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Indian Pediatr 2012;49:
457-461 |
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Ages and Stages Questionnaire as a Screening Tool for
Developmental Delay in Indian Children
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Monica Juneja, Mugdha Mohanty , Rahul Jain and
Siddarth Ramji
From Department of Pediatrics and Neonatology, Maulana
Azad Medical College and associated Lok Nayak Hospital,
2, Bahadur Shah Zafar Marg, New Delhi, India.
Correspondence to: Prof Monica Juneja, C-77 South
Extension-II, New Delhi 110 049.
Email:
[email protected]
Received: April 17, 2011;
Initial review: May 18, 2011;
Accepted: August 8, 2011.
Published online: 2011, October 30.
PII: S097475591100339-1
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Objective: To evaluate the ability of ‘Ages and Stages
Questionnaire’, a parent completed developmental screening questionnaire
to detect developmental delay in Indian children.
Design: Cross-sectional study.
Setting: Child Development Clinic of a tertiary
care center located in Northern India
Participants and Methods: 200 children, 50 each
in the age groups of 4±1, 10±1, 18±1 and 24±1 months were recruited (20
high risks and 30 low risks in each age group). The Ages and Stages
Questionnaire (ASQ) was translated into Hindi and administered to the
parents, followed by standardized development assessment using
Developmental Assessment Scale for Indian Infants (DASII).
Results: 102 (51%) children failed on ASQ and 90
(45%) children failed on DASII. The overall sensitivity of ASQ for
detecting developmental delay was 83.3% and specificity was 75.4%. The
sensitivity was best for the 24-months questionnaire (94.7%) and
specificity was best for the 4-month questionnaire (86.4%). The
sensitivity of ASQ was much higher in the high risk group (92.3%) as
compared to the low risk group (60%).
Conclusion: ASQ has strong test characteristics
for detecting developmental delay in Indian children, especially in high
risk cases. It may be easily converted into other Indian languages and
used widely for developmental screening.
Key words: Ages and Stages Questionnaire,
Developmental delay, Developmental screening, Diagnosis, Hindi.
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Most of the traditional screening tools for
detection of developmental disabilities involves direct elicitation of
the child’s skills and are cumbersome to use. They are not only time
consuming and costly, but also require child’s cooperation in the clinic
setting [1]. Recently, there has been a growing interest in parent-based
assessment. Studies have shown that parental report of the current
skills is predictive of developmental delay and parental concerns about
language, fine motor, cognitive, and emotional and behavioral problems
are highly predictive of true problems [2-7].
Ages and Stages Questionnaire (ASQ) has been a
valuable addition to the group of developmental screening tools based on
parent completed questionnaire. It is simple, cost-effective, and has
the advantage of parents being active participants in the evaluation of
their children. After the revision of ASQ in year 1997, it has been
translated into many languages. Studies on ASQ in both high risk and low
risk populations have shown that it has good psychometric properties
[8-13]. However, there are no published studies on the use of this
questionnaire in the Indian context. This study was planned to evaluate
ASQ for detecting developmental delay in Indian children.
Methods
The study was conducted at the Child Development
Clinic (CDC) of Lok Nayak Hospital, New Delhi, India from February, 2009
to January, 2010. Children in the four age groups; 4±1 months, 10±1
months, 18±1 month and 24±1 months, attending the Pediatric Out Patient
Department or High Risk Clinic of the hospital were included in the
study. The included children were stratified into high and low risk
groups. The high risk group comprised of children with any of the
following risk factors: history of hospitalization in the first four
days of life, birthweight <2 kg, gestation age <37 weeks, history of
central nervous systems infections, known dysmorphic syndrome or
chromosomal anomalies, suspected cerebral palsy or developmental delay,
and or history of two or more episodes of afebrile seizures. Children
with none of the above mentioned risk factors comprised the low risk
group. Children with non-availability of birth records or the primary
caregiver at the time of evaluation were excluded.
