IJE Advance Access originally published online on May 3, 2006
International Journal of Epidemiology 2006 35(3):689-690; doi:10.1093/ije/dyl090
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Commentary |
Commentary: The epidemiology of neurodevelopmental disorders in Sub-Saharan Africa—moving forward to understand the health and psychosocial needs of children, families, and communities
1 Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of Natal, 719 Umbilo Road, Durban, 4001, South Africa
2 Department of Epidemiology, Mailman School of Public Health, Columbia University, 72 West 168th Street, New York, NY 10032, USA
* Corresponding author. E-mail: lld1{at}columbia.edu
Developmental disabilities have always been an important but largely yet to be addressed public health problem for children in developing countries.1,2 Until recently, premature birth, vaccine preventable childhood illnesses, bacterial and acute viral infections, parasitic infestations, toxic exposures, nutritional deficiencies, and injuries have accounted for the vast majority of infant and childhood mortality; childhood disability was barely ever measured. Addressing neurodevelopmental disabilities has become increasingly important with the decrease in infant mortality seen in recent decades. Disability in children can lead to lower health status and also increase the risk of death resulting from a range of potential mechanisms; children with developmental disabilities may be less likely to receive appropriate preventive and therapeutic health interventions.3 Such children may also have difficulty maintaining an adequate nutritional balance for health and growth even in the face of an adequate food supply; many live in poverty where even access to food is not certain. In addition, children with disability are often denied access to appropriate schooling or the acquisition of skills to sustain employment as adults.
While many causes of developmental disability in children in developing countries are identical to those in developed countries, there are risk factors, like HIV, which now have an impact primarily in developing countries. Some of these are preventable at low cost.1 Others will require substantial social transformation; for example, in Bangladesh and Pakistan, maternal literacy and landlessness predicted mental retardation in children.4,5 Today HIV/AIDS has emerged as the leading cause of disability in Sub-Saharan Africa (SSA).6 Finally, HIV, a major challenge to survival itself, is highly prevalent in SSA among adults with children. It has recently become clear that a proportion of children infected with HIV are surviving to school age.7 Thus many children with developmental disabilities live with parents who are ill or have become orphans because their parents have died from AIDS.8 These psychosocial stresses, alongside depression, substance use, and poverty, can have a huge impact on child development.
While primary prevention of disability is essential, secondary and tertiary prevention will also be necessary to ensure that children with developmental disabilities are supported by their families and communities and that they do not suffer additional challenges to their ability to function. Thus, it is essential to have studies, such as the one by Mung'ala-Odera et al.9 that both provide accurate population-based estimates of prevalence for planning services and interventions and identify the pattern of risk factors in children in that area.
This study uses sound methodology to estimate the prevalence of moderate-severe neurological impairment in a rural community of Kenya. Apart from using a large representative sample of 6- to 9-year-old children, the study demonstrates the feasibility of performing clinical and psychological assessments by trained community workers. The study further illustrates the value of investing in the development of locally applicable and validated tools for the assessment of cognitive functioning, a major advantage when standardized normative values for African children are lacking.
This age group is of particular importance as this is the period when the child leaves home and starts schooling. Though motor disability often manifests earlier, this is a period when sensory impairments often become overt, particularly disorders of hearing and visual acuity. This is a time when cognitive difficulties begin to impede progress in learning skills and when community institutions are in place that can support intervention. Moreover, this is simultaneously a period of vulnerability as independence from maternal care is achieved. Successful school entry and primary school completion are substantive challenges facing many children in developing countries. Without identification and support, children with neurodevelopmental disabilities may not even begin to achieve these two central benchmarks of successful development.
The Ten Questions (TQ or TQQ, as it is called in this study) was used as the screen for childhood disability in this study. This initial version of the Ten Questions screen and the later version including behaviour, the TQP, have been used successfully employing a range of variations in design in a large number of developing countries10 including Jamaica, Bangladesh, Pakistan, India, China, Egypt, Kenya,11 and South Africa.12,13 The advantages of the two-phase design used in this study are several: it is efficient in its use of professionals' time, professionals who are scarce in developing countries. Because it weights the statistics for any cases missed by the screen, the inclusion of a random sample of negatives allows for an accurate estimation of the prevalence of developmental disability in this population14 and also for point estimates of putative risk and protective factors.4,5 This study, however, is important particularly because it is the first large-scale population-based study in Africa to use a two-phase design with both clinical and psychological assessment incorporating children who screened negative as well as those who screened positive.
