The association of cumulative risk scoring with ASQ-3 outcomes in a rural impoverished region of Guatemala

Abstract

Background: Child development is a global health priority. Cumulative risk scoring may be a useful tool to design more effective interventions to help high-risk young children reach their developmental potential in impoverished rural regions. Objective: To develop a risk score comprised of easily obtainable factors to design interventions and identify high-risk children who would most benefit from the interventions. Methods: Mother-child behavior interaction surveys and Ages and Stages Questionnaire, Third Edition (ASQ-3) developmental screens were completed in a convenience sample of 148 mothers with children aged 12-52 months in rural Guatemala. Associations between abnormal scores in the ASQ-3 developmental domains and demographic variables and mother-child interactions were examined. Scores were calculated by assigning 1 point for each of the included factors: 1) Maternal Demographic Risk score (DR): having no formal education, cannot read and write, having 3 or more children, and having 4 or more pregnancies; 2) Mother-Child Interaction score (MCI): sings songs, tells stories, plays with child with toys, converses with child while feeding, points to and names objects for child, and reads books to child; and 3) Combined Risk score (CR): combined two significant demographic elements and two significant negative mother-child interactions. Results: At baseline, 58% of children had abnormal scores in ≥1 ASQ-3 domain, and 35% in ≥2 domains. The probability of having ≥2 domains with abnormal scores increased significantly with an increasing DR score (OR, 1.46 [95% CI, 1.15-1.86] p<0.05) and an increasing CR score (OR, 2.08 [95% CI, 1.41-3.07], p<0.05). Conclusion: Rural Guatemalan children have high rates of ASQ-3 defined abnormal scores. A combined demographic and mother-child interaction cumulative risk index appears to be a useful tool to predict which children have abnormal scores across multiple domains. This CRI should be validated with more structured developmental testing that is not based on parent report. *Correspondence to: Stephen Berman, Director, Center for Global Health, Colorado School of Public Health, Mail Stop A090, 13199 E Montview Blvd, Suite 310, Aurora, CO 80045, USA, E-mail: stephen.berman@childrenscolorado.org Received: December 15, 2019; Accepted: December 27, 2019; Published: December 30, 2019 Introduction Child development is a global health priority. Approximately 4 in 10 children living in the developing world have developmental delays early in life. This risk of developmental delay is probably considerably higher for children born into rural impoverished communities [1]. Multiple studies document that children exposed to adverse environmental factors are at increased risk for atypical brain development, developmental delay, increased psychological stress, poor school readiness and poor academic achievement [2-13]. Recognizing the importance of these factors, the American Academy of Pediatrics Committee on Children with Disabilities recommends assessing the risk of developmental delay in conjunction with developmental surveillance and screening [14]. Adverse environmental factors are mediated through the ‘home ‘cognitive environment”, which supports the development of young children through the quality and quantity of mother (caregiver)-child interactions especially talking, playing, reading/storytelling and praise. These will impact the child’s long-term developmental trajectory and future academic success [5]. Having stressful or traumatic experiences in early childhood and/or having a mother with depression will adversely impact the home cognitive environment [2,15-17]. Assessing the risk of developmental delay for children living in impoverished communities in lowand middleincome countries (LMICs) is challenging because multiple factors in addition to adverse home environmental factors adversely impact the developmental trajectories of these children. These factors include low birth weight (prematurity and intrauterine growth retardation), neonatal infections, microcephaly, post-natal acute malnutrition and stunting (chronic malnutrition), iron deficiency anemia, and exposure to lead and other possible toxins [1,15,16]. While interventions to minimize these factors are important, enhancing the home cognitive environment remains one of the most effective interventions to promote development. Assessing potentially useful ways to determine the impact of risk factors on the home cognitive environment, subsequent developmental milestones and academic functioning would be useful in designing and implementing effective interventions. The concept of cumulative risk Mehner LC (2019) The association of cumulative risk scoring with ASQ-3 outcomes in a rural impoverished region of Guatemala Volume 4: 2-6 Pediatr Dimensions, 2019 doi: 10.15761/PD.1000198 recognizes that risk increases as the number of adverse environmental factors to which a child is exposed increases. In 1979, Michael Rutter described how chronic psycho-social stresses interact with and potentiate each other, creating a larger effect on psychiatric outcomes in children [9]. Rutter demonstrated that this effect is greater than when the impact of each stress is considered singly and then added together. The cumulative risk index (CRI) described by Sameroff et. al.in 1987 is a simple, additive score based on the number of specified environmental factors to which a child is exposed [10]. The CRI uses only the number of risks to which a child is exposed, ignoring both the intensity and pattern of the exposure. The CRI was derived by counting a child’s exposure to a possible 10 personal and family risk factors and correlating the score with IQ at age 4 and 13 years of age. In his analysis there was a significant drop in IQ scores as the number of risks increased. Five of the 10 factors used were simple demographic family characteristics, such as low maternal education, and low income. Since Sameroff ’s publication, CRIs have been widely used in developmental psychology to analyze the effects of multiple risk exposure on developmental outcomes. Pati et al. [11] studied 12 personal, family and environmental risk factors, present at age 2. He reported that four of these factors (low maternal education, low income, racial/ethnic minority and single-parent household) were strong predictors of poor academic achievement scores in 6 and 7 year old children. These four factors are commonly used in studies of CRI effects on development [18,19] Similar findings have been reported in LMIC settings. A 1996 study of Guatemalan school children demonstrated a linear relationship between an increasing number of risk factors encountered by age three years and subsequent decrease in school achievement and cognition [12]. Cumulative risk may become a useful tool for predicting the neuro-developmental outcomes of interventions in low, middleand high-income countries and for targeting interventions to the most vulnerable children who are most likely to benefit. In 2011, the Center for Global Health at the Colorado School of Public Health, in partnership with a local agro-business foundation, began a community-based nursing program in a rural impoverished area in southwestern Guatemala [20]. Prior to designing the program, Ages and Stages Questionnaire, Third Edition (ASQ-3) screens [21] and a maternal –child interaction survey were obtained from a convenience sample of children under 3 years of age to determine the baseline distribution of normal, borderline, and abnormal scores. We constructed a several cumulative risk scores using both sociodemographic factors and mother -child interactions to predict which children would have borderline, and abnormal scores. We then assessed how this information would be useful in identifying key elements of an effective intervention program and targeting families to be enrolled.