Helping kids through early developmental screening

A common thread throughout all disciplines of pediatrics is the goal to have children succeed in their development. The early years of child development are often a foreteller of developmental attainment at older ages. Thus, a child struggling to make early developmental milestones is at risk of having a more complicated neurodevelopmental trajectory going forward, especially if the child is having delays and rehabilitative therapies or other treatments are not begun. Recognizing deviances in normal neurodevelopment through screening is essential to institute therapies to address neurodevelopmental delays at their onset and improve a child’s developmental trajectory.

Despite our understanding of the importance of neurodevelopmental screening for populations of young children, many children do not receive the recommended schedule of developmental screening or monitoring.¹ Cha and colleagues report in Pediatric Research on the findings of country-wide neurodevelopmental screening instituted in Korea to identify early neurodevelopmental delays in children under age 24 months, and their association with neurodevelopmental disorders at 4 to 6 years of age.² The study found that children with positive screening results indicating a concern for a neurodevelopmental delay, specifically in gross motor function, were at higher risk for cerebral palsy and autism spectrum disorder.² Screening positively for a language delay was associated with a developmental language disorder and autism spectrum disorder.² It is impressive that 77.2% of the population born during that time participated in this surveillance screening at 9-12 months.² Accomplishing such high screening is hard to do; even during the Zika-virus epidemic, despite the recommendation that all children with antenatal Zika virus exposure receive neurodevelopmental screening, only around a third of children received all recommended evaluations.³ It is known that early identification can help children receive the needed services to improve their neurodevelopment, which is especially important during the first few years of age when there is greater neurological plasticity.⁴

Enhanced efforts to conduct neurodevelopmental surveillance can be of huge benefit to children. Such an effort can also create normative databases for child development in children globally and can be used to understand trends and changes in child neurodevelopment that may arise, for example after a global pandemic. In Korea, they developed and utilized a specially designed questionnaire called the Korean Developmental Screening Test for Infants & Children (K-DST) that assesses 6 domains with 8 questions each which was developed for their country.^5,6 It is similar to the Ages and Stages Questionnaire (ASQ-3), commonly used in the United States and elsewhere, which provides developmental screening in 5 domains, each with 5 questions. While the American Academy of Pediatrics and others have recommended routine child neurodevelopmental surveillance,¹ it may not be performed for every child when needed. Developmental screeners will typically identify children with significant delays but may have lower sensitivity for detecting neurodevelopmental delays in more mildly affected children.⁷ Therefore, not all children who have a neurodevelopmental disorder at school age will be detected by early screening. Regardless, all children should receive serial developmental screening during early childhood.

Large scale efforts to screen children for neurodevelopmental delays will require a greater number of providers to provide clinical evaluations to confirm diagnoses and availability of rehabilitative therapy programs, therapists, and school programs. In the United States, for example, there can be a long wait for a child to have an appointment with a specialist for an evaluation for autism spectrum disorder. This is likely a similar issue throughout many other countries. Certain pediatric groups may be at higher risk for neurodevelopmental disorders such as those born prematurity or with other medical conditions and neurodevelopmental screening in them is especially important. Preterm born children during the COVID-19 pandemic were found to have higher neurodevelopmental delays and lower enrollment in early intervention services.⁸

There are both clinical, demographic, and environmental factors that can also affect risk for differences in child neurodevelopment. The study by Cha et. al. found that male sex and preterm birth were associated with increased risk for autism spectrum disorder.² This has been found in other studies.⁹ They, however, did not find that the association between autism spectrum disorder and socioeconomic status (SES) was significant.² Social determinants of health also present important factors to consider that can affect risk for child development. In the study by Cha et. al., they found that higher SES children had lower risk of neurodevelopmental language impairment.² SES encompasses many variables, and so better understanding more specifically what factor or factors enhanced language development in children could help lead to the development of tools and recommendations to promote language skills. Maternal education, for example, is often discussed as a major factor when considering environmental and community factors that impact child neurodevelopment.

Early childhood developmental screeners will not detect all children with neurodevelopmental delays, cognitive or learning disabilities.^1,7,10 Typically, these tools work well to capture children with more moderate to severe delays that are of high likelihood to continue to have neurodevelopmental delays to school age. Children with milder phenotypes of neurodevelopmental delay or cognitive differences may not be detectable until older ages of childhood or when more comprehensive neuropsychological testing can be performed. For example, the Bayley Scales of Infant and Toddler Development which is a commonly used child evaluation for early development, has poor concurrent validity with school age cognitive scores, especially among children with milder delays.⁷ Thus, Henry David Thoreau’s quote, that “you are never out of the woods,” is applicable to child neurodevelopment since neurodevelopment proceeds across many years with increasing complexity of the tasks needed to adulthood, any one of which may present an unforeseen challenge. Thus, negative early screening may miss neurodevelopmental differences that are still to come. This underscores the importance of long-term neurodevelopmental surveillance in any pediatric group, especially those at higher risk like children born preterm.^1,8,9 If screening is to be done, then there needs to be availability of resources to support the children identified by this effort. Thus, to take better care of kids, we must all strive for greater neurodevelopmental screening and surveillance. This should be a priority for the pediatric community and for public health.