Exploring the validity of the ASQ-SE for socio-emotional competency screening of a low-risk Asian cohort at 2 years of age.

AIMS: To assess the Ages & Stages Questionnaire: Social-Emotional (ASQ-SE)'s concurrent validity in a low-risk Singapore cohort and study its association with maternal mental health status. METHODS: Concurrent validity of the parent-filled ASQ-SE with Child Behavior Checklist (CBCL1.5-5) was evaluated in 341 children at age 24 months. Data on maternal anxiety and depression were collected using the State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory-Second Version (BDI-II). ASQ-SE cut-off scores based on receiver operating characteristic curve were compared to CBCL scores to derive a local ASQ-SE "at risk" cut-off score. Correlations of ASQ-SE with CBCL scores and with maternal STAI and BDI scores were evaluated using Pearson coefficients. RESULTS: Using a cut-off score of 51 at 24 months, ASQ-SE had acceptable concurrent validity, with an AUC of 0.819(0.765-0.872), 70 % sensitivity and 79 % specificity. Mothers of children with "at-risk" ASQ-SE scores had significantly higher STAI and BDI-II scores. ASQ-SE had moderate- high correlations (r = 0.32-0.53) (p < .01) with CBCL scores at 24 and 48 months and with maternal mental health status(r = 0.32). INTERPRETATION: ASQ-SE can be a useful tool for screening child's socio-emotional competence for primary health care use in Singapore Dyadic mental health screening would be helpful in identifying families at risk.

Concurrent validity of the ages and stages questionnaires with Bayley Scales of Infant Development-III at 2 years - Singapore cohort study.

BACKGROUND: With increasing acceptance of universal developmental screening in primary care, it is essential to evaluate the local validity and psychometric properties of commonly used questionnaires like the parent-completed Ages and Stages Questionnaires, 3rd Edition (ASQ-3) in identifying developmental delays. The aim of this study is to assess the convergent validity of the ASQ-3 with the Bayley Scales of Infant Development-3rd edition (Bayley-III) in identifying developmental delay in a low-risk term cohort in Singapore. METHODS: ASQ-3 and Bayley-III data was collected prospectively with generation of ASQ-3 cut-off scores using three different criteria: 1-standard deviation (SD) (Criterion-I) or 2-SD (Criterion-II) below the mean, and using a Receiver Operator Curve (ROC) (Criterion-III). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. Correlations between the ASQ-3 and Bayley-III domains were evaluated using Pearson coefficients. RESULTS: With all three criteria across different domains ASQ-3 showed high specificity (72-99%) and NPV (69-98%), but lower sensitivity (19-74%) and PPV (11-59%). Criterion-I identified 11-21% of children as "at-risk of developmental delay," and was the most promising criterion measure, with high specificity (82-91%), NPV (69-74%) and overall agreement of 64-71%. Moderate-strong correlations were seen between ASQ-3 Communication and Bayley-III Language scales (r = 0.44-0.59, p < 0.01). The lowest sensitivities were seen in the motor domains. CONCLUSIONS: ASQ-3 is reliable in low-risk settings in identifying typically developing children not at risk of developmental delay, but it has modest sensitivity. Moderate-strong correlations seen in the communication domain are clinically important for early identification of language delay, which is one of the most prevalent areas of early childhood developmental delay.

Single Center Outcome of Multiple Births in the Premature and Very Low Birth Weight Cohort in Singapore.

