adolescents with BIF usually struggle both as regards school performance and in respect of social functioning. BIF is common in attention deficit hyperactivity disorder, but sometimes attention problems in schoolchildren with BIF may be a consequence of nonadapted academic demands. Autism and BIF may also coexist, and there are many cases of so-called high-functioning autism who are high functioning only in the sense that they do not meet criteria for intellectual disability, but function in the area of BIF. Currently, too little attention is given to the negative effects of BIF on child development and adaptation. Learning, academic, and behavioral problems and grade retention may be markers of BIF. Our diagnostic and classification manuals need to have specific categories that clarify the problems that BIF entails so that affected individuals can avail themselves of better educational support and understanding.

Integrating capacity development during digital health research: a case study from global health

Background: The Bloomberg Data for Health Initiative Research and Development Arm at Johns Hopkins University Bloomberg School of Public Health, has thus far collected NCD risk factor data from more than 13,000 citizens of three LMICs (Bangladesh, Tanzania and Uganda), and has actively worked to improve capacity with partners worldwide.

Objective: This paper focuses on how a research project, can also act as a capacity building activity through its research into collecting non-communicable disease risk factor data using different mobile phone modalities.

Methods: This paper evaluates the activities undertaken by the project using the ESSENCE Planning Monitoring and Evaluation Framework for Research Capacity Strengthening.

Results: The project was able to successfully integrate meaningful capacity development activities across all partners. Training, networking, sharing resources, joint data collection, and analysis across individual, organizational and project levels were some of the strategies used. The ESSENCE framework allowed a good assessment strategy for this type of work.

Conclusions: This paper highlights the value of making capacity development a high priority for digital health research activities, while also considering the need to monitor and evaluate those activities in order for them to be meaningful and sustainable. It also considers how to utilize the ESSENCE Framework to evaluate capacity development activities through research, and how best to adapt the Framework to different programs.

Young children who screen positive for autism: Stability, change and "comorbidity" over two years

BACKGROUND

Autism spectrum disorder (ASD) is a developmental disorder with a wide variety of clinical phenotypes and co-occurrences with other neurodevelopmental conditions. Symptoms may change over time.

AIMS

The aim of the present study was to prospectively follow 96 children, initially assessed for suspected ASD at an average age of 2.9 years.

METHODS AND PROCEDURES

All children had been identified with autistic symptoms in a general population child health screening program, and had been referred to the Child Neuropsychiatry Clinic in Gothenburg, Sweden for further assessment by a multi-professional team at Time 1 (T1). This assessment included a broad neurodevelopmental examination, structured interviews, a cognitive test and evaluations of the child́s adaptive and global functioning. Two years later, at Time 2 (T2), the children and their parents were invited for a follow-up assessment by the same team using the same methods.

OUTCOMES AND RESULTS

Of the 96 children, 76 had met and 20 had not met full criteria for ASD at T1. Of the same 96 children, 79 met full ASD criteria at T2. The vast majority of children with ASD also had other neurodevelopmental symptoms or diagnoses. Hyperactivity was observed in 42% of children with ASD at T2, and Intellectual Developmental Disorder in 30%. Borderline Intellectual Functioning was found in 25%, and severe speech and language disorder in 20%. The children who did not meet criteria for ASD at T2 had symptoms of or met criteria for other neurodevelopmental/neuropsychiatric disorders in combination with marked autistic traits. Changes in developmental profiles between T1 and T2 were common in this group of young children with ASD. The main effect of Cognitive level at T1 explained more than twice as much of the variance in Vineland scores as did the ASD subtype; children with IDD had significantly lower scores than children in the BIF and AIF group. Co-existence with other conditions was the rule.

CONCLUSIONS AND IMPLICATIONS

Reassessments covering the whole range of these conditions are necessary for an optimized intervention-adapted to the individual child's needs.

Febrile Seizures and Epilepsy: Association With Autism and Other Neurodevelopmental Disorders in the Child and Adolescent Twin Study in Sweden

BACKGROUND

There is a recently well-documented association between childhood epilepsy and earlysymptomaticsyndromeselicitingneurodevelopmentalclinicalexaminations (ESSENCE) including autism spectrum disorder, but the relationship between febrile seizures and ESSENCE is less clear.