However, the study also raises some operational issues. Although the two-phase approach makes efficient use of qualified clinicians to conduct the second phase assessments, even this may not be feasible in many severely resource-limited settings. This study addresses some of these issues by using trained community workers in performing the culturally appropriate psychological assessments. Scientific study of the validity and reliability of replacing psychologists and doctors in the assessment phase with such mid-level workers will be important in taking this approach to scale across Africa.
The commitment of communities in SSA to improve the plight of all their people, even in the face of the AIDS epidemic, makes this a critical time to focus on health and psychosocial well-being in children who will be the foundation for the future. However, with improvement in child survival has come increased awareness of the widespread incidence of neurological, psychiatric, physical, and developmental disorders. Unfortunately, understanding the burden of developmental disabilities in these children and the causes of these disabilities is relatively limited. The study by Mung'ala-Odera et al. advances our understanding of this burden in Kenya and begins the investigation of the causes of neurodevelopmental disability, an essential step towards planning and testing interventions.
Conflict of Interest: None declared.
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References |
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 Top References |
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1 Davidson LL, Durkin MS, Khan N. Studies of children in developing countries: How soon can we prevent neurodisability in childhood. Dev Med Child Neuro 2003;(Suppl 45):18–24.
2 Durkin M, Zaman S, Thorburn M, Hasan M, Davidson L. Population-based studies of childhood disability in developing countries; rationale and study design. Int J Ment Health 1991;20:47–60.[Medline]
3 Khan NZ, Ferdous S, Munir S, Huq, S, McConachie H. Mortality of urban and rural young children with cerebral palsy in Bangladesh. Dev Med Child Neurol1998;40:749–53.[Web of Science][Medline]
4 Durkin MS, Hasan ZM, Hasan KZ. Prevalence and correlates of mental retardation among children in Karachi, Pakistan. Am J Epidemiol 1998;147:281–88.
5 Durkin MS, Khan NZ, Davidson LL et al. Prenatal and postnatal risk factors for mental retardation amoung children in Bangladesh. Am J Epidemiol 2000;152:1024–33.
6 Institute of Medicine. Neurological, Psychiatric and Developmental Disorders: Meeting the Challenge in the Developing World. Washington, DC: National Academy Press; 2001.
7 Brookes H, Shisana O, Richter L. The National Household HIV Prevalence and Risk Survey of South African Children. Capetown, South Africa: Human Sciences Research Council, 2004.
8 UNAIDS/UNICEF/USAID. Children on the Brink 2004: A Joint Report of New Orphan Estimates and a Framework for Action. New York: UNICEF, 2004.
9 Mung'ala-Odera V, Meehan R, Njuguna P, Mturi N, Alcock KJ, Newton CR. Prevalence and risk factors of neurological disability and impairment in children living in rural Kenya. Int J Epidemiol 2006; 2006;35:683–88.
10 Davidson LL. The development of the Ten Questions: a tool to screen for serious disability in children in countries with few professional resources. In: XIth ILSMH World Congress, 1995; New Delhi, India: Bishop Bekkers Institute, 1995; pp. 11–21.
11 Njoroge F, van der Linden, J. Results from disability surveys in Eastern Kenya. In: Schuurman M (ed.). Assessment of Childhood Disabilities in Developing Countries. Utrecht: Bishop Bekkers Institute, 1995.
12 Couper J. Prevalence of childhood disability in rural KwaZulu-Natal. S Afr Med J 2002;92:549–52.[Medline]
13 Christianson AL, Zwane ME, Manga P et al. Children with intellectual disability in rural South Africa: prevalence and associated disability. J Intellect Disabil Res 2002;46:179–86.[Medline]
14 Durkin MS, Davidson LL, Meher ZM et al. Estimates of the prevalence of childhood seizure disorders in communities where professional resources are scarce: results from Bangladesh, Jamaica and Pakistan. Paediatr Perinat Epidemiol 1992;6:166–80.[Medline]
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