Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

Physician Voices on ECHO Autism India-Evaluation of a Telementoring Model for Autism in a Low-Middle Income Country.

OBJECTIVES: Training pediatricians in low- and middle-income countries (LMICs) in early diagnosis and comprehensive management of autism spectrum disorder (ASD) is crucial to ensure optimal developmental outcomes for a substantial number of children with ASD in this region. This study evaluates the relevance and effectiveness of an evidence-based telementoring model Extension for Community Healthcare Outcomes (ECHO) Autism in increasing pediatricians' access to best-practice care for children with ASD in LMIC contexts. METHODS: ECHO Autism was launched by a ?hub" team of multidisciplinary ASD experts at a child development center in Mumbai, India. The culturally modified model included 13 biweekly sessions conducted annually using video-conferencing technology. Sessions combined expert-delivered didactics and facilitated case-based discussions on best-practice methods in screening, diagnosing, and managing autism and its comorbidities. Sixty-two physicians, including 59 pediatricians across 2 cohorts (2019-2020), participated in the mixed-methods study to evaluate participants' reactions, knowledge, behaviors, and impact on children and families. RESULTS: Participants represented a broad geographic reach across India (n = 47) and other LMICs (n = 15). Both quantitative and qualitative data revealed high levels of participant satisfaction and improved knowledge and self-efficacy in ASD diagnosis and management. Qualitative themes highlighted the adult-learning processes of ECHO Autism that participants considered novel and beneficial, such as reflective discussions, respectful mentoring, having a parent as ?expert," and cultural relevance, alongside changes in practice behaviors. CONCLUSION: ECHO Autism clinics facilitated by local experts in LMICs can improve access to early diagnosis and evidence-based, comprehensive management for children with ASD and their families by positively influencing pediatricians' knowledge, attitudes, and practice behaviors.

Adaptation of the Measure of Processes of Care for the Evaluation of Family-Centeredness of Services in India.

OBJECTIVE: This study aims to (1) adapt the Measure of Processes of Care (MPOC-20) for use in India and (2) evaluate family-centered services for children with disabilities and their caregivers in an urban Indian context. METHODS: In this cross-sectional observational study, we translated the MPOC-20 into Hindi. Caregivers of children diagnosed with developmental disabilities who read and/or understood Hindi and had received services for ≥6 months were recruited. The psychometric properties of the Hindi MPOC-20 were assessed using factor analysis followed by reliability analyses. The Hindi MPOC-20 was used to assess caregiver perceptions about the family-centeredness of services delivered between October 2016 and February 2017 at Ummeed Child Development Center. RESULTS: Of the 170 eligible children, 141 (83%) comprised the study sample. Most were boys (66%) with a median age of 67 months. Factor analyses yielded a 4-factor scale with items loading differently from the original measure. The resulting Hindi MPOC-20 had acceptable to good internal consistency (Cronbach's alpha of scales: 0.71-0.86). On the Hindi MPOC-20, Respectful and Coordinated Care, Enabling Partnership, and Providing Specific Information were identified as strengths and Providing General Information as a relative limitation of the service by caregivers across different income and education groups. CONCLUSION: The Hindi MPOC-20 shows acceptable psychometric properties for use with caregivers of children with disabilities in India. The availability of Hindi MPOC-20 paves the way for the assessment of the family-centeredness of services in India and provides a roadmap for adaptations in other low- and middle-income countries.

Providing Services for Children With Developmental Difficulties, Delay or Disability - Early Diagnosis and Interventions at the Community Level.

This paper describes two programs using the recommended tiered approach - World Health Organization's (WHO) Nurturing Care Framework (NCF), viz., Early Childhood Champions (ECC) program and Child Development Aide (CDA) program delivered by Ummeed Child Development Center, a non-governmental organization in Mumbai. The ECC program builds capacity in community health workers (CHWs) employed by community based organizations in urban, semi-urban and rural areas to deliver the responsive caregiving and early learning components of WHO-NCF framework to all children (universal services) and those with or at risk for disabilities (targeted and indicated services). The CDA program trains CHWs to become disability workers in communities where rehabilitation services are scarce or nonexistent. ECC and CDA programs integrate ECD services into the existing work of established CHWs in the communities and have preliminary evidence of reach, effectiveness and acceptability. Till date, the 145 CHWs trained by the ECC program have reached 7073 children, of whom 835 (7.4%) have been identified with developmental delays. The ECC program meets the well-recognized need for training packages on responsive caregiving and early learning components of WHO NCF framework.

Hybrid type 1 effectiveness/implementation trial of the international Guide for Monitoring Child Development: protocol for a cluster-randomised controlled trial.

Introduction: More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala. Methods and analysis: Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness. Ethics and dissemination: The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals. Trial registration number: NCT04665297, CTRI/2020/12/029748. Protocol version: 1.0 (12 November 2020).

Validation of the International Guide for Monitoring Child Development demonstrates good sensitivity and specificity in four diverse countries.

AIM: It is of critical importance to have internationally constructed tools to address early childhood development. The aim of this second phase of a two-phase study was to examine the sensitivity and specificity of the Guide for Monitoring Child Development (GMCD) in identifying developmental delay in four diverse countries. METHODS: The first phase of this 2011-2015 back-to-back study included 4949 children up to 42 months of age from primary healthcare centres in Argentina, India, South Africa and Turkey. Distribution curves were generated to show the ages when the children attained GMCD milestones and those that could be used across sexes and countries were placed in age ranges corresponding to the 85th and 97th percentile point estimates. Phase two examined a separately recruited sample of children in those countries to determine sensitivity and specificity of the GMCD. RESULTS: The validation phase of the 85 milestones in the GMCD identified delayed development in 30% of the 1731 children in the four countries. The sensitivity and specificity ranged from 0.71-0.94 and 0.69-0.82, respectively, for the total sample and the different age groups. CONCLUSION: The GMCD standardised in four diverse countries has appropriate accuracy for identification of children with developmental delay.

Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study.

BACKGROUND: Knowledge about typical development is of fundamental importance for understanding and promoting child health and development. We aimed to ascertain when healthy children in four culturally and linguistically different countries attain developmental milestones and to identify similarities and differences across sexes and countries. METHODS: In this cross-sectional, observational study, we recruited children aged 0-42 months and their caregivers between March 3, 2011, and May 18, 2015, at 22 health clinics in Argentina, India, South Africa, and Turkey. We obtained a healthy subsample, which excluded children with a low birthweight, perinatal complications, chronic illness, undernutrition, or anaemia, and children with missing health data. Using the Guide for Monitoring Child Development, caregivers described their child's development in seven domains: expressive and receptive language, gross and fine motor, play, relating, and self-help. Clinicians examining the children also completed a checklist about the child's health status. We used logit and probit regression models based on the lowest deviance information criterion to generate Bayesian point estimates and 95% credible intervals for the 50th percentile ages of attainment of 106 milestones. We assessed the significance of differences between sexes and countries using predefined criteria and regions of practical equivalence. FINDINGS: Of 10 246 children recruited, 4949 children (48·3%) were included in the healthy subsample. For the 106 milestones assessed, the median age of attainment was equivalent for 102 (96%) milestones across sexes and 81 (76%) milestones across the four countries. Across countries, median ages of attainment were equivalent for all play milestones, 20 (77%) of 26 expressive language milestones, ten (67%) of 15 receptive language milestones, nine (82%) of 11 fine motor milestones, 14 (88%) of 16 gross motor milestones, and eight (73%) of 11 relating milestones. However, across the four countries the median age of attainment was equivalent for only two (22%) of nine milestones in the self-help domain. INTERPRETATION: The ages of attainment of developmental milestones in healthy children, and the similarities and differences across sexes and country samples might aid the development of international tools to guide policy, service delivery, and intervention research, particularly in low-income and middle-income countries. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Educational and Behavioral Interventions in Management of Autism Spectrum Disorder.

The increasing prevalence of autism spectrum disorder (ASD) makes early recognition, evaluation and management an important task for pediatricians, physicians and other professionals caring for children. Educational interventions form the mainstay of management for children with autism spectrum disorder. Such interventions focus on improving social interaction, communication and challenging behaviors, thereby promoting learning and independence in children. This article provides an overview of educational and behavioral interventions in autism spectrum disorder, with special reference to challenges and feasible solutions in the Indian context. Articles were retrieved from various databases including Google Scholar, Medscape, Cochrane, PubMed using the search terms 'autism spectrum disorder OR autism AND educational interventions'; 'autism spectrum disorder OR autism, educational interventions AND India' and 'autism spectrum disorder OR autism AND India'. Reference lists from retrieved articles as well as websites of organizations working in this space in India were also searched. Extracted manuscripts were analysed for content related to various aspects of educational and behavioral interventions in autism spectrum disorder. Intervention models for autism spectrum disorder are based on various theoretical orientations and target specific deficits associated with the disorder. In addition, evidence-based principles for effective intervention are highlighted. In developing countries like India, access to interventions is a challenge and resources are limited. In such settings, the pediatrician's or physician's role is vital in supporting families choose programs that are evidence-based, target individual needs and result in improved outcomes.

Incorporating developmental screening and surveillance of young children in office practice.

CONTEXT: Developmental concerns voiced by parents need to be responded to by structured developmental screening. Screening is the use of validated developmental screening tools to identify children with high risk of developmental delay out of an apparently normal population, while surveillance is the process of monitoring children identified as high risk by screening. Absence of routine screening can be attributed to problems at the level of parents, pediatricians or National policies. Hence vulnerable children are not detected early, and are denied benefit from appropriate developmental interventions. There are no definite guidelines for screening or for suitable tools for screening and surveillance. OBJECTIVES: To review existing developmental screening and monitoring tools for children validated in Indian under-five children, and provide a proposed practice paradigm for developmental screening in office practice. EVIDENCE ACQUISITION: Scientific papers were retrieved by an electronic database search using MeSH terms 'screening tool', 'developmental delay', and filter of 'children under 5 years'. Those relevant to office practice and validated internationally or in Indian children were reviewed. RESULTS: Screening tools applicable to Indian office practice have been compared and certain tools have been recommended according to the level of risk of developmental delay. An algorithmic approach to screening has been given along with strategies for incorporation. CONCLUSIONS: Screening and surveillance for high risk of developmental delay are essential components of child health care. It is possible to incorporate both into routine practice.

Ethical considerations in conducting research on autism spectrum disorders in low and middle income countries.

Autism spectrum disorder (ASD) is being identified in an ever-increasing number of countries, including many that are low or middle income (LMIC). Research conducted in these countries requires awareness of unique ethical issues. Drawing on the experience of two organizations that have been involved in conducting and collaborating in ASD research in India, we describe specific considerations in conducting epidemiological, genetic and treatment studies as well as general principles from the field of multinational clinical research as they apply to the conduct of ASD research. We argue that greater attention to ethical concerns will result in quality studies conducted in LMICs that are also of greatest relevance for families and children with ASD.