Methodological Challenges in Child Neurodevelopmental Assessment

Lisa Thompson, RN, FNP, PhD School of Nursing

University of California, San Francisco

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

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

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

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)

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

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

Ten Questions Tool • > 2 years of age • Yes on any question is “screen +” refer

Zaman, et. al 1990, IJE

Considerations for screening questionnaires

• Mother’s education • Maternal depression/mental health • Social acceptability • Gender: over-reporting in boys; under-

reporting in girls

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

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

MDAT

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.

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

• 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

Training and Calibration

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)