OBJECTIVE: The aim of this study is to compare neonatal mortality and morbidity in multiple and singleton preterm/very low birthweight (PT/VLBW) multiethnic Asian infants. STUDY DESIGN: Cohort study of 676 singleton and 299 multiple PT/VLBW infants born between 2008 and 2012 at KK Women's and Children's Hospital, the largest tertiary perinatal center in Singapore with further stratification by gestational ages 23 to 25 (Group 1), 26 to 28 (Group 2), and ≥29 (Group 3) weeks. Outcome measures included predischarge mortality and major neonatal morbidity. RESULTS: Overall survival to discharge was comparable for singletons 611/676 (90%) and multiples 273/299 (91%). Use of assisted reproductive technologies (47 vs. 4%), antenatal steroids (80 vs. 68%), and delivery by cesarean section (84 vs. 62%) were significantly higher (p < 0.001) in multiples while pregnancy induced hypertension (8.7 vs. 31.6%, p < 0.001) and maternal chorioamnionitis (31 vs. 41%, p < 0.01) were seen less commonly compared with singleton pregnancies. Survival was comparable between singletons and multiples except for a lower survival in multiples in Group 2 (81.7 vs. 92.4%, p = 0.007). Major neonatal morbidities were comparable for multiples and singletons in the overall cohort. Presence of hemodynamically significant patent ductus arteriosus (HsPDA) requiring treatment (88.9 vs. 72.5%), air leaks (33 vs. 14.6%, p = 0.02), NEC (30 vs. 14.6%, p = 0.04), and composite morbidity (86 vs. 66%, p = 0.031) were significantly higher in multiples in Group 1. A significantly higher incidence of HsPDA (68.1 vs. 52.4%, p = 0.008) was also observed in multiples in Group 2. Multiple pregnancy was not an independent predictor of an adverse outcome on regression analysis (OR: 0.685, 95% confidence interval: 0.629-2.02) even in GA ≤25 weeks. CONCLUSION: Neonatal mortality and morbidity were comparable in our cohort of PT/VLBW singletons and multiple births, but preterm multiple births ≤25 weeks had a higher incidence of neonatal morbidity. KEY POINTS: · Use of assisted reproductive technologies was significantly higher in multiples as compared to singletons.. · Major neonatal morbidities and mortality were similar between singletons and multiples in our cohort.. · In gestations less than 25 weeks multiples had higher neonatal morbidities than their singleton counterparts..

Novel two-tiered developmental screening programme for Singaporean toddlers: a quality improvement report.

Early identification of developmental delays with timely intervention, especially before the age of 3 years, can improve child development. In Singapore, however, diagnosis and intervention for developmental delays occur at a median age of 44 months. As early detection and intervention depends on an effective developmental screening programme, we aimed to improve the detection of developmental delays before the age of 3 years in a primary care setting. We did this by implementing a novel two-tiered screening programme which uses three standardised screening tools (Parents' Evaluation of Developmental Status, PEDS-Developmental Milestones and Ages and Stages Questionnaire-3). We used quality improvement methods to integrate and optimise this two-tiered programme into the existing 9-month and 18-month screening schedule, with an additional screening at 30 months to replace the pre-existing 36-month screening of the National Child Health Surveillance Programme. A total of three Plan-Do-Study-Act cycles were performed to ensure programme feasibility and sustainability. They focused on adequately training the primary care nurses, targeting an 80% screening rate and aiming for 20 min screening tool administration time per child. We assessed the proportion of children referred to the child development units after positive screening for developmental concerns under the new programme, with a pre-post and with-without intervention comparison, and reviewed the screening rates and screening tool administration time. The proportion of 18-month old children referred for developmental concerns improved from 3.5%-7.1% over a 6-month period. For those who received further assessment by developmental specialists after the two-tiered screening, 100% received a definitive diagnosis of developmental delays, similar to the situation before programme introduction. Our quality improvement efforts facilitated successful integration of the two-tiered programme into the pre-existing screening schedule with minimal impact to the clinic workflow. While we highlight challenges in implementation that need to be addressed, our findings support a potential nationwide adoption of the two-tiered programme.

The Test of Infant Motor Performance (TIMP) in very low birth weight infants and outcome at two years of age.

OBJECTIVE: To evaluate TIMP in preterm very low birth weight (VLBW) infants, analyze risk factors, for atypical TIMP (aTIMP) scores, and explore TIMP's predictive relationship with Bayley-III at 2 years. METHOD: A prospective study of 288 VLBW infants, with TIMP assessment between 34 weeks postmenstrual age and 16 weeks age, corrected for prematurity. RESULT: aTIMP scores were observed in 58/288(20%) infants, whose mean birth weight (BW) and gestational age were 1122 ± 257 g and 29.2 ± 2.12 weeks respectively. Risk factors included BW < 750 g (OR 4.8, 95% CI 1.3-17.7) and 750-1000 g (OR 2.9, 95% CI 1.2-6.9), presence of necrotizing enterocolitis ≥ stage 2; or focal intestinal perforation (OR 4.6, 95% CI 1.4-14.4), periventricular leukomalacia (OR 22.4,95% CI 2.0-246.2), and need for intensive resuscitation at birth (OR 2.7, 95% CI 1.3-5.5). aTIMP scores correlated with Bayley-III Score <85 in motor and cognitive domains with high specificity (80-82%) and negative predictive value (85-94%). CONCLUSION: Identification of the risk factors for aTIMP scores will enable targeted intervention to optimize resources and outcomes in VLBW infants.

Evaluation of the Ages and Stages Questionnaire (ASQ 3) as a developmental screener at 9, 18, and 24 months.

BACKGROUND: Without the use of standardized screening tools, only 30% of the estimated 5-15% of children with developmental delay can be identified, potentially delaying intervention. AIM: 1)To evaluate the ASQ-3's reliability and validity at 9, 18, and 24 months and to compare the results with normative USA data. 2)To determine the risk factors for a screen positive result, which requires further evaluation. METHODS: Study of 649 low-risk children was part of a larger longitudinal cohort study, the GUSTO project. Socio-demographic and ASQ3 data were analyzed to estimate reliability, validity, mean ASQ scores, and cut-off scores. RESULTS: ASQ-3 showed an acceptable to good internal consistency (0.49-0.83) and a medium level of correlations (0.22-0.59) between the five domains but differed significantly compared to normative USA data. Using local cut-off scores, 12.6-13.6% of the cohort had a positive screen in ≥ 1 domain at 9, 18, or 24 months. ASQ-3 screening categorization was consistent, with only 3-11% of children showing change in categorization longitudinally. On regression, lower family income (OR 3.3-9.42) and maternal education (OR2.65-3.03) were predictive of a positive screen across domains and age intervals. INTERPRETATION: ASQ-3 is a useful, valid screening tool in Singapore. Further research is needed to investigate item functioning and to assess its concurrent validity with a criterion standard tool for culturally sensitive developmental screening.

Factors affecting neurodevelopmental outcome at 2 years in very preterm infants below 1250 grams: a prospective study.

OBJECTIVE: To evaluate the neurodevelopmental outcomes of preterm very-low birth weight (PT/VLBW) infants at 2 years and identify risk factors associated with significant developmental delay or neurodevelopmental impairment (NDI). STUDY DESIGN: We evaluated 165 PT/VLBW infants born between January 2010 and December 2011, using the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III). NDI was defined as the presence of neurosensory impairment or significant delay with Bayley-III score < 70 in any domain and risk factors for delay/NDI were assessed using logistic regressions. RESULTS: Median Bayley-III composite scores in the cognitive, language and motor domains were 95, 89 and 94, respectively. NDI was present in 20% of the children, with 5-18% having significant delay in either cognitive, language or motor domain, seven (4%) children had cerebral palsy, three (2%) were deaf and none were blind. Regression models identified significant positive associations of delayed cognitive skills with male gender (Odds ratio (OR) 22.4, 95% confidence interval (CI) 1.5-341.1; P = 0.025), lack of anntenatal steroids (ANS) (OR 41.5, 95% CI 3.5-485.7; P = 0.003), and hypotension needing inotropes (OR 36.0, 95% CI 2.6-506.0; P = 0.008); delayed language skills with lower maternal education (OR 3.8, 95% CI 1.4-10.3; P = 0.10), lack of ANS (OR 2.8, 95% CI 1.1-7.4; P = 0.04), and 5 minute Apgar Score ≤ 5 (OR 7.4, 95% CI 1.4-38.4; P = 0.017) and delayed motor skills with chronic lung disease at 36 weeks (OR 38.3, 95% CI 2.4-603.4; P = 0.010). NDI was associated with lack of ANS (OR 2.91, 95% CI 1.21-7.00; P = 0.02) and use of postnatal steroids (OR 3.36, 95% CI 1.07-10.54; P = 0.0374). CONCLUSION: Risk factors for both NDI and individual domain delay were identified and will be helpful in planning of specific and targeted early intervention services.