Monitoring tools for child development: an opportunity for action
Authors: Sharon Goldfeld, Aisha Yousafzai
Journal: The Lancet Global Health (2018)

During the past decade, a number of increasingly immutable facts have emerged from child development research, arising from disciplines such as neuroscience, health, psychology, and economics. Such research has converged on two important findings: that the early years of child brain development provide a unique and cost-effective window of opportunity for intervention to promote better adult outcomes, and that children's developmental trajectories can be influenced by socioenvironmental factors, including the families and communities in which they live.1Walker SP Wachs TD Grantham-McGregor S et al.Inequality in early childhood: risk and protective factors for early child development.Lancet. 2011; 378: 1325-1338Summary Full Text Full Text PDF PubMed Scopus (938) Google Scholar These findings are applicable to all children across all contexts. Subsequently, this research has increased the demand for interventions that support early childhood development. A complementary body of intervention evidence exists for potentially effective programmes and policies that can positively affect children's development across high-income, middle-income, and low-income countries. The 2015 UN Sustainable Development Goals (SDGs) have further contributed to this ambition, especially SDG3 (health) and SDG4 (education), which are intrinsically and fundamentally linked for young children. The SDGs mark a global shift from improving child survival rates towards improving children's health and developmental trajectories.2Bhutta ZA Community-based primary health care: a core strategy for achieving sustainable development goals for health.J Glob Health. 2017; 7: 010101Crossref PubMed Scopus (14) Google Scholar However, considerable inequalities exist globally in access to, and quality of, services to help young children thrive despite an increasing developmental burden. For example, of the 13 million surviving preterm infants worldwide, an estimated 2·7% have moderate to severe neurodevelopmental impairments and 4·7% have mild neurodevelopmental impairments with poor access to developmental monitoring and early interventions, particularly in resource-constrained settings.3Lawn JE Blencowe H Oza S et al.Every newborn: progress, priorities, and potential beyond survival.Lancet. 2014; 384: 189-205Summary Full Text Full Text PDF PubMed Scopus (1030) Google Scholar SDG 4.2 highlights the importance of assessing both access and quality of early childhood care, development, and education services, and early childhood development for all children. This target has generated high demand for tools that can monitor children's development. These tools hold promise in three areas that are relevant to young children—and consequently SDG3 and SDG4—across all countries: clinical tools to stimulate greater attention (through early detection and intervention) for children with developmental risks, delays, and difficulties; population monitoring of early childhood development with a focus on subpopulations to highlight inequities within and across countries; and accelerating the spread and implementation of effective health and education interventions through large-scale evaluations. To date, little information has been available about early childhood development especially from low-income and middle-income countries (LMICs). Barriers to assessing early childhood development include the scarcity of cross-culturally appropriate tools that are also feasible and affordable with good psychometric properties. Most of the currently available tools were developed in high-income settings, particularly the USA (eg, the Ages and Stages Questionnaire and the Bayley Scales of Infant and Toddler Development).4Fernald LC Prado E Kariger P et al.A toolkit for measuring early childhood development in low and middle-income countries.https://openknowledge.worldbank.org/handle/10986/29000?locale-attribute=enDate: 2017Google Scholar Tools used in LMICs, such as the Malawi Developmental Assessment Tool, Rapid Neurodevelopmental Assessment, Kilifi Developmental Inventory, and the Caregiver Reported Early Development Index, have helped to address this important gap.5Sabanathan S Wills B Gladstone M Child development assessment tools in low-income and middle-income countries: how can we use them more appropriately?.Arch Dis Child. 2015; 100: 482-488Crossref PubMed Scopus (68) Google Scholar, 6McCoy DC Sudfeld CR Bellinger DC et al.Development and validation of an early childhood development scale for use in low-resourced settings.Popul Health Metr. 2017; 15: 3Crossref PubMed Scopus (47) Google Scholar However, to enable global comparisons across countries, more studies providing high-quality evidence on the equivalence of developmental milestones across high-income and LMICs are needed, with the aim of developmental attainment equivalence and reduction of inequalities across and within all countries. In this context, the Article7Ertem IO Krishnamurthy V Mulaudzi MC et al.Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study.Lancet Glob Health. 2017; 6: e279-e291Summary Full Text Full Text PDF Scopus (47) Google Scholar by Ilgi Ertem and colleagues in The Lancet Global Health is especially relevant. The evaluation of the Guide for Monitoring Child Development (GMCD) in four LMICs showed that the tool has cross-cultural appropriateness, reliability, and validity for children from birth to age 42 months and encompasses constructs of cognitive language, socioemotional development, and motor development. The findings of this cross-sectional observational study suggest the potential emergence of a tool for developmental monitoring that has equivalence across all resources contexts, at least for healthy children. The interview approach used by the health-care professional with the caregivers in the GMCD also helps to connect monitoring, clinical evaluation, and counselling interventions. Although these tools might still require thoughtful, sensitive, and accurate local adaptations that are culturally and linguistically appropriate, meaningful comparisons on global progress in supporting the development of all children from birth is promising. So far, previous studies8Engle PL Fernald LC Alderman H et al.Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries.Lancet. 2011; 378: 1339-1353Summary Full Text Full Text PDF PubMed Scopus (507) Google Scholar, 9Yousafzai AK Lynch P Gladstone M Moving beyond prevalence studies: screening and interventions for children with disabilities in low-income and middle-income countries.Arch Dis Child. 2014; 99: 840-848Crossref PubMed Scopus (36) Google Scholar comparing the prevalence of children at-risk and with disabilities have been hindered by the scarcity of comparable cross-country data, particularly for children in the first 3 years of life. Challenges associated with the provision of early identification and intervention services for children with developmental risks, delays, and difficulties remain in all countries. In addition to the GMCD, global tools that have the sensitivity and specificity to enable accurate detection and diagnosis of developmental difficulties are still required. Similarly, although some examples of effective innovations for this population in LMICs exist—eg, the Child Development Centres in Bangladesh10Richter LM Daelmans B Lombardi J et al.Investing in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2017; 389: 103-118Summary Full Text Full Text PDF PubMed Scopus (396) Google Scholar—the scarcity of targeted services remains acute and inequitable.11WHODevelopmental difficulties in early childhood. Prevention, early identification, assessment and intervention in low-and middle-income countries. A review.http://apps.who.int/iris/bitstream/10665/97942/1/9789241503549_eng.pdfDate: 2012Google Scholar The need for innovative approaches providing universal health and developmental care within existing resources to at least ameliorate the effect of environmental deprivation should remain a priority. Promising tools and robust evaluations are a crucial starting point, but investment is needed in evidence-based services and large-scale programmes that include effective monitoring of both process (implementation) and outcomes (early childhood development). How child development monitoring tools are integrated in health systems and how these data inform action for individuals and early intervention services also warrants attention. The GMCD evaluation indicates that tools for monitoring early childhood development are available, but the effective implementation of such tools in health and education systems remains a challenge for global research.7Ertem IO Krishnamurthy V Mulaudzi MC et al.Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study.Lancet Glob Health. 2017; 6: e279-e291Summary Full Text Full Text PDF Scopus (47) Google Scholar SG is supported by a National Health and Medical Research Council Career Development Fellowship (1082922). We declare no competing interests. Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational studyThe 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. Full-Text PDF Open Access