A convenience sample of 200 children of either sex,
50 in each of the four specified age strata were enrolled in the study.
In each age group, 30 low risk and 20 high risk children were enrolled.
A detailed history and physical examination was done in all the children
at the time of enrollment, followed by administration of ASQ by a
pediatric Resident to any of the available parent, mostly mothers. On
the same day, developmental assessment of the child was also done by
Clinical Psychologist using Developmental assessment Scale for Indian
Infants (DASII). All the parents were administered ASQ by the
same Resident; however, DASII was administered by any of the Clinical
Psychologists at CDC. Clinical psychologists were blinded to the scores
on ASQ.
Assessment tools: The Ages and Stages
Questionnaire-Second Edition is a set of 19 age-specific
parent-completed questionnaires aimed at assessing the developmental
status of infants and young children up to 5 years of age. Each
questionnaire is valid for 1 month on either side of the target age and
consists of 30 simple worded developmental items, equally divided into
five domains of child development: communication, gross motor, fine
motor, problem solving and personal social skills. The reading level of
the items ranges from fourth to sixth grade. For each item, there is a
choice of three responses: ‘Yes’, ‘Sometimes’, or ‘Not yet’, which are
scored as 10, 5, or 0, respectively. Domain scores are then obtained by
the sum of the items. Children with ASQ score below the cut off (<2SD)
in any of the domain are taken as screen failed [14].
For the present study, only 4, 10, 18 and 24 months
questionnaires were used. The questionnaires were translated into Hindi
language and back-translated into English and this procedure was
repeated until the back-translation matched the English versions.
Developmental assessment Scale for Indian Infants
(DASII), based on Bayley Scale of Infant Development (BSID) was used in
this study as gold standard for developmental assessment. It assesses
development in the age range of birth to 30 months and provides a
measure of Motor development and Mental development as Motor
Developmental Quotient (DQ) and Mental DQ, respectively, as in BSID. The
normative values on DASII have been established based on a sample of
Indian Children [15]. Although the published literature on it’s use is
scarce, it is commonly used in India [16,17]. Developmental delay is
defined on DASII as DQ score £70
(£2SD) in
either the mental or motor scale.
Ethics and consent: Informed consent was obtained
from parents of all the children enrolled in the study. Ethical approval
was taken for conducting this study from the Institutional Ethical
Committee. Children found to have developmental delay were offered
appropriate intervention and management at CDC.
Statistical analysis: The data was entered and
analyzed using Epi Info. The psychometric properties of ASQ were
calculated using DASII as gold standard. Pearson correlation coefficient
was used for correlation between the ASQ and DASII scores.
Results
Overall, 268 children were screened for inclusion in
the study. Out of these, 51 did not meet the inclusion criteria and 17
denied consent for the study. The final study group comprised of 200
children, 50 each in the 4 age groups. Table I shows the
demographic characteristics of the study sample. The risk factors
present in the high risk group are tabulated in Table II.
TABLE I Demographic Characteristics of the Study Sample (N=200)
Characteristic |
No (%) |
Gender, Male |
112 (56) |
Mother’s age, years |
|
<20
|
5 (2.5) |
20-29
|
155 (77.5) |
30-35
|
32 (16) |
>35
|
8 (4) |
Primiparous mother |
115 (57.5) |
Antenatal problems, n (%) |
|
Fever with rash
|
2 (1) |
Anemia
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31 (15.5) |
PIH/preclamsia/eclampsia
|
1 (0.5) |
Antepartum hemorrhage
|
5 (2.5) |
Gestational diabetes mellitus
|
1 (0.5) |
Mode of delivery |
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Vaginal delivery
|
175 (88) |
Cesarean section
|
24 (12) |
Birthweight, g, mean±SD |
2.56±0.60 |
Mother’s education |
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Illiterate
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17(8.5) |
Primary
|
11(5.5) |
Secondary
|
71(35.5) |
Graduation
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46 (23.0) |
Post-graduation
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55 (27.5) |
Father’s education |
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Illiterate
|
5 (2.5) |
Primary
|
38 (19) |
Secondary
|
120 (60.0) |
Graduation
|
29 (14.5) |
Post-graduation
|
8 (4.0) |
Socioeconomic class* |
|
Upper
|
20 (10) |
Upper Middle
|
55 (27.5) |
Lower Middle
|
87 (43.5) |
Upper Lower
|
7 (3.5) |
Lower
|
31 (15.5) |
*According to Kuppuswamy scale [21]. |
TABLE II Risk Factors of the High Risk Group (N=80)
Risk factor* |
No (%) |
Prematurity |
21 (26.2) |
Low birthweight (< 2 kg) |
33 (41.2) |
Hospitalization in the first four days of life |
55 (68.7) |
History of CNS infection |
5 (6.2) |
Suspected CP or Developmental delay |
15 (18.7) |
Known dysmorphic syndrome or |
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chromosomal anomalies |
6 (7.5) |
Seizure disorder |
4 (5.0) |
*Multiple risk factors were present in many patients; CP:
cerebral palsy; CNS: central nervous system. |
On detailed clinical evaluation, 17 (8.5%) children
were found to have feeding problems, 20 (10%) had hearing impairment, 11
(5.5%) had visual impairment, 8 (4%) had squint, and 15 (7.5%) had
cerebral palsy; all of them belonged to the high risk group.
A total of 102 (51%) children failed on ASQ. Among
the high risk group, 66 (82.5%) children failed ASQ whereas in the low
risk group 36 (30.0%) failed. The results of ASQ according to domain are
shown in Web Table I. The largest number of
failures was found in the fine motor domain (36.5%) and lowest number in
personal social domain (27%). Maximum numbers of the failures in fine
motor domain were in the 4 months age group. Overall 90 (45%) children
failed on DASII (DQ £70
in either Motor or Mental Scale). Among the high risk group 65 (81%)
failed DASII, whereas in the low risk group 25 (21%) failed. There were
greater numbers of failures in the motor than mental scale (Web
Table II).
The overall sensitivity of ASQ in detecting
developmental delay was 83.3% and specificity was 75.4% with a negative
predictive value of 84.6% (Table III). The sensitivity was
best for the 24 months questionnaire (94.7%) and the specificity was
best for the 4 month questionnaire (86.4%). The sensitivity was much
higher in the high risk group.
TABLE III Screening Test Characteristics of ASQ
Age group/ |
Sensitivity |
Specificity |
PPV† |
NPV‡ |
Percentage |
OR# |
UR§ |
Risk group |
(%) |
(%) |
(%) |
(%) |
agreement (%) |
(%) |
(%) |
4 months |
71.4 |
86.4 |
86.9 |
70.3 |
82 |
6 |
16 |
10 months |
80 |
76 |
76.9 |
77 |
74 |
12 |
10 |
18 months |
94.4 |
65.6 |
60.7 |
95.4 |
78 |
22 |
2 |
24 months |
94.7 |
77.4 |
72 |
96 |
82 |
14 |
2 |
Low risk |
60 |
77.8 |
41.6 |
79.1 |
74.1 |
17.5 |
8.3 |
High risk |
92.3 |
60 |
90.9 |
64.2 |
86.2 |
7.5 |
6.2 |
Overall |
83.3 |
75.4 |
73.5 |
84.6 |
79 |
13.5 |
7.5 |
†PPV – Positive Predictive Value, ‡NPV - Negative Predictive
Value, #OR- Over-referral, §UR - Under-referral. |
The ASQ Communication, fine motor, problem solving
and personal social domain scores were correlated with the Mental DQ of
DASII (Table IV). The ASQ Gross motor domain score was
correlated with the Motor DQ of DASII. All correlations were found to be
good (r, 0.76-0.80).
TABLE IV Correlation of ASQ Scores with DASII Scores
ASQ domain |
DASII Mental, Pearson r |
ASQ Communication |
0.761 |
ASQ Fine motor |
0.799 |
ASQ Problem solving |
0.788 |
ASQ Personal social |
0.795 |
|
DASII Motor, Pearson r |
ASQ Gross motor |
0.808 |
Discussion
This study shows that ASQ has strong test
characteristics for detecting developmental delay in Indian children.
This study also reaffirms the value of ASQ as an effective developmental
screening tool.
The validity and reliability of this revised edition
of ASQ was established in year 1997, in a sample of 2008 children,
comprising of both high risk and normative sample. The sensitivity of
ASQ was found to be 74.56%, specificity was 86.21% and percentage
agreement with the standardized assessment was 84.11% [8]. After the
study that validated ASQ-Second edition, a number of other authors have
also evaluated ASQ in different populations and in different age groups,
using a combination of multiple gold standard assessment tools and found
good results [8-13]. In the present study, the sensitivity
was found to be good for 10, 18 and 24 months, and modest for the 4
month questionnaire. The specificity was best for the 4 month
questionnaire but was particularly low for the 18 months. The lower
sensitivity in our study of 71% for the 4 month questionnaire is
consistent with finding of 51% sensitivity in the study that validated
the revised ASQ [8]. This may be related to the fact that parental
assessment of language and cognitive delay in infancy is less objective
allowing more favourable reporting at lower ages. The high sensitivity
and specificity of the 24 months ASQ is also noted by other authors
[11].
The present study also showed that the sensitivity
was higher in the high risk group whereas specificity was higher in low
risk group. The over-referral and under-referral rate was also lower in
the high risk group. Two Australian studies also showed similar results
while evaluating ASQ in population medically at risk for developmental
delay, premature infants and survivors of hypoxic ischemic
encephalopathy [12,13].
In the present study, there was good correlation
between the domain scores of ASQ and DASII. Most other studies have not
presented this data, but in one study, the correlation of ASQ domain
scores with BSID-II scales was moderate except for ASQ fine motor and
BSID-II motor scale, which was negligible [11]. This poor correlation
obtained could be because the items in fine motor domain of ASQ are
included in the mental scale of developmental tests and not in the motor
scale.
This study had certain limitations. This being a
hospital based study, it involved only a small number of children. The
lower reading ability of our population entailed the administration of
the questionnaire by a doctor although it was originally constructed as
a take-home questionnaire. Even though, the questions in the ASQ
were made suitable for our population by replacing
some words like kishmish (raisins) for "cheerio", some questions
were almost universally unanswered because of the cultural
inappropriateness of the questions, for example, questions on looking at
large mirror at 4 months of age and the use of fork were answered by
few.
This study is the first to evaluate ASQ in Indian
population. The test characteristics of the ASQ were studied both in low
risk children and those at risk for developmental delay. It included
children from different socioeconomic backgrounds and also those in
early infancy, where timely intervention is more likely to be
beneficial.
In conclusions, this study shows that ASQ has strong
test characteristics for detecting developmental delay in Indian
children, especially at 18 and 24 months of age and in high risk
children. Though further large scale community based studies are needed
to evaluate ASQ in Indian population at all age groups, it can be easily
converted into other Indian languages and used, especially for younger
age groups where early intervention is more likely to be beneficial.
Contributors: MJ, MM and SR: were involved
in study designing and recruitment of the patients; MM: did assessment
of the patients; MM and RJ: did literature review, statistical analysis
and initial drafting of the manuscript; MJ, RJ and SR: did final
revision of the manuscript. The final manuscript was approved by all
authors
Funding: None; Competing interests: None
stated.
What is Already Known?
• Age and stages questionnaire has not been
evaluated in the Indian population.
What This Study Adds?
• ASQ has strong test characteristics for
detecting developmental delay even in low resource settings
• The sensitivity of ASQ is higher in the high
risk group, whereas specificity is higher in low risk group.
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