Prevalence of early childhood disability in a rural district of Sind, Pakistan

Worldwide, estimates are that approximately a third of the 200 million children under 5 years old living in resourcepoor countries are failing to reach their potential because of the effects of multiple risk factors (including poverty, malnutrition/stunting, poor health, and psychosocial deprivation). However, what remains poorly defined is what proportion of these children has developmental disability. Prevalence estimates for disability in lowand middleincome countries (LMIC) range from 0.09 to 18.3%. Data from these countries are often poor, with the studies small or restricted, and methodology variable. National or published statistics on young children’s cognitive or socialemotional development are not available for most LMICs and this gap contributes to the under-recognition of developmental delay and disability in these environments. What is known is that disability is shared unequally. According to the 2011 UNICEF world report on disability, 80% of people with disabilities live in LMICs, where the increasing burden of non-communicable diseases accounts for two-thirds of disabilities. Ibrahim and Bhutta attempt to address this data gap in a vulnerable, largely impoverished population in rural Pakistan. This is a large population-based study which looked at an under-represented population in the literature on disability prevalence. Rural areas are less accessible than semiurban or urban populations, and therefore are more expensive and logistically complicated to study. The authors also chose to include children under 2 years old which is a far more specialized, but important group to assess. The rather surprising prevalence of 5.5 per 1000 in the 0 to 2-year age bracket, and 5.4 per 1000 in the 2to 5-year age bracket respectively, may well be a reflection of the lack of parental insight into expected developmental milestones and potential disabilities in their children, rather than representing this lower than expected prevalence. Though widely validated as a tool across cultures and continents for the screening of childhood disability, the Ten Questions screen is likely to be less reliable in populations such as this where there is less than 50% literacy and of the group of parents who were reported as literate, less than 50% had completed primary school education. Future studies may want to look at using a second stage assessment with a more in-depth developmental assessment tool. Repeating the screening tool, which even if administered by trained medical personnel still only reflects parental insight, is unlikely to pick up the false negatives in the group. Although these data are important to report, they are likely to be an under-representation of disability in this population. This reflects the reality for the vast majority of the population in LMICs. The recognition of an infant or young child with a disability relies on the parents or caregivers identifying a problem and presenting to medical facilities. In countries where levels of parental education are low, access to even the most basic health services is poor, and the burden of acute diseases high, many children with special needs remain unrecognized and hence without appropriate intervention. Initiatives which show promise include targeted programmes aimed at particularly vulnerable groups of children with ongoing medical needs (such as HIVpositive children). Harnessing a model of linking developmental followup and stimulation to medical care visits integrated with nutritional and social support seems to be achieving anecdotal success in some communities. As a global strategy, targeting families and/or communities solely on the basis of psychosocial or biomedical risk is not justified from a scientific or ethical standpoint. A universal or whole-population programme must be the core of any reliable and effective early intervention strategy. The targeting of risk is most effective when it is done from a strong base of universal services that is not only accessible but is actually accessed by all children and families. Programmes such as the one described above can provide a model for multi-sector collaboration which must be the future strategy. In resource-poor countries across the globe where significant proportions of young children are challenged by impoverished environments, risks to health, under-nutrition, and compromised care and stimulation, programmes should attend to children’s physical, social, and emotional needs, as well as providing developmental support and screening. Successful management of children’s physical health and developmental trajectory in LMICs will continue to require firm political and financial commitment across many sectors.