Neurodevelopmental disorders in low‐ and middle‐income countries

Effective prevention and treatment of infectious diseases has led to a significant decrease in childhood mortality over the last decade in lowand middle-income countries (LMIC). This is likely to increase the prevalence of neurodevelopmental impairments and disabilities, since there appears to be a greater mortality in children with neurodevelopmental disabilities than in typically developing children. There are considerable differences in the prevalence of severe or moderate neurodevelopmental disorders in LMIC, ranging from 19 to 63 per thousand in older children. This is likely to be an underestimate since the prevalence is dependent upon the age of children surveyed, with the sensitivity of the tools for detecting neurodevelopmental disorders (lower in young children) and many of the children with severe disabilities acquired early in life die prematurely in LMIC. Scherzer et al. have highlighted the potential increase in neurodevelopmental impairments and disabilities, which is affecting an increasing number of children in LMIC. However, there are little data to support this increase as yet, since there are few studies measuring the prevalence of these disorders, and none measuring changes over time. Further epidemiological studies are required to determine the burden, secular trends, and the risk factors for these disorders. Scherzer et al. point out the lack of culturally appropriate tools to screen for impairments and disabilities in children. The tenquestion questionnaire is used in cross-sectional surveys across different settings. This short questionnaire administered to the parent or guardian may be useful in the clinic, although it is only sensitive for moderate or severe disabilities. Scherzer et al. have suggested incorporating simple measures to identify children with neurodevelopmental delay in routine screening. Such screening is more likely to be rolled out if it can be incorporated into established health care programmes such as vaccine schedules, but would need to be short, easy to administer, and not require much training so as not to add to the workload of primary health care workers. These initiatives need to be promoted in conjunction with the development of services for the children identified with these disabilities. Many areas in LMIC do not have rehabilitation services, and even if they exist, they usually occur in hospitals which are not accessed by the affected families. There are few trained staff, and, as pointed out by Scherzer et al., many health care workers have little knowledge of effective interventions. Community-based rehabilitation programmes may be helpful, but are rarely assessed robustly. Since the health care provided by the governments of LMIC and non-governmental organizations has largely focused on the reduction of mortality and infectious diseases, there appears little acknowledgement of children with neurodevelopmental disabilities. The prevention and management of these conditions are rarely taken into consideration in the plans for health care in these regions, although they are a considerable burden on the health care systems. Even with the recognition of the burden of non-communicable disease by the United Nations, as proclaimed by the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, neurodevelopmental disorders are only mentioned in the context of the advantages of breastfeeding, and this declaration does not call on governments to put these disorders on the agenda. The World Health Organization has recognized the importance of these disorders and included a module of neurodevelopmental disorders in the Mental Health Gap Action Programme (mhGAP) initiative to increase the detection of these conditions by primary health care workers. Scherzer et al.’s timely review should prompt health care workers to make further efforts to highlight the burden of neurodevelopmental disorders to Ministries of Health in LMIC and non-government organizations involved in the health of children.