|Year : 2017 | Volume
| Issue : 3 | Page : 734-740
Assessment of intellectual development in preschool children in west of Menoufia Governorate, Egypt
Soheir S Abou El-Ella, Maha A Mohammed Tawfik, Wafaa M Abo El-Fotoh, Amany A Kamal Baker Gomma MBBCh
Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||17-Apr-2016|
|Date of Acceptance||26-Jun-2016|
|Date of Web Publication||15-Nov-2017|
Amany A Kamal Baker Gomma
Ashmoun, Menoufia, 32811
Source of Support: None, Conflict of Interest: None
The aim of the present study was to assess intellectual development with screening of other domains of development in preschool children in west of Menoufia Governorate, Egypt.
Ages and Stages Questionnaires (ASQ) is one of the validated developmental screening tools recommended by the American Academy of Pediatrics for the early detection of developmental delay in preschool children.
Patients and methods
This cross-sectional study was conducted on 502 children from the age group 24–60 months (304 children were recruited from three city centers and 198 from three villages located in the west of Menoufia Governorate). All children were screened by using the ASQ (which is specific for each age) in the first stage of assessment. A child with a score of less than or equal to the cutoff point for one or more of the developmental areas was considered as having suspected developmental delay (SDD), and further evaluation was carried out in the second stage of assessment (detailed history taking, clinical examination, and intelligence quotient and genetic counseling).
Our results demonstrated that the overall prevalence of SDD for the age group 24–60 months was 3.6%, and for communication, gross motor, fine motor, problem-solving, and social-personal domains it was 2.4, 0, 2.2, 3, and 1%, respectively. Significant associations were found between children with SDD and paternal and maternal education, as well as consanguinity (P = 0.014, ≤0.001, ≤0.001, respectively). Boys had a higher percentage compared with girls among SDD children (72.2, 27.8%, respectively). The most observed problems in children with SDD were learning problems (33.3%), followed by specific language disorder (27.8%).
ASQ is the most valid and reliable developmental screening test for the early detection and intervention of developmental delay in preschool children, and we recommend that it should be used in our community as a preventive method.
Keywords: ages and stages questionnaires, preschool children, suspected developmental delay
|How to cite this article:|
Abou El-Ella SS, Mohammed Tawfik MA, Abo El-Fotoh WM, Kamal Baker Gomma AA. Assessment of intellectual development in preschool children in west of Menoufia Governorate, Egypt. Menoufia Med J 2017;30:734-40
|How to cite this URL:|
Abou El-Ella SS, Mohammed Tawfik MA, Abo El-Fotoh WM, Kamal Baker Gomma AA. Assessment of intellectual development in preschool children in west of Menoufia Governorate, Egypt. Menoufia Med J [serial online] 2017 [cited 2019 Nov 23];30:734-40. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/734/218256
| Introduction|| |
Developmental delay is defined as a delay in areas of speech and language development, motor development, social development, and cognitive development .
Biological and psychosocial risk factors that affect the development of children are more common in developing countries .
The American Academy of Pediatrics recommends that all infants and young children be formally screened for developmental delay at periodic intervals and if developmental concerns are raised by the parent or provider during routine developmental surveillance .
One of the validated screening tools recommended by the American Academy of Pediatrics is the Ages and Stages Questionnaires (ASQ). The ASQ provides age-specific questions about the child that are completed by the child's parent, and can be used to screen development in children from 4 to 60 months of age .
The Stanford–Binet Intelligence Scale assists in determining appropriate educational settings for children. It can help determine the level of intellectual and cognitive functioning in preschoolers, children, adolescents, and adults, and assist in the diagnosis of a learning disability (LD), developmental delay, mental retardation, or giftedness. It is used to provide educational planning and placement, neuropsychological assessment, and research .
