Scaling up child development centres in Bangladesh.

BACKGROUND: Child Development Centres (CDCs) have been established within government medical college tertiary hospitals across Bangladesh. Services entail a parent-professional partnership in a child and family friendly environment with a focus on assessment, diagnosis, and management of a range of neurodevelopmental disorders in children and adolescents 0-16 years of age. Services are provided by a multidisciplinary team of professionals (child health physician, child psychologist, and developmental therapist) who emphasize quality of services over the numbers of children seen. METHODS: In 2008, Dhaka Shishu (Children's) Hospital was given the mandate by the government to conceptualize, train, and monitor CDCs nationwide. Here, we describe the rationale and processes for the establishment of the national network of CDCs and discuss lessons learned on scaling up early childhood development services in a low resource setting. RESULTS: Fifteen CDCs were established in major government hospitals across Bangladesh and have recorded 208,866 patient visits. The majority (79%) of children were from the lowest and middle-income families, and about one third (30%) were < 2 years of age at first presentation. Two thirds of children seen in follow-up demonstrated improvements in functional skills since their first visit, 77% in their adaptive behaviour (i.e., activities of daily living) and 70% in cognitive functions. CONCLUSIONS: CDCs are expanding coverage for child neurodevelopment services across Bangladesh through a tiered system of home-based screening, community- and clinic-based functional assessment, and CDC-based diagnosis, support, and referral. Vulnerable populations-the lowest income groups and younger children-comprised the majority of patients, among whom there is high unmet need for psychological services that is being met for the first time. Innovative human resource development, including a 3-month training for the multidisciplinary teams, enabled wide coverage for assessment and diagnosis of a range of neurodevelopmental problems. Demand for services is growing, especially among non-government and private hospitals.

Validation of a rapid neurodevelopmental assessment tool for 10- to 16-year-old young adolescents in Bangladesh.

OBJECTIVE: To validate a Rapid Neurodevelopmental Assessment (RNDA) tool for use by child health professionals to determine neurodevelopmental impairments (NDIs) in young adolescents aged 10-16 years in Bangladesh. STUDY DESIGN: In a convenience sample of community children (n = 47), inter-rater reliability was determined between four testers, and concurrent validity was determined by simultaneous administration of an intelligence quotient (IQ) test (Wechsler Intelligence Scale for Children, Revised) by a child psychologist. RESULTS: Inter-rater reliability was excellent between the testers on the 47 children administered the RNDA (kappa = 1.00). Significantly lower IQ scores were obtained in those identified with 'any (>1) NDI' (n = 34) compared with those with no NDI (n = 13) on Verbal IQ (P-value < 0.0001), Performance IQ (P-value < 0.0001) and Full-scale IQ (P-value < 0.0001) scores on the Wechsler Intelligence Scale for Children, Revised. CONCLUSION: The RNDA shows promise as a tool for use by child health professionals for identifying NDIs in young adolescents aged 10-16 years. A larger study sample is needed to determine its usefulness for identification of some impairments not found in the study population, i.e. gross motor, fine motor, hearing and seizures.

Neurodevelopmental Outcomes in Children Born to Climate Refugee Mothers in Bangladesh: Experiences from Cyclone Aila.

Cyclone Aila hit the South-West coast of Bangladesh in May 2009, when in Dacope Upazilla over 50,000 people were left homeless as climate refugees (CRs) for over two years. We determined neurodevelopmental status of children born as CRs compared to their non-Climate Refugee (NCR) counterparts. Pregnant mothers were enrolled from May 2009 to April 2010 in entire Dacope in a study which profiled their health conditions. From among these mothers, 12 months post-Aila 267 CR mother-child dyads, and 552 NCR mother-child dyads were enrolled to assess their children's neurodevelopmental outcomes. There were significantly more landless families among CRs compared to NCRs (p value = 0.0001; OR = 1.86, 95% CI: 1.37 - 2.51). The mean±SD age at assessment of CR children was 8.52±4.57 months compared to a mean age 9.09±4.13 months of the NCR children (p=0.610). Neurodevelopmental Impairments (NDIs) were three times higher in the former (21.3%), compared to the latter (7.4%) group (p=0.0001; OR 3.83, 95% CI: 2.16 - 5.21). Specifically, expressive language (p value 0.002; OR 2.86, 95% CI: 1.46 - 5.57) and gross motor functions (p=0.007; OR 2.27, 95% CI 1.22 - 4.20) were the most significantly affected areas of impairment. Children born to CR mothers had a three times higher proportion of NDIs. The findings are of concern as in Bangladesh large populations are forced to leave their homes and become CRs annually. Optimum antenatal care of pregnant women as well as their offsprings within refugee situations needs to be ensured to prevent NDIs and poor quality of survival.

Validation of a home-based neurodevelopmental screening tool for under 2-year-old children in Bangladesh.

BACKGROUND: Home-based screening to identify young children at risk for neurodevelopmental impairments (NDIs) is needed to guide the targeting of child neurodevelopmental intervention services in Bangladesh. This study aimed to validate such a tool for children under age 2 years. METHODS: A Developmental Screening Questionnaire was administered to mothers of children aged 0-<2 years in an urban community. Inter-rater reliability among the interviewers, who were high school graduates, was determined. All children who were screen positive and a proportion of screen negatives were subsequently assessed for NDIs by professionals. Sensitivity and specificity were calculated by comparing screening with assessment results. RESULTS: Mean kappa coefficient of agreement among interviewers was 0.95. A total of 197 children were screened, of whom 17% screened positive. Fifty-one children, including 24 screen negatives, were assessed for NDIs. Screen-positivity was significantly different between income groups (P = 0.019), and higher in stunted children (odds ratio = 5.76, 95% confidence interval = 1.72-19.28), indicating good discriminant validity Specificity was excellent (84-100%) for all developmental domains. Sensitivity was 100% for vision and hearing; 70% for speech; and 63%, 53%, 48%, and 45% for gross motor, behaviour, fine motor and cognitive impairments, respectively. CONCLUSION: A tool for screening <2-year-old children at risk for NDIs showed high specificity; and was able to identify all children at risk for vision and hearing impairments, nearly three-fourths with speech impairments, two-thirds with gross motor impairments, and about half with behavioural, cognitive and fine motor impairments. The Developmental Screening Questionnaire tool has potential for use by frontline workers to screen large populations and to link to definitive assessment as well as intervention services.