2.0 Assessment And Evaluation 

Assessment in early childhood may be performed in many different ways for many different purposes, using various tools which makes it confusing. The neurodevelopmental assessment in early childhood consists of the administration of specific tasks, observation of behaviour and use of the 

caregiver report. It is a process which is designed for a better understanding of a child’s abilities  and competencies, and to be able to provide an appropriate learning environment to help children make maximum use of their developmental potential (Greenspan &Meisels, 1996, p.11.).  Early childhood assessment is a process where the professionals gather information about the development of a child, and review and interpret that information to better understand the strengths,  abilities & interests. They then use this information to make educational plans most suitable to the needs of a child for better long-term neurodevelopmental outcomes.

2.1 Process: 

Screening ------------------------> Assessment -------------------> Evaluation Screening tools are administered quickly, and identifychildren with impairment but do not make a diagnosis.  Screening methods are used for developmentalsurveillance programs. 

Assessments are done byprofessionals to informus about the support services required accordingto the needs of the child.

Evaluation is conductedto determine or diagnosedevelopmental delayand to develop strategiesfor intervention.

In the Indian context, there are various challenges in routine developmental surveillance and screening. Lack of proper guidelines for the professionals and lack of awareness  amongst the parents about their existence leads to delays in the detection of developmental delays 

thereby delaying access to the required services. Informal assessments are being routinely practised by most professionals due to various reasons like time constraints, lack of knowledge and  training on the use of screening tools and unavailability of referral centres. It has been proved  that informal assessments are unreliable in detecting developmental delays. Desai PP & Mohite P (2011) 

As of now, there are no recommendations for developmental screening by the Indian Academy of  Pediatrics (IAP). The government of India has made an attempt in this direction by launching the  ‘Rashtriya Bal SwasthyaKaryakram (RBSK)’ in 2013 which aims at screening for birth defects,  deficiency disorders, diseases and development delays including disabilities (4 D’s) in children  between 0 to 18 years as per the NRHM operational Guidelines (2013). According to the National Sample Survey Organisation (NSSO 2002), approximately 1.8% of the population is disabled in India however the actual estimates may be higher. Under the RBSK program confirmation of  diagnosis by an expert followed by planning the management, referral and then tracking and follow-up visits are all planned according to the age group of the child. According to the program  guidelines, District Hospital level early intervention centres are to be established as District Early  Intervention centres (DEIC) across the country. The purpose of DEIC is to be able to provide  support to children identified with various health conditions during the screening programs with  appropriate referrals. The team comprising a Pediatrician, a medical officer, staff Nurses,  and paramedics shall be assigned to provide these services. A manager can also be occupied to carry  out the mapping of tertiary care facilities in various government institutions to ensure adequate referral support. The funds for the same shall be approved under NHM for management at the tertiary level at the cost fixed by State Governments in consultation with the Ministry of  Health & Family Welfare. The rationale behind establishing DEIC was early detection leading to early intervention thereby minimizing disability. Once the disability is already established then the intervention would enhance the development of that child to its highest potential and prevent  progression to handicap. 

2.1.1 Guidelines for Screening, assessment, and evaluation:

1. The professionals and families must be educated about the importance of screening, assessment and evaluation of a child which also should be an integral part of child care. Its integration with the regular health care plan of a child shall reinforce its utility in the early detection of developmental delays.

2. The screening and assessment tools must be used by persons who are familiar with and trained to use those tools. The person using the tool must also have the basic knowledge about the properties of the tool.

3. It must happen at periodic intervals in a growing and developing child.

4. Tools/instruments used for screening, assessment, and evaluations must be reliable and valid. They should be culturally sensitive, age-appropriate, and language-appropriate. The tool used must be standardized on a population group which is representative of the group to be tested.

5. The tool or instrument used should assess all developmental domains; like cognitive, language, motor, adaptive and social-emotional areas in order to guide interventions.

6. Parents, families, teachers, and caregivers must be an integral part of the whole process.

7. All the assessments must be conducted in natural, non-threatening settings and may involve age-appropriate and relevant activities and tasks.