METHODS

The Child and Adolescent Twin Study in Sweden (CATSS) is an ongoing population-based study targeting twins born in Sweden since July 1, 1992. Parents of 27,092 twins were interviewed using a validated DSM-IV-based interview for ESSENCE, in connection with the twins' ninth or twelfth birthday. Diagnoses of febrile seizures (n = 492) and epilepsy (n = 282) were based on data from the Swedish National Patient Register. Prevalence of ESSENCE in individuals with febrile seizures and epilepsy was compared with prevalence in the twin population without seizures. The association between febrile seizures and ESSENCE was considered before and after adjustment for epilepsy. Age of diagnosis of febrile seizures and epilepsy was considered as a possible correlate of ESSENCE in febrile seizures and epilepsy.

RESULTS

The rate of ESSENCE in febrile seizures and epilepsy was significantly higher than in the total population without seizures (all P < 0.001). After adjusting for epilepsy, a significant association between febrile seizures and autism spectrum disorder, developmental coordination disorder, and intellectual disability remained. Earlier age of onset was associated with all ESSENCE except attention-deficit/hyperactivity disorder in epilepsy but not with ESSENCE in febrile seizures.

CONCLUSIONS

In a nationally representative sample of twins, there was an increased rate of ESSENCE in childhood epilepsy and in febrile seizures. Febrile seizures alone could occur as a marker for a broader ESSENCE phenotype.

ESSENCE-Q - used as a screening tool for neurodevelopmental problems in public health checkups for young children in south Japan

BACKGROUND

Screening for developmental disorders is an important task for Child Health Care. The concept of ESSENCE (early symptomatic syndromes eliciting neurodevelopmental clinical examinations) was created to cover all types of early developmental disorders and the ESSENCE-Questionnaire (ESSENCE-Q containing 12 questions with possible total scores ranging from 0 to 22) was developed as a tool for early detection of these disorders. The aim of this study was to perform a validation study in a public health situation in Japan.

METHODS

The psychometric properties of the ESSENCE-Q, completed by mothers, public health nurses (PHNs), and psychologists at 18-month (n=143 children) and 36-month (n=149 children) checkups were evaluated in a small city of Japan. Results were validated against clinical ESSENCE diagnoses. Receiver operating characteristic curves were generated and compared by using the area under the curve (AUC). Optimal cutoff values were explored.

RESULTS

At the 18-month checkup, AUC by mothers was 0.72, by PHNs 0.86, and by psychologists 0.82. An optimal cutoff was 3 with a high negative predictive value (NPV). At the 36-month checkup, AUC by mothers was 0.57, by PHNs 0.82, and by psychologists 0.87. Optimal cutoff was 2 with high NPV.

CONCLUSION

The ESSENCE-Q completed by PHNs and psychologists had good diagnostic validity. The results suggested that almost all children scoring under cutoff would not have any ESSENCE problems/diagnoses.

A connective tissue disorder may underlie ESSENCE problems in childhood

BACKGROUND

Ehlers-Danlos syndrome hypermobility type, also known as Joint Hypermobility Syndrome (EDS-HT/JHS), is the most common hereditary disorder of the connective tissue (HDCT). It is characterized by tissue fragility, joint hypermobility and a wide range of articular and non-articular manifestations, which often appear in infancy. The clinical picture of EDS-HT/JHS is poorly known by the medical community, as is the presence of "ESSENCE" (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) problems in affected children.

AIM

The present work reviews the clinical and empirical evidence for ESSENCE difficulties in children with EDS-HT/JHS.

METHOD

A narrative review of the literature was undertaken following a comprehensive search of scientific online databases and reference lists. This included publications of quantitative and qualitative research.

RESULTS

Motor abnormality, hyperactivity/hypoactivity, inattention, speech/language, social interaction, behavioral, sleep, feeding and emotional problems are ESSENCE difficulties for which there is some evidence of an association with EDS-HT/JHS.

CONCLUSION

Children with EDS-HT/JHS present ESSENCE problems that often coexist and tend to be recognized before the HDCT. Clinicians encountering children with ESSENCE problems should consider the possibility of an underlying HDCT such as EDS-HT/JHS, probably influencing neurodevelopmental attributes in a subgroup of children. Awareness of these interconnected clinical problems might help improve early referral, diagnosis and treatment of EDS-HT/JHS.

Infant Motor Delay and Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations in Japan

BACKGROUND

Abnormalities of early motor development have been reported in autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual developmental disorder, developmental coordination disorder, and other Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations (ESSENCE). However, few studies have been conducted with a view to following up a clinically representative cohort of children coming for assessment of motor delay before age two years. We performed a prospective clinical cohort study to examine whether or not early motor delay is often an indication of ESSENCE.

