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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 741-747

Assessment of intellectual development in preschool children in the East of Menoufia Governorate, Egypt


Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission17-Apr-2016
Date of Acceptance26-Jun-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Amany M Ali Mohammed Elatabany
Diarb Negm, El Sharqia, 44661
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218257

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  Abstract 

Objective
The aim of the present study was to assess the intellectual development and other developmental domains in apparently normal preschool children in the east of Menoufia Governorate, Egypt.
Background
Assessing suspected developmental delays (SDDs) in preschool children is necessary for early intervention and decreasing developmental disabilities, because subtle disabilities, such as language impairment, mild intellectual and learning disabilities, are associated with poor health status.
Patients and methods
This cross-sectional study included 510 kindergarten children of both sexes chosen from the age group 24–60 months in the east of Menuofia Governorate, Egypt. The mean age of the children was 48.4 ± 10.2 years. The study was carried out in two stages. In the first stage, all children were screened by using the Ages and Stages Questionnaire (ASQ); those who scored below the cutoff point of the ASQ (which is specific for each age) were considered as having SDD, and were then passed onto the second stage for further evaluation (detailed history taking, clinical examination, and intelligence quotient and genetic counseling).
Results
Our results showed that the prevalence of SDD in the age group 24–60 months is 2.9%, and that of communication, problem-solving, fine motor, social and personal, and gross motor skills was 2.7, 2.2, 1.7, 0.6, and 0%, respectively. SDD was found to be more common among boys. Significant associations were found between children with SDD and paternal education, as well as consanguinity (P ≤ 0.001 and 0.01, respectively), which may indicate that the risk posed by genetic and environmental factors on child development is high. The most observed problem in children with SDD was a specific language disorder, followed by learning disability.
Conclusion
Developmental surveillance and screening is an important method of detecting delays in preschool children and the ASQ is the most valid and reliable developmental screening test, and should be used in our community.

Keywords: Ages and Stages Questionnaires, preschool children, suspected developmental delay


How to cite this article:
Abou EL-Ella SS, Mohammed Tawfik MA, Barseem NF, Ali Mohammed Elatabany AM. Assessment of intellectual development in preschool children in the East of Menoufia Governorate, Egypt. Menoufia Med J 2017;30:741-7

How to cite this URL:
Abou EL-Ella SS, Mohammed Tawfik MA, Barseem NF, Ali Mohammed Elatabany AM. Assessment of intellectual development in preschool children in the East of Menoufia Governorate, Egypt. Menoufia Med J [serial online] 2017 [cited 2017 Dec 18];30:741-7. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/741/218257


  Introduction Top


Developmental delay is widely used in the area of child health. It is a condition in which the child is not developing and/or does not reach skills in accordance with the sequence of predetermined stages [1].

The prevalence of developmental delay is largely unknown, but data from the WHO indicate that 10% of the population of any country consists of individuals with some type of disability, with a rate of 4.5% among those younger than 5 years of age [2].

The children under age 5 are not reaching their developmental potential because of poverty, malnutrition, high rates of infection, lack of stimulation, and education and instability in the home, thereby detrimentally affecting their cognitive, motor, and socioemotional development [3]. Thus, developmental screening tests have been used for decades to help identify children with developmental or behavioral disabilities [4].

One of the validated standardized screening tools recommended by the American Academy of Pediatrics is the Ages and Stages Questionnaires (ASQ). The ASQ comprises age-specific questions about the child that are completed by the child's parents, and can be used to screen development in children between ages 4 and 60 months [5].

The Stanford–Binet Intelligence Scale is the standardized test used to measure intelligence and cognitive abilities in children and adults. It can help in determining 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 in educational planning and placement and neuropsychological assessment [6].


  Patients and Methods Top


Patients

This cross-sectional study included 510 children, with a mean age of 48.4 ± 10.2 years (275 boys and 235 girls). They were selected randomly from kindergarten schools of both urban and rural areas in the east of Menuofia Governorate, Egypt, during the period from April 2015 to February 2016. The children included in the study were from both sexes and preschoolers (24–60 months old). We excluded children with genetic diseases, chronic illness, and those with neurological diseases.

Informed consent was obtained from the parents of all the children enrolled in the study. Ethical approval was taken for conducting this study from the Menoufia University Ethical Committee.

Methods

The study was carried out in two stages.

First stage

All children were subjected to be screened by using the ASQs.

The ASQs is a parent-completed developmental screening instrument in which age-specific questions about child development are used to screen development in children from 4 to 60 months of age. It is divided into 19 questionnaires according to age of the child to assess performance of children in five developmental areas (communication, gross motor skills, fine motor skills, and problem-solving and social skills); 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 with the cutoff, which is different for all skills and ages. A score above the cutoff point means the child is on the track of development; a score below the cutoff point means the child needs further assessment [7]. The questionnaire takes 10–15 min to be completed, and 2–3 min to be scored and applied by the doctor with the child and either the parent or caregivers.

We used nine questionnaires of ASQ for the age group 24–60 months after we translated it to Arabic language for smooth use in our community.

Children who had scores below the cutoff point, which was specific for each age group, were passed onto the second stage of assessment.

Second stage

According to the score achieved in the ASQ screening test, there were 15 children with scores below the cutoff point; they were of different ages. In total, 13 children were from rural areas and two were from urban areas. They were subjected to the following:

  • Full detailed history taking (antenatal, natal, postnatal, family, developmental, and past histories)
  • Full clinical examination (general and systemic examination)
  • Intelligence quotient (IQ) which was done by using the Stanford–Binet intelligence test. We used the Arabic version of Stanford–Binet test of general intelligence by Lewis Meleka in 1998, 4th ed. for measuring intellectual functioning in children with suspected developmental delay (SDD) in ASQ screening results
  • Genetic counseling, which was carried out for families who had children with SDD by explaining the importance of early identification of children with or with a risk for developmental delays so that the services could be provided in a timely manner, which will improve health outcomes in children and decrease the need for special education; discussing the results with the parent; and explaining everything about the child's needs and the strength area in the child.


Statistical analysis

The results were statically analyzed by using the statistical package SPSS, version 20 (SPSS Inc., Chicago, Illinois, USA). Data were described in term of frequencies, mean, range, SD, percentage. When comparing categorical data, the c2-test, Fisher's exact test and the t-test were used. A P value of less than 0.05 was considered statistically significant [8].


  Results Top


This study included 510 apparently normal children from the age group 24–60 months (275 boys and 235 girls). Overall, 59.8% of them were from rural and 40.2% from urban areas [Table 1]. The mean age of the children was 48.4 ± 10.2 years.
Table 1: Demographic characteristics of the studied children

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The current study showed, on the basis of the ASQ results, that 97.1% of all studied children had normal development and the prevalence of SDD in east of Menuofia Governorate was 2.9% in the age group 24–60 months. The prevalence of SDD in ASQ skills was 2.7, 2.2, 1.6, 0.6, and 0% as regards communication, problem-solving, fine motor, personal and social, and gross motor skills, respectively.

In the present study, statistically significant sex variability was observed in the mean scores for different skills of the ASQ: girls had higher scores in comparison with boys for communication and problem solving at age 60 months (P = 0.019 and 0.08, respectively); on the other hand, for gross motor skill boys had higher scores at 24, 27, and 54 months (P = 0.01, 0.06, and 0.048, respectively) [Table 2].
Table 2: Skills difference of ages-based ASQ among all studied children

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There were statistically significant differences between children with SDD and normal children as regards the demographic data and each skill of the ASQ, such as communication, fine motor, and problem solving (P < 0.001, 0.006, 0.001, 0. 045, respectively) regarding paternal education, presence of consanguinity, sex and residence of the SDD and normal children [Table 3].
Table 3: Comparison between five skills of the ASQ and demographic data of SDD and normal children

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As regards demographic data of normal and SDD children, there were statistically significant differences as regards sex, residence, parental education, and consanguinity (P < 0.001, 0.03, 0.001, and 0.01, respectively) [Table 4].
Table 4: Comparison between demographic characteristics of normal and SDD children

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Regarding provisional diagnosis, the problems observed most in children with SDD were specific language disorder (40%) followed by learning problems (26.7%). Children with learning problems and language disorder were boys more than girls and more often from rural areas. In addition, they have a family history of language disorder and learning difficulties. Moreover, most of the SDD children have a history of delayed in their developmental history [Table 5].
Table 5: Specific data of children with SDD

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Regarding IQ of SDD children by using the Stanford–Binet intelligence test, 53% of the children had average IQ followed by 20% with low average, 20% with mild intellectual disability (ID), and 7% with borderline IQ.


  Discussion Top


Child development is influenced by biomedical and sociocultural factors that are in a continuous interaction. A number of risk factors associated with an increased risk for developmental delay have been identified, including child sex and the mothers' educational level [9].

This study revealed that the prevalence of SDD was 2.9% in the east of Menuofia Governorate. Similar findings were reported in a study by Sajedi et al. [10]; they reported a prevalence of undetected developmental delays in Iranian children screened by using the ASQ ranging from 3.69 to 4.31% in different developmental domains; in addition, Dermirci [11] reported that the prevalence of developmental delay by using the ASQ–transforming rehabilitation during childhood in Turkey was 6.4% in a community-based sample consisting of children aged 3–60 months. Another study, using the Norwegian ASQ cutoff points, suggested that between 5.7 and 7.0% of young children had SDD [12].

It was found that the prevalence of SDD among the studied children was 2.7, 2.2, 1.6, 0.6, and 0% regarding communication, problem-solving, fine motor skills, personal and social skills, and gross motor skills, respectively. This was in agreement with the results of a study in Iran that showed the Iranian children delayed in the communication, gross motor, fine motor, problem-solving and social-personal domains (3.87, 4.04, 4.31, 4.15, and 3.69%, respectively) [10].

In the current study statistically significant sex differences were observed in the mean scores for different skills of the ASQ. Girls had higher scores in comparison with boys for communication and problem solving at age 60 months (P = 0.019 and 0.08, respectively); on the other hand, boys had higher scores than girls at 24, 27, and 54 months (P = 0.01, 0.06 and 0.048, respectively) for gross motor skills. These variations are normal as several factors affect development among children, such as a child's characteristics (e.g., sex, age, and somatic conditions). This was agreement with the findings of a study by Richter and Janson [13], according to which the developmental stage for girls in a Norwegian population was found to be higher than that for boys for all ASQ areas except for gross motor skills.

Regarding the sex, there was a statistically significant difference between SDD children and normal children as SDD was found to be more common in boys than in girls; this was in agreement with Rydell and colleagues, who showed that boys have a significantly higher rate of delay, which is in accordance with the findings of other studies on sex differences in preschoolers. It has been proposed that boys might be at greater risk owing to the fact that X-linked disorders are encountered more frequently in boys, and that these disorders are related to developmental delay [14].

On the other hand, Kapci et al. [15] did not find any significant differences between sexes in their study carried out on Turkish children using the ASQ.

The results of our study support the association between developmental delay and maternal/paternal education as there was a statistically significant difference between children with SDD and normal children as regards paternal and maternal educations. This is in agreement with a study in Ghana that using ASQ screening for developmental delay reported that higher education among the parents had a positive effects on child development [16].

Moreover, it has been shown that maternal/paternal education and the socioeconomic status (SES) of the family had important influences on development [17].

On the other hand, another study using ASQ for neurodevelopmental screening of children at 5 years of age showed no statistical difference according to the level of maternal education [18].

In the present study, residence had a major role in the prevalence of SDD; this is in agreement with Attanasio et al. [19] who found that developmental delays in children in the rural areas are more prevalent than in the urban areas in Chinese children.

Regarding consanguinity in the present study, there was significant value (P = 0.01) between SDD and normal children as developmental delay may be more prevalent in a consanguineous marriage. Pederson et al. [20] showed that consanguinity is a well-known risk factor for genetic disorders, including diseases and syndromes that present with ID and developmental disability; this is due to autosomal recessive disorders and also other inherited disorders.

In the current study, there were statistically significant differences between children with SDD and normal children in communication, fine motor, and problem-solving skills (P < 0.001) as regards paternal education. A higher parent education correlated with good fine motor skills and problem-solving performance of their children. Furthermore, educated parents were associated with better SES, and children of families with low SES and low parenteral education performed badly in problem-solving skills [21]. On the other hand, there was study that indicated maternal education and parental education had no significant associations with the areas of the ASQ and child development [22].

It was found that specific language disorder (40%) and learning problem (26.7%) were more prevalent in SDD children regarding provisional diagnosis. This came in agreement with Shevell et al. [23] who showed that language delay was the chief complaint of 41% of children who visited developmental delay clinics; speech and language delay accounted for a large majority of developmental disorders and it may be caused by not only specific language delay but also global developmental delay or ID, autism spectrum disorder, or by other motor or psychomotor developmental areas.

The prevalence of LD in the US children in 2003 was 9.7%, meaning that an estimated six million US children under the age of 18 years had LD. Lifetime prevalence of LD increased with age, from just more than 2% in children aged 3 and 4, 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 [24].

It was found that children with SDD had a family history of language delay and learning difficulties, and also that boys, lower household education, and social isolation were associated with language and learning problems. In their study, Snowling et al. [25] showed that the prevalence of LD increased among children with a family history of LD – those who live in poverty and under stimulating environments. In addition, Campbell et al. [26] showed a correlation between male sex, previous family history, and maternal education in language delay.

Regarding IQ of the SDD children, there were 53% children with average IQ, followed by 20% with low average, 20% with mild, and 7% with borderline IQ; we also found that children with SDD in more than one developmental area had low IQ; which was in agreement with the study (using the ASQ and IQ score for neurodevelopment screening) conducted on children 5 years of age that showed that low ASQ scores correlated well with low IQ scores [18].


  Conclusion Top


Our study demonstrates the usefulness of the ASQ for detecting developmental impairment in preschoolers as the prevalence of SDD was 2.9% in the east of Menuofia Governorate. The ASQ provides a simple, cost-effective alternative to formal standardized assessments for use in both screening programs and field-based research. We hope to use it in primary care in our community.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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