2.1.2 Prerequisites and Procedure for Developmental Screening, assessment and evaluation

1. Build a rapport with the parents/caregivers and know the primary concerns. 2. Takedown detail birth history including prenatal, natal and postnatal history followed by a detailed developmental and family history.

3. Observe the child while playing spontaneously with parents and/or familiar caregivers  and if possible, with the evaluator.

4. Special assessment can be performed depending on the individual requirement. 5. Compile data to create a complete picture of the child with emphasis on the current competencies, strengths and functional capabilities of the child.

3.0 Standardized Tools Used For Screening and Assessment A Review of screening tools that may be used in lower and middle-income countries are available but the lack of clear guidelines and their practice algorithm hampers their usage and awareness about their availability. Krishnamurthy V & Srinivasan R (2011), Junejaet.al (2012), Majnemer&  Rosen Blatt (1994). Screening tools used must have good psychometric qualities (sensitivity and  specificity or more than 70-80%). The screening tools must be norm-referenced and standardized  on a representative population(3-5). American Academy of Paediatrics (AAP) recommends routine developmental surveillance of high-risk children at every health visit from birth to 3 years and routine developmental screening of all children at 9, 18, and 24/30 months or earlier if concerns are observed. These recommendations are as per the Council on disabilities, the section on Developmental-BehaviouralPaediatrics et all. Screening for behavioural and learning disorders is also  recommended (Macias & Lipkin, 2009).

Psychometric properties of developmental screening tools and their and acceptable standards Mukherjee et. al (2014) (a)

1. A developmental screening tool has to be standardised on a representative population and there has to be uniformity in the administration and scoring system of the tool. 2. The developmental screening or assessment tool has to be validated against a gold standard tool to an acceptable standard of 70% or more.

3. The developmental screening tool must be able to identify delays correctly in 70% or  more cases indicating a good sensitivity.

4. It should be able to correctly screen developmentally typical children with no delays in at  least 80% or more indicating a good specificity.

5. The percentage of children having identified as delayed on screening tool later confirmed to  have been delayed by the assessments in 50% and more would give us a fair positive predictive value of the tool

6. Children who were screened as typically developing were later confirmed by assessment as typically developing indicating a good negative predictive value

7. Some other important properties which can be known about screening tools are reliability, interpreter and test-retest reliability.

4.0 Selection of The Tool Suited For Indian Children

An ideal screening tool for Indian children could be hypothetically brief, inexpensive with good  psychometric properties, available in various Indian languages, comprising of culturally adapted  items, requires minimal training to use and it has to be validated on representative Indian children [17]. There is a whole list of developmental screening tools used in different parts of the  world. There are some international developmental screening tools being widely used in the In Indian population. Here we shall discuss some of the international-origin developmental screening tools which have been validated on Indian children.

Some of the International Developmental screening tools commonly used on Indian children are  the Denver Developmental Screening Tool ( DDST) and Developmental Profile 3( DP-3). DDST is used for children aged 0-6 years and screens children in 4 different developmental domains under 125 items but its low specificity leads to more false-positive results leading to unnecessary  apprehension and anxiety for parents hence this tool is not considered appropriate for screening.  DP-3 is another tool which is used for screening in children from 0-12 years of age, assesses the  child in 5 different domains under 180 items and has fair psychometric properties, it is very widely used in India but the drawback is that it is not validated on the Indian population. Certain other tools like the Ages and Stages Questionnaire(ASQ) which is a parent, caregiver-reported questionnaire, that assesses development in various developmental domains, has fair psychometric properties and as per Juneja, et al. it is validated against the developmental scale for assessment of Indian infants.  Therefore ASQ has the potential to be used as a screening tool. For every parent-reported tool if is supported by interview-based when required it may help improve the outcomes and may positively impact the sensitivity and specificity of the tool can be considered for research in the future. The Bayleys-III screening tool is used mostly in high-risk infants, though it has acceptable psychometric properties it is not validated on the Indian population and is an expensive tool.  Bayley -4 has been released with an overview of ASD and a red flag ASD checklist, however, its use on the Indian population is yet to be tested. Parent evaluation of developmental status  (PEDS) has been little researched in the Indian population and has suboptimal psychometric properties. 