METHODS

The sample comprised a one-year cohort of all children who came to a Japanese neurodevelopmental center before their second birthday because of delayed or abnormal gross motor development. The children were followed up from the ESSENCE viewpoint.

RESULTS

Of the 30 children, 28 (18 boys and 10 girls) (93%) were given diagnoses subsumed under the ESSENCE umbrella. Of the 15 children with an identified or strongly suspected etiology, 13 (8 boys and 5 girls) (87%) had ESSENCE disorders or symptoms. Of the 15 children without a known etiology, all had ESSENCE disorders or symptoms.

CONCLUSION

This study indicated that the vast majority of children with motor delay or abnormality in the first two years of life meet criteria for a disorder within the group of ESSENCE at follow-up; this means that young children, presenting with motor problems always need a broad clinical assessment, not just related to motor function, and systematic follow-up.

ESSENCE-Q - a first clinical validation study of a new screening questionnaire for young children with suspected neurodevelopmental problems in south Japan

BACKGROUND

Early identification of autism spectrum disorder, intellectual developmental disorder, attention-deficit/hyperactivity disorder, and other neurodevelopmental disorders/problems is crucial, yet diagnosis is often delayed for years under the often misguided "wait-and-see" paradigm. The early symptomatic syndromes eliciting neurodevelopmental clinical examinations-questionnaire (ESSENCE-Q) is a brief (12-item) screening questionnaire developed specifically for the purpose of speeding up the identification process of a wide variety of neurodevelopmental problems. The aims were to 1) estimate the reliability of the ESSENCE-Q, 2) evaluate the clinical cutoff levels suggested by the author of the ESSENCE-Q, and 3) propose optimal cutoff levels based on receiver operating characteristic analysis.

METHODS

The ESSENCE-Q was used for 1 year by a psychiatrist in Kochi, Japan, assessing children under the age of 6 years referred for developmental problems. The children were also clinically assessed with regard to whether or not they met criteria for a developmental disorder (diagnosis positive and diagnosis negative groups). We contrasted the results of the ESSENCE-Q and those of clinical diagnostic assessments in 130 cases.

RESULTS

Cronbach's alpha was 0.82, sensitivity was 0.94 (95% confidence interval [CI]: [0.88, 0.98]), and specificity 0.53 (95% CI: [0.28, 0.77]), which are reasonable psychometrics for a first-step screening tool. Based on receiver operating characteristic analysis, we recommended an optimal cutoff level of yes ≥2 or maybe/a little ≥3 on the ESSENCE-Q (0.87 (95% CI: [0.79, 0.92]) sensitivity and 0.77 (95% CI: [0.50, 0.93]) specificity).

CONCLUSION AND IMPLICATION

The ESSENCE-Q can be a good instrument for use as a screening tool for aiding in the process of early identification of neurodevelopmental disorders in clinical settings. To establish the broader validity and reliability of the ESSENCE-Q, case-control studies and general population studies of children in different age groups are needed.

Autism in community pre-schoolers: developmental profiles

Autism is often a complex developmental disorder. The aim of the present study was to describe the developmental characteristics of 129 1-4-year-old children (102 boys, 27 girls) referred for clinical assessment (mean age 2.9 years) due to suspicion of autism spectrum disorder (ASD) after community screening at Child Health Care centers. All children were clinically assessed at the Child Neuropsychiatry Clinic (CNC) in Gothenburg by a research team (neurodevelopmental examination, structured interviews and general cognitive and language examinations). Of the 129 children, 100 met diagnostic criteria for ASD (69 with autistic disorder, and 31 with atypical autism/pervasive developmental disorder-not otherwise specified). The remaining 29 children had a variety of developmental disorders, most often attention-deficit/hyperactivity disorder (ADHD), language disorder, borderline intellectual functioning, and intellectual developmental disorder (IDD) with (n=25) or without (n=4) autistic traits (AT). IDD was found in 36% of the 100 children with ASD, and in 4% of the 25 children with AT. Of the children with ASD, 56% had language disorder with no or just a few words at the initial assessment at the CNC, many of whom in combination with IDD. Hyperactivity was found in 37% of those with ASD and in 40% of those with AT. Epilepsy was found in 6% of the total group and in 7% of those with a diagnosis of ASD. Of the latter group 11% had a history of regression, while none of the AT cases had a similar background. When results were compared with a non-screened preschool ASD group of 208 children, referred for ASD intervention at a mean age of 3.4 years, very similar developmental profiles were seen. In conclusion, early community ASD screening appears to systematically identify those children who are in need of intervention and follow-up.