However, there are no published studies on the use of this questionnaire in the Egyptian context. This study was planned to evaluate ASQ for detecting developmental delay in preschool children in west of Menoufia Governorate, Egypt.
| Patients and Methods|| |
This cross-sectional study was conducted on 502 preschool children from the age group 24 to 60 months: 304 children were recruited from three urban centers (Ashmoun, Sadat, Menof) and 198 children were recruited from three villages (Tahway, Sdod, Ramla) in west of Menoufia Governorate, Egypt, in the period from April 2015 to February 2016. Children excluded from the study were those with chromosomal and/or genetic disorders, chronic illness, neurological disease, and those with congenital anomalies.
Informed consent was obtained from parents of all the children enrolled in the study. Ethical approval was taken for conducting this study from the Menoufia University Ethical Committee.
This study was conducted on 502 children in two stages according to the cutoff point listed in the scoring sheet.
All the included children (502) were screened by using the age-based ASQ . The ASQ is a parent-completed developmental screening test consisting of 19 age-specific questionnaires intended for use from the age of 4 to 60 months. Each questionnaire in the ASQ consists of 30 question items covering five areas: communication, gross motor, fine motor, problem solving, and personal social. The reading level of the items ranges from fourth to sixth grade. Each area has six questions. For each item, there is a choice of three responses: 'Yes', 'Sometimes', or 'Not yet', which are scored as 10, 5, or 0, respectively. The total score for each area is obtained by adding the scores of the six items and comparing it with the cutoff point (which is different for all skills and ages). A score above the cutoff point means that the child is on the track of development, and a score below the cutoff point means that the child needs further assessment . The questionnaire takes 10–15 min to complete, and 2–3 min to be scored and applied by the doctor with the child and either the parent or caregivers. We used the ASQs to assist children with developmental delay from 24 to 60 months of age (nine questionnaires). We translated it to Arabic to use it in our community.
We compared the scores obtained by children for the five skills with the respective cutoff points listed on the scoring sheet.
Scores above the cutoff points suggested that the child was on the track developmentally (normal achievement), and scores at or below the cutoff points indicated a need for further assessment (the second stage of assessment).
According to the achieved child score in ASQ screening test, 18 children (10 children from rural areas and eight children from urban areas) had scores below cutoff points for one or more of the developmental skills and were subjected to the following:
- Full detailed history (antenatal, natal, postnatal, past, family, and developmental history)
- Thorough full clinical examination (general and systemic examination)
- The Stanford–Binet intelligence test: 4th ed. by Lewis Meleka, 1998 http://www.riverpub.com/product/sb5/details.html . We used the Arabic version of the Stanford–Binet test in this study as the gold standard to assess the intellectual function in the children with suspected developmental delay (SDD)
- Genetic counseling, which was carried out for the families (who had a child with SDD) by explaining the importance of early identification of children who have or are at risk for developmental delays so that services could be provided in a timely manner to improve health outcome in children and decrease the need for special education, and discussing the result with the parent with explanation of everything about the child's need and the strength area in the child.
Results were statistically analyzed by using the statistical package SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA). Data were described as frequencies, mean, range, SD, and percentage when appropriate. For comparing categorical data, the c2-test, Fischer's exact test and the t-test were used. A P value less than 0.05 was considered statistically significant .
| Results|| |
Overall, 502 children from the age group 24 to 60 months were included in this study (271 boys and 232 girls; 60.2% from urban and 39.8% from rural areas). Their mean age was 48.4 ± 10.2 months [Table 1]. These children were screened by using the age-based ASQ. A child with a score of less than or equal to the cutoff point for one or more developmental areas (communication, gross motor, fine motor, problem solving, social personal) was considered as having SDD.
The results demonstrated that among 502 studied children, 484 (96.4%) had normal development and the overall prevalence of SDD in the age group 24–60 months in west of Menoufia Governorate was 3.6%. The prevalence of SDD for different developmental domains, communication, gross motor, fine motor, problem-solving, and social-personal domains, was 2.4, 0, 2.2, 3, and 1%, respectively.
A statistically significant sex variability was observed in the present study among different domains of development regarding the mean of scores, where girls had higher scores in comparison with boys for communication and fine motor skills at 48 months (P = 0.025 and 0.007, respectively); on the other hand, for gross motor skills boys had higher scores than girls at 54 months (P = 0.01) [Table 2].
|Table 2: Relation between sex and the mean of scores for the five skills of the ASQ|
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Significant statistical differences were found between children with SDD and normal children and paternal education (P = 0.014), maternal education (P < 0.001), and the presence of consanguinity (P < 0.001). However, no significant difference between children with SDD and normal children concerning sex and residency were found (P = 0.11 and 0.154, respectively) [Table 3].
|Table 3: Comparison between demographic data of normal children and those with SDD|
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Comparing different developmental skills and demographic data of both normal children and those with SDD revealed statistically significant differences in fine motor and problem-solving skills as regards maternal education (P = 0.03 and < 0.001, respectively), presence of consanguinity (P = 0.015 and < 0.001, respectively), and paternal education (P < 0.001) [Table 4].
|Table 4: Relation between demographic data of studied children and five skills of the ASQ|
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Eighteen children in our study were identified as having SDD, which was higher in boys in comparison with girls (72.2 vs. 27.8%, respectively).
The most observed problems in children with SDD were learning problems (33.3%), followed by specific language disorder (27.8%). Children with learning problems were boys more than girls (66.7 and 33.3%, respectively), more from rural than from urban areas (66.7 and 33.3%, respectively), and the paternal education level was primary education for 50% of the children, and the maternal education level was secondary education, primary education, and illiterate (33.3% children for each). In addition, family history of learning difficulties was observed in 22.2% of the children with SDD [Table 5].
Moreover, children with language disorder were boys more than girls (60 and 40%, respectively), and more from rural than from urban areas (60 and 40%, respectively); the paternal education level was primary for 20% of the children and university and secondary education for 40% of them, whereas the maternal education level was secondary education for 60% and university education for 40% of the children. In addition, 50% of the children with SDD had a family history of language delay [Table 5].
Intelligence quotient (IQ) assessment in children with SDD using the Stanford–Binet intelligence test revealed that 38.9% of the children had average IQ, followed by 27.8% with borderline IQ, and 5.6% with mild IQ.
| Discussion|| |
Many children with developmental problems are not identified until they reach preschool age or even elementary school; thus, they cannot benefit from early intervention services. The utilization of parent-completed instruments as ASQ to identify developmental problems in young children therefore is crucial. Early identification of developmental disabilities allows intervention at the earliest possible point to improve the developmental potential.
Our study revealed that among 502 children, 484 (96.4%) children had normal development and the overall prevalence of SDD from 24 to 60 months was 3.6%. The prevalence of SDD for communication, gross motor, fine motor, problem-solving, and social-personal domains was 2.4, 0, 2.2, 3 and 1%, respectively. In their study, Demirci and Kartal  reported that the prevalence of developmental delay by using ASQ-transforming rehabilitation during childhood in Turkey was 6.4% in a community-based sample consisting of children aged 3–60 months. The mean age was 29.8 ± 16.6 months (3–59 months) in the Izmir urban core.
The prevalence of developmental disorder in Tahran using the ASQ was 3.69–4.31%, with a high frequency of developmental delay related to fine motor and personal-social skills. The study was conducted in several cities, the site of implementation was health centers, the age was lower than that in our study, and no other inclusion or exclusion criteria were settled .
Relatively low prevalence percentage in this study compared with other studies may be explained by relatively small sample size and wider age range (24–60 months) and selected criteria.
In terms of sex differences, a statistically significant sex variability was observed in the present study regarding the mean of scores of five skills of the ASQ, where girls had the higher scores in comparison with boys for communication and fine motor skills at 48 months; on the other hand, for gross motor skill, boys had higher scores than girls at 54 months. This is in agreement with the findings of Sajedi and colleagues who demonstrated that for the majority of age-domain subgroups, the differences between the two sexes were nonsignificant. However, in 20 age-domain subgroups, most frequently in the personal-social and fine motor domains (in terms of domains), and most frequently at 36 and 48 months of age (in terms of age ranges), girls showed significantly higher scores than did boys. Boys showed significantly higher scores in two age-domain groups (gross motor domain at 20 and 22 months of age) . Our findings are somewhat different from that of Richter and Janson  who reported that the developmental stage of girls was on average higher than that of the boys for all areas except for gross motor function for which no significant differences were detected.
Out of 18 children in our study identified as having SDD, the boys had higher percentage compared with girls (72.2 and 27.8%, respectively). This is in agreement with Kapci et al.  who did not find any significant differences between the sexes in their study carried out on Turkish children using the ASQ; but is in contrast to Amir Ali Akbari et al.  who found that male sex increased the risk for developmental delay.
The results of our study support the association between developmental delay and parental education and presence of consanguinity as there was a statistical significant difference between children with SDD and normal children as regards paternal and maternal educations and consanguinity; moreover, Pilz and Schermann  found that the maternal/paternal education and the socioeconomic status (SES) of family also had important influences on development.
According to Bozaslan and Kaya , mothers and fathers with high educational levels have democratic attitudes and their children have greater academic success and problem-solving skills and lower social anxieties. Parental education correlated with fine motor skills of their children; furthermore, educated parents are associated with better SES, and also, children with low SES and low parenteral education performed badly during balanced cluster task. Parents with high education expose their children to play with gadgets such as video games as fine motor skills involve hand–eye coordination . Our study also demonstrated the association between mother's and father's educational levels and performance of their children in different skills as there was a statistically significant difference in children with SDD and normal children in fine motor and problem-solving skills and their paternal and maternal education and consanguinity.
Consanguinity is a well-known risk factor for genetic disorders, including diseases and syndromes that present with intellectual and developmental disabilities. This is due to autosomal recessive disorders and also due to other inherited disorders .
In the current study, learning problems and specific language disorders were observed in children with SDD. In addition, family history of language delay and learning difficulties were documented more frequently in children with SDD.
Altarac and Saroha reported that the prevalence of LD in US children in 2003 was 9.7%, meaning that an estimated six million US children under the age of 18 years ever had LD. The prevalence of LD increased with age from just more than 2% in children aged 3 and 4 years to 3.8% in children aged 5, to 5.9% in children aged 6, to 8.4% in children aged 7, to 8.9% in children aged 8, to 10.3% in children aged 9, and leveling off at the 12–14% range in children aged 10–17 years by using questions about whether a doctor or other healthcare or school professional ever told the survey respondent that the child had a LD .
We also found that male sex and lower household education were associated with higher odds of LD. In their study, Rutter et al.  found LD to be associated with male sex, poverty, and lower parental education.
Male sex was a significant risk factor for language delay, and also a child born late in the family birth order had an association with speech and language delay. An association between lower parental education and language delay has also been reported .
Most studies reported that family history was the most consistent significantly associated risk factor for language delay and LD. Family history was defined as family members who took late to talking or had language disorders, speech problems, or learning problems .
In terms of IQ and parental educational level in our study, for 50% of the children with mild and borderline ID, their paternal and maternal education levels were secondary education, whereas for children with average IQ, the paternal education level was primary education in 57.1% of cases and the maternal education level was secondary education in 71.4% of cases.
Davis-Kean  found direct effects of parental education, but not income, on European–American children's standardized achievement scores (intelligence equation); both parental education and income exerted indirect effects on parents' achievement-fostering behaviors, and subsequently children's achievement, through their effects on parents' educational expectations.
Further studies on a more representative population incorporating a larger sample size, wider demographic range, and geographic characteristics are necessary for applying the ASQ as a reliable screening tool for routine developmental surveillance in the pediatric primary care setting in Egypt.
| Conclusion|| |
Developmental delay is an important worldwide health problem and thus we stress the importance of application of a standardized validated screening tool such as ASQ for a universal screening in primary care units and pediatric clinics, which has the potential to assist in the early identification of developmental delays, referral to rehabilitative services, and improvement of developmental outcomes for young children and their families needed supports in a timely manner.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]