Bhutan-Child Development 2014

Report
Good afternoon!
CHILD DEVELOPMENT and
CHILDREN WITH DISABILITIES
Brad D. Berman, MD
Clinical Professor Pediatrics, University of California,
San Francisco, USA
Consultant to Ability Bhutan Society
CHILD DEVELOPMENT in BHUTAN
Child Development
Child Development – the unfolding process of
growth and maturation from fetus through
adolescence
• CNS maturation
• Sequential that is orderly, timed and
“predictable” Gesell A
• Interactions between biologic, social and
environmental influences
Early Child Development Concepts
4 major domains:
• Sensory-motor (hearing, vision, gross, fine motor)
• Speech-language
• Cognitive
• Psychosocial/emotional
Each domain is interrelated with the others
Olysanya, B: JDBP 2011
WHAT IS DISABILITY?
International Definition of
Disability:
International Classification of Functioning,
Disability and Health (ICF)
• Disability comes from an interaction
between health and contextual factors –
environmental and personal
International Definition of Disability:
International Classification of Functioning,
Disability and Health (ICF)
• Physicalimpariments
• Activity limitations
• Participation restrictions
WHAT IS CULTURE ?
• Socially transmitted behavior patterns, beliefs,
institutions… (online Free Dictionary)
• Values
• Attitudes and beliefs
• Interpersonal behaviors
Determinants of child development
Wegner, 2009
Society
Family
Child
SOCIO-ECONOMIC STATUS – IMPACT
ON HEALTH
• Access to care and resources for maternal
health, prenatal care
• Access to adequate postnatal health and
monitoring
• Access to adequate health services,
immunizations, preventive care
• Access to adequate nutrition
Hypothesized relationship between
poverty, stunting, child development
and school achievement Grantham-McGregor S, Lancet
2007
SOCIOECONOMIC STATUS –
INFLUENCE ON EDUCATION
• Access to quality Early childhood/preschool,
elementary, secondary education, university,
vocational education
• Appropriate curriculum for all students –
special education opportunities and needs
• Impact on individual skills – language,
cognitive development
Bhutan National Survey 2010-2011
Prevalence of Children with Disabilities
• Sponsored by the Ministry of Education,
National Statistics Bureau, UNICEF-Bhutan
• Two-tiered questionnaire process
• 11,370 children screened
• 10 Question Screen by MS Durkin
Durkin MS, et al: J ClinEpidemol (48), 1995
TEN QUESTIONS SCREEN– MS Durkin, 1992
• Compared with other children, did the
child have serious delay in sitting,
standing, walking?
• Does the child appear to have difficulty
with hearing?
• Does the child speak at all?
• Does the child learn to do things like
other children his/her age?
Bhutan National Survey 2010-2011
Prevalence of Children with Disabilities
• Estimated Prevalence of disabilities ages 2-9
years is 21.3%
• Mild disability
18.6%
• Moderate disability 2.1%
• Severe disability
0.7%
• Cognitive disabilities most frequent
• Motor and behavioral disability less frequent
Bhutan National Survey 2010-2011
Children with Disabilities
• Estimated 1:1 ratio of male/female (most
international studies describe 3:1 ratio)
• Higher prevalence of disability in rural
(23.1%)
compared to urban (14.1%) setting
 Higher prevalence of disability amongst
families with lower level of maternal
education
CAUSES OF NEURODEVELOPMENTAL
DELAY IN CHILDHOOD
• Infections
– Acute e.g. meningitis, encephalitis
– Chronic e.g. parasitic, TB
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Sensory impairments – visual, hearing
Thyroid disorders – hypo, hyperthyroidism
Seizure disorders
Medications e.g. seizure medications
Head trauma
NUTRITIONAL FACTORS IN
NEURODEVELOPMENT
• Iron deficiency – childhood effects can include
anemia, attention and learning challenges,
motor, social-emotional development
• Protein deficiency – effects muscle mass,
neurologic-brain development, hair growth,
others
• Micronutient deficiency -  Vitamin A, D, C, B
complex, B12, Calcium, Zinc, others
PREMATURITY
CAUSES OF PREMATURE BIRTH
• Lack of adequate prenatal care
• Poor nutrition during pregnancy
• Difficulty with access to appropriate health
care
• Adverse effects of low socioeconomic status
• Maternal infections
• Young maternal age < 18 years old
ASSESSMENT OF CHILD WITH
NEURODEVELOPMENTAL DELAY
• History and interview with parent
- Direct face-to-face interview
- Use of questionnaires
- Must take into account family language,
culture
• Physical examination
• Observation of the child: ALWAYS!
ASSESSMENT OF CHILD WITH
NEURODEVELOPMENTAL DELAY
• Neurodevelopmental evaluation
- gross motor
- fine motor
- receptive language
- expressive language
- learning skills (if appropriate)
- awareness and response to environment
ASSESSMENT OF CHILD WITH
NEURODEVELOPMENTAL DELAY
• Use of screening questionnaires
– Several available; main issue is cultural
sensitivity and lack of available norms for
Bhutan
– Two functions for questionnaires:
• Guide single patient evaluation
• Monitor or refer for assessment
RNDA – Rapid Neurodevelopmental
Assessment
• A structured tool to ascertain rapidly
neurodevelopmental status of children who
are younger than 2 years has been developed
and validated for use by multidisciplinary
health professionals
• “structured, reliable, valid tool”
NZ Khan, MD, PhD, et al: Pediatrics, March 2010
ASSESSMENT OF CHILD WITH
NEURODEVELOPMENTAL DELAYMEDICAL TESTS
• Evaluate for hearing/vision when indicated
• Medical laboratory testing: Primary
- CBC, iron, ferritin, metabolic panel, thyroid,
lead, urinalysis, tests for infection as needed
• Medical laboratory testing: Secondary
– Genetic testing, amino acid profile, organic acid
profile, CPK, ammonia
– MRI
– EEG (when available)
PROPOSED INTERVENTIONS for
CHILDREN and DISABILITIES
• National Policies – role of pediatricians here!
• Investment in maternal and child health is an
investment in labor force and economic wellbeing (GNH)
• Improve nutrition, basic health services
• Psychosocial stimulation (remember culture?)
• Reduce violence to women and children!!!
PROPOSED INTERVENTIONS for
CHILDREN and DISABILITIES
• Multi-sectoral and transdisciplinary
• National policies - role of pediatricians
here!
• Holistic
– culturally meaningful and relevant
– blend traditional child-rearing practices with
“evidence-based approaches”
– blend traditional health practices with
“modern medicine”
PROPOSED INTERVENTIONS FOR
CHILDREN and DISABILITIES
• Systematic developmental surveillance and
screening
• Mandatory newborn laboratory screening
• Mandatory hearing screening 0-3 mos
• Promote early childhood education (C4CD,
ECCD) model
• Ensure adequate and healthy nutrition
CHILD DEVELOPMENT INTERVENTION
SERVICES in BHUTAN
• JDW National Referral Hospital
– Neonatal follow-up clinic
– Child Development clinic
– Pediatric Physiotherapy
Dr. Yoriko, Dr. Kinley, Dr. Mimi, Dr. Tashi, Karma
Lhaki, PT
CHILD DEVELOPMENT INTERVENTION
SERVICES in BHUTAN
• Ability Bhutan Society – Ms. Beda Giri, PT,
Executive Director
• DrakTsho– Ms. JigmeWangmo, Director
• Special Education Units in Government
Schools – Chief Kinley, Director of Special
Education services, Ministry of Education
CHILD DEVELOPMENT INTERVENTION
SERVICES in BHUTAN
• ECCD preschool program – ages 3-5 years
(Early Childhood Care and Development –
UNICEF-Bhutan, Special Education Division
Ministry of Education)
• C4CD Program – ages 0-2 years (Care for Child
Development – WHO, UNICEF-Bhutan,
Ministry of Health)
PROPOSED INTERVENTIONS for
CHILDREN and DISABILITIES
• Need for trained professionals in child health
and development
• Support and involvement for mothers prenatal forward…
• Development and on-going support of early
intervention programs and education
• Trans-sector collaboration
It takes a village: Professionals with
challenged learners
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Teachers - educators
Psychologists – neuropsychologists
Educational specialists
Speech-language pathologists
Occupational therapists
Counselors/social workers
Psychiatrists
Developmental-behavioral pediatricians

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