methodological challenges in … challenges in child neurodevelopmental assessment lisa thompson,...
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Methodological Challenges in Child Neurodevelopmental Assessment
Lisa Thompson, RN, FNP, PhD School of Nursing
University of California, San Francisco
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Neurodevelopmental Impairment (NDI)
• Disturbances in cognition, behavior, language development, motor skills and emotional regulation
• Higher rates of NDI in preterm infants and IUGR infants
• Higher rates of NDIs in LMICs • 80% of children with NDIs in LMICs • Mild impairment, if recognized early enough,
can be reversible with intervention
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Etiology of NDIs
• Pregnancy: Congenital infections, congenital hypothyroidism, congenital anomalies, maternal nutrition, environmental insults
• Delivery: Birth trauma, birth asphyxia, neonatal sepsis, jaundice
• Infancy: Protein-Energy Malnutrition, Micronutrient (Iodine, Vitamin A, Zinc, Iron) deficiency, , environmental insults
• Poverty
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Approaches
• Home-based screening questionnaires • Observer-rated child assessments • Age of assessment
– Hard to detect at very young ages (esp. speech, cognition, behavior)
– Important to detect and intervene at very young ages
• Training intensity • Professional vs. non-professional
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Screening Instruments
• Bayley Infant Neurodevelopment Screener (BINS) • Clinical Adaptive Test/Clinical Auditory Milestone
Scale (CAT/CLAMS) • Denver Developmental Screening Test • Ages and Stages Questionnaire • Developmental Screening Questionnaire (Khan, et al.
2011, Child) • 10 Questions (Zaman, et. al 1990, IJE)
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Developmental Screening Questionnaire (DSQ)
• Child < 2 years of age • Administered to mothers • 1 question for eight functional domains is
asked: gross motor, fine motor, vision; hearing, cognition, socialization, behavior and speech
• Yes on any question is “screen +” refer
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DSQ, 14 month old 14 mo.
Gross motor Can stand , hold on, from sitting position and can cruise around furniture
DSQ-113
Fine motor Can grasp object, e.g., biscuit, puffed rice with fingers DSQ-114
Vision Can see small objects, e.g., an M&M DSQ_115
Hearing Can hear (i.e. turns towards sound, or responds to call from out of sight) DSQ-116
Cognition Demonstrates affection on request / Plays pat-a-cake or waves bye-bye on request
DSQ-117
Socialization Responds when spoken to DSQ-118
Behavior Responsive to surroundings and sleeps well DSQ-119
Speech Vocalizes imitative or meaningless words (e.g., mom, dad) DSQ-120
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Ten Questions Tool • > 2 years of age • Yes on any question is “screen +” refer
Zaman, et. al 1990, IJE
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Considerations for screening questionnaires
• Mother’s education • Maternal depression/mental health • Social acceptability • Gender: over-reporting in boys; under-
reporting in girls
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Child Assessment/Ability Instruments
• (Brazelton) Neonatal Behavioral Assessment Scale (NBAS): 28 behavioral items and 18 primitive reflexes
• Network Neurobehavioral Scale (NNNS): 115 items
• Malawi Developmental Assessment Tool (MDAT): 136 items (gross & fine motor, language and social)
• Rapid Neurodevelopmental Assessment (RNDA) • Bayley Scale of Infant Development, III:
325 items, receptive communication, expressive communication, fine motor, gross motor and cognitive, 1-42 months
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Considerations for direct child assessment
• Alertness • Optimal performance • Examiner facilitation/engagement • Endurance • Familiarity with objects/past opportunities • Stranger anxiety/shyness • Cultural factors • Engagement in active playing-learning activities
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MDAT
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Rapid Neurodevelopmental Assessment (RNDA)
Khan NZ, Muslima H, Begum D, et al. Validation of rapid neurodevelopmental assessment instrument for under -two-year-old children in Bangladesh. Pediatrics. Apr;125(4):e755-762.
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Purpose
Train project staff to assess infant neurodevelopment Assess inter-rater reliability and concurrent validity
between RNDA and Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III)
Assess validity based on chronic malnutrition (stunting)
Study purpose
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• 27 items • 9 domains: primitive reflexes, gross and fine
motor development, vision, hearing, speech, cognition, behavior and seizures in children<24 months of age
• 20-30 minutes • Differences in degree of disability -- “any”,
“mild” and “moderate or severe”
RNDA
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Training and Calibration
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BSID III vs. RNDA vs ?
• Performed by community health workers after short training period with intermittent recalibration of assessments
• Assesses vision and hearing impairment • Rapid assessment, but not “diagnostic” • Lack of familiarity with testing activities • Unobserved behavior (speech)-parent report? • Normed data (Cromwell, 2013, Eur J Ped Neuro)
• Age band widths (Veldhuizen, 2014, Arc Dis Child)