While we have many international developmental screening tools being used, we have to have  adequate knowledge of some of the most commonly used Indian developmental screening tools  and their properties that may help us in selecting the correct one based on our requirement. Bar Oda developmental screening tool has acceptable psychometric prosperities but has not been  revalidated since its time of inception is one of the major drawbacks. The ICMR screening tool has again not been revalidated for long and its psychometric properties are not known. Trivandrum developmental screening tool (TDSC) was validated against DDST which is no longer considered appropriate for screening hence TDSC needs to be revalidated against another standardized tool.  Trivandrum developmental screening is quick and very easy to perform but cannot assess the development in different domains of development. All of the below-mentioned screening tools can be performed in both office settings and community settings and require minimal training.

Table -2 Indian Developmental Screening Tools Mukherjee et. al (2014) (c) 

Once screening is done to identify the child at risk of developmental delay a multidisciplinary  assessment may have to be conducted for a better understanding of the developmental functioning in various domains. The assessment and evaluation tools recommended by the Ministry of National Health and Family Welfare, Government of India, 2014 are enumerated as follows: For Speech and language disorders

Receptive-Expressive Emergent Language Test—Third Edition (REEL-3) for age group 0-3  years and Linguistic profile test (LPT) for 3-9 years

For assessment of Cognition, Intellectual disability, and mental disorder Developmental assessment for Indian Infants (DASII) from birth to 30 months of age. Vineland Social-adaptive Maturity Scale 0-9 years.

Bayley-III screening and assessment test month to 42 months.

Developmental Screening Test (DST) by Bharat Raj for 1-15 years.

Denver Developmental Screening Test II (DDST-II) for age group 1 month to 6 years of age. Stanford Binet test (Indian adaptation) 2-9 years.

Piaget's Sensorimotor Intelligence Scale and cognitive task for ages 0-2 years.

Screening and Assessment tools recommended for various neurodevelopmental disorders  are

Autism Spectrum disorder

INCLEN-ASD or Indian Scale for Assessment of Autism (ISAA) 2-9years

Attention Deficit Hyperactivity ADHD: INCLEN 6-9 years

Specific Learning Disability: NIMHANS battery for learning disability 6-9 years Dyslexia Early Screening Test (DEST) 4-6 years and Dyslexia Screening Test Junior (6-11 years) Behavioural assessment can be performed using the Childhood Behavioural Checklist CBCL 0- 2 years.

Cerebral Palsy and Neuro-motor impairment: INCLEN (INDT-NMI) 0-9 years. It is important to start the practice of routine screening. Work towards creating awareness and  demand in society about the same. Do not miss any opportunity to perform screening, select an appropriate screening tool and get trained to administer the same. The results of screening must be documented and records maintained. Results must be communicated to parents and referral for further evaluation can be done when required. Parents can be sensitized about following up on developmental milestones on a timely basis.

Record keeping must be encouraged so that comparison with previous records can be done and  potential developmental problems regression, or dissociation can be identified. Screening, assessment, and evaluation are considered as the initial step in intervention services as documented in the Early Head Start National Resource Center accessed in Jan 2018.

Intervention must be initiated once delays are detected on screening and should proceed in parallel to detailed assessment and evaluation for diagnosis establishment. Follow-up sequential assessment may be performed to monitor the outcome of the intervention and developmental progress of the child.

5.0 Importance of School Readiness Assessment

In typically developing children when the professionals are planning and designing the early  education programs for children they must not forget to assess the child for school readiness.  Usually, children cope with early education and academics, but children who are not developmentally ready may find it difficult to cope with the typical educational system. Hence the role of assessment and evaluation of a child at this stage will be essential in understanding the developed mental status of a child and shall be helpful in planning the educational program for that child.  The assessment tools used for evaluating school readiness must assess the child in various dimensions like general physical growth, skill assessment, attentional, emotional and social readiness. It must also check for reading, writing and arithmetic readiness. Again, assessments must be conducted using a screening tool rather than performing an informal assessment. Before going  to school child must be competent in all developmental areas as it helps him to adjust to the new  surroundings of a school and enjoy the atmosphere (Mervin Fox, 2000).