Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 182-185 (doi:10.1542/peds.2007-1059)

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COMMENTARY

Counting Children With Disