Indian Pediatrics 2002; 39:271-275  

Role of Parents’ Evaluation of Developmental Status in Detecting Developmental Delay in Young Children

From the Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Correspondence to: Dr. Prahbhjot Malhi, Associate Professor, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.

Manuscript received: January 25, 2001;
Initial review completed: March 15, 2001;
Revision accepted: August 1, 2001.

The importance of early identification of children with developmental delay has emerged in recent years as a matter of growing concern among pediatricians(1-3). There is, however, no consensus as to how such early identification can be optimally performed. Some of the commonly used techniques include reviewing developmental milestones with parents, relying on clinical judgement based on history, physical examination and observation(4,5). However, physicians subjective impressions and their estimates of children’s developmental status is often inaccurate(6). Research reveals almost half of the children with developmental disabilities are not identified by their pediatricians(7).

Research over the last several decades has endeavoured to identify the most appropriate and cost effective method for early detection of children with developmental problems(8). One screening method developed in recent years elicits parents’ concerns regarding children’s development status(9). A study has documented that parents who expressed concerns about speech, language, fine motor or cognitive skills had children with an 80% chance of failing standardized developmental screening(10). On the other hand, parents who felt that their children were developing normally or who had concerns only about behavior, self help or socio-emotional development had children with a 94% chance of passing screening. The importance of parents concerns about their children’s development is unknown in our country, although it has been found to be a useful clinical tool in the West(11). In the Indian context an important question is whether a developmental concern reflects a child’s true deviation or does it simply reveal parental anxiety? Moreover, does not expressing a concern mean that the child is developing normally or does it reveal that the Indian parents are not well informed about normal development or that they are hesitant to discuss non-medical concerns with the physicians?

Keeping this in view, the present study aimed at: (i) identifying the range of concerns parents have about their child’s development; and (ii) evaluating the relationship between parents concerns and the child’s develop-mental status.

Subjects were 79 parent-child dyads who were seeking well-child pediatric services in the outpatient department of a tertiary care teaching hospital. Children in the age range of 24 to 60 months with no history of motor or sensory impairment, chronic illness or perinatal problems were recruited in the study.

Parental concerns were elicited using a standardized questionnaire, Parents Evalua-tion of Developmental Status (PEDS,9). The PEDS includes an open ended question which asks parents "Please tell me any concerns about your child’s learning, development and behavior". The second part of the question-naire separately probes developmental concerns in each domain."Do you have any concerns about how your child understands what you say, talks, makes speech sounds, uses his hands and fingers to do things, uses arms and legs, behaves, gets along with others, is learning to do things for himself, is learning pre-school skills and any other concerns". The responses are then categorized into various developmental domains and into significant and non-significant concerns (depending on the developmental domain and age of child) as per the guidelines of PEDS.

Developmental status of the child was assessed by the Developmental Profile II(12). The DP II is an 186 items inventory which assesses child’s developmental status from birth through 9½ years in five domains: physical, self help, social, academic and communication. The functioning of the child is expressed in developmental age in months for each domain. The academic age of the child can be converted into an IQ equivalent score and the score has been found to correlate with individually administered measures of intelligence(12). IQ scores less than 70 are considered as failing the screening test. In addition, children were administered the Indian adaptation of the Vineland Social Maturity Scale (VSMS)(13), which measures child’s adaptive behavior and skills in communication, self help, social relations, locomotion, and self direction. The scale yields a social age which can be converted to a Social Quotient score (SQ).

In the present study, parents were asked to state any concerns about the way their child was learning, developing and behaving. Parental concerns were fairly common and were expressed by 67% of all parents. Behavior concerns were most common (40.5%) followed by socio-emotional (21.5%), medical (17.7%), expressive langu-age (17.7%), and global/cognitive (6.3%).

In order to assess the accuracy of parents concerns in detecting developmental delay, children were categorized into two groups, those with IQ less than 70 and those with IQ of 70 and above. These two groups were categorized by parental concerns (Table I). Of the 79 children, 83.5% (N = 66) were found to be performing within normal limits and 16.5% (N = 13) met criteria for delayed development. In comparison to children with normal development, parents of children with delayed development were more likely to raise concerns regarding expressive language (p <0.01), gross motor (p <0.01), global/cognitive (p <0.05) and self help (p <0.05) (Table I). On the other hand, parents of children with typical development either did not raise concerns (p <0.05) or raised behavior, social and self help concerns. Overall, the presence of significant parental concerns identified 61.5% of children with delayed development and 65.2% children with normal development. The positive predictive value of the PEDS was 25.8% and the negative predictive value was 89.6%.

Table II presents comparisons of parents’ judgements by the characteristics of parents and children. Following Glascoe’s(11) classification, parents were categorized into 4 categories depending on the accuracy of their concerns. Of the 13 children who had IQ scores lower than 70, parents of 8 (61.5%), raised one or more significant concern while 5 (38.5%) either raised no concern or raised non significant concerns such as socio-emotional (40%) and/or behavior (20%). There were no differences between the accurately concerned and inaccurately non-concerned parents on socio-demographic variables such as age and sex of the child, level of mothers’ and fathers’ education, birth order, income and on a combined index of socio-economic status. However, children of accurately concerned parents were more likely to show delayed development on physical and communication domains than children of inaccurately non-concerned parents. There were no differences between the two groups on IQ, SQ, self help and social skills.

Table II__Comparison of Parents’ Judgement by Childrens’ Development

Of the 66 parents of children with normal development, 65.1% were accurately non-concerned., i.e., had no concerns or had non-significant concerns and 34.8% were inaccurately concerned, i.e., had significant concerns about their child’s development even though the child’s development was typical. These two groups of parents and their children did not differ from each other on demographic and socio-economic character-isitics. However, children of inaccurately concerned parents had relatively lower IQ and SQ scores than non-concerned parents. The children of inaccurately concerned parents were also more likely to show delay in communication skills than children of accurately non-concerned parents.

Previous research conducted in North America has documented a strong relationship between parents’ concerns and children’s developmental status and it is recommended that since parents’ concerns in some areas of development such as fine motor, language and global/cognitive correctly identifies young children with developmental problems, the PEDS should be used as a screening test to make reasonably accurate referral decisions(11,14,15). Our results reveal that parents concerns about expressive and receptive language, gross and fine motor development were moderately sensitive predictors of developmental delay in children between 2 to 5 years. The absence of concerns or concerns in behavior, social-emotional and self help domains had moderate specificity in correctly identifying children with normal development. Since both the sensitivity and specificity of PEDS found in our study is lower than that reported earlier(9) (sensitivity = 75%, specificity = 74%) for North American children aged 0-7 years, the PEDS should not be used as an alternative to standardized developmental screening measure in our setting. However, the PEDS may be used as a prescreening instrument in a busy outpatient setting in order to identify those children who may require a more in-depth developmental screening.

There were no demographic or socio-economic differences between parents who were concerned or not concerned about their child’s development. Demographic and socio economic characteristics such as age and sex of child, educational level of parents, birth order, and income also did not influence whether parental concerns were accurate or inaccurate with respect to child’s screening test performance. However, parents of children who were inaccurately concerend about their child’s development did have children with relatively lower IQs and SQs as compared to the accurately non-concerned parents. Similar findings have been reported previously(11). Glascoe(11) had argued that parents of children with normal development who have significant concerns about their child’s development are actually highly accurate observers of subtle developmental differences. In the light of these findings, it seems that children of parents who express several concerns even when their children have IQs above 70, may need anticipatory guidance regarding developmental promotion and these children also need to be periodically assessed.

Pediatric primary care providers have to play an important role in the early detection of children’s developmental problems. Research, however, suggests that develop-mental problems, unless very severe, elude early detection(16,17). Our results reveal that parents of delayed children very often do not raise global/cognitive concerns, and are more likely to raise social, gross motor, behavior, expressive language and medical concerns (e.g., not growing well, remains sick, not eating). It is suggested that pediatricians should routinely and carefully elicit parents’ opinions and concerns. Parents concerns should be viewed as helpful adjuncts to routine assessment and should be used to make appropriate referrals. More research is, however, needed to confirm and extend these findings using a larger sample and using diagnostic developmental tests to determine developmental status.

Contributors: PM co-ordinated the study, designed it, collected the data and drafted the paper and will act as the guarantor of the manuscript. PS helped in designing the study and drafting of the paper.

Funding: Postgraduate Institute of Medical Educa-tion and Research, Chandigarh.

Competing interests: None stated.

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