Hollie Hix-Small, PhD

 

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

In some low- and middle-income countries (LMICs), for example, researchers have begun the process of creating country-specific developmental screening measures. Other LMICs, in contrast, have chosen to translate and adapt measures developed predominately in high-income countries (HICs) to local languages and contexts. Each approach has benefits and drawbacks; however, misinformation about measures developed in HICs and a reinterpretation of the terms “screening,” “surveillance,” and “monitoring” are fueling confusion.

In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.

We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.

Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.

Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.

Although our findings suggested broad and varied use of the ASQ, there is an ongoing need for country- or region-specific norming and validation studies, not just for the ASQ but also for other screening and monitoring tools being used in LMICs. Although this suggestion may seem rudimentary to those familiar with test development, we believe it is important to highlight given that more and more frequently measures that are being adapted for, or developed in, LMICs are being promoted as meeting feasibility and psychometric criteria despite limited or narrow evidence to support their reliability and validity.

 

As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.

Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].

 

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

In some low- and middle-income countries (LMICs), for example, researchers have begun the process of creating country-specific developmental screening measures. Other LMICs, in contrast, have chosen to translate and adapt measures developed predominately in high-income countries (HICs) to local languages and contexts. Each approach has benefits and drawbacks; however, misinformation about measures developed in HICs and a reinterpretation of the terms “screening,” “surveillance,” and “monitoring” are fueling confusion.

In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.

We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.

Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.

Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.

Although our findings suggested broad and varied use of the ASQ, there is an ongoing need for country- or region-specific norming and validation studies, not just for the ASQ but also for other screening and monitoring tools being used in LMICs. Although this suggestion may seem rudimentary to those familiar with test development, we believe it is important to highlight given that more and more frequently measures that are being adapted for, or developed in, LMICs are being promoted as meeting feasibility and psychometric criteria despite limited or narrow evidence to support their reliability and validity.

 

As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.

Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].

 

Over the last decade, three series published in the Lancet on child development have increased global awareness of the importance of early brain development and highlighted the critical role nurturing care plays in the first 3 years of a child’s life. Yet, as practitioners and policy makers in low- and middle-income countries increasingly acknowledge the influence early development has on later developmental, educational, and socioeconomic trajectories, there has been less agreement regarding the most appropriate methods and measures for screening and monitoring child development over time.

In some low- and middle-income countries (LMICs), for example, researchers have begun the process of creating country-specific developmental screening measures. Other LMICs, in contrast, have chosen to translate and adapt measures developed predominately in high-income countries (HICs) to local languages and contexts. Each approach has benefits and drawbacks; however, misinformation about measures developed in HICs and a reinterpretation of the terms “screening,” “surveillance,” and “monitoring” are fueling confusion.

In an article published in Developmental Medicine & Child Neurology, we and our colleagues, Emily Vargas-Barón, PhD, of RISE Institute, Washington, and Kevin P. Marks, MD, of PeaceHealth Medical Group in Eugene, Ore., countered some of the concerns raised about translating and adapting screening measures developed in HICs. In the paper, we documented the translation, cultural adaptation, and implementation of the Ages and Stages Questionnaires (ASQ) in LMICs based on a critical examination of 53 studies published in a variety of peer-reviewed journals.

We used a consensus rating procedure to classify the articles into one of four categories: feasibility study, psychometric study, prevalence study, or research study. In total, we identified 8 feasibility studies, 12 psychometric studies, and 9 prevalence studies. The main objectives of these studies varied by economy and region.

Overall, the review revealed that the ASQ is already being used broadly in a range of countries, cultures, and linguistic contexts. As of 2017, the ASQ has been used in 23 LMICs distributed across all world regions and has been translated into at least 16 languages for use in these countries. Over half of the studies reported that parents filled out the ASQ, a finding that runs contrary to recent misconceptions about the use of developmental screeners in LMICs.

Additionally, we found that adaptation and use of the ASQ in LMICs often followed one of two paths. The first path involved engagement in a systematic translation and adaptation process, collection of evidence to support reliability and validity, completion of prevalence studies, and use in research or practice. This first path resulted in higher rates of parent completion and, in general, closer adherence to the administration procedures recommended by the ASQ development team. In contrast, a second path utilized the ASQ solely for research purposes. This path tended to result in more frequent deviations from recommended procedures for adaptation and translation (for example, on-the-fly translation or administration by assessors) and may be fueling some of the misunderstandings associated with developmental screening in LMICs.

Although our findings suggested broad and varied use of the ASQ, there is an ongoing need for country- or region-specific norming and validation studies, not just for the ASQ but also for other screening and monitoring tools being used in LMICs. Although this suggestion may seem rudimentary to those familiar with test development, we believe it is important to highlight given that more and more frequently measures that are being adapted for, or developed in, LMICs are being promoted as meeting feasibility and psychometric criteria despite limited or narrow evidence to support their reliability and validity.

 

As countries begin to develop and scale up Early Childhood Development and Early Childhood Intervention systems and services worldwide, it is vitally important that properly standardized developmental screening measures with strong evidence of reliability and validity are available for parents and practitioners. Regardless of whether researchers develop these measures locally or adapt them from measures developed in HICs, it is imperative that decision makers step back, compile available psychometric and feasibility information across the studies that have been conducted for a given measure, and draw their own conclusions.

Finally, given that some LMICs may have fewer early intervention resources and may face more barriers to ensuring service follow-up, it would be ideal if evidence-based developmental promotion (for example, early literacy promotion, positive parenting tips, or resiliency counseling) is incorporated into the process of developmental screening. In theory, this would make the screening process more effective and parent-centered.

Mr. Small is with the Oregon Research Institute, Eugene. Dr. Hix-Small is with Portland (Ore.) State University. The authors have stated that they had no interests that might be perceived as posing a conflict or bias. Dr. Hix-Small has worked as a paid ASQ trainer. Email them at [email protected].