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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.
Fine motor
Can stand , hold on, from sitting position and can cruise around
furniture
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
DSQ-117
Socialization
Demonstrates affection on request / Plays pat-a-cake or waves bye-bye
on request
Responds when spoken to
Behavior
Responsive to surroundings and sleeps well
DSQ-119
Speech
Vocalizes imitative or meaningless words (e.g., mom, dad)
DSQ-120
Gross motor
DSQ-113
DSQ-118
Ten Questions Tool
• > 2 years of age
• Yes on any question is “screen +” refer
Zaman, et. al 1990, IJE
Considerations for screening
questionnaires
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Mother’s education
Maternal depression/mental health
Social acceptability
Gender: over-reporting in boys; underreporting 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
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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.
Study
purpose
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)
RNDA
• 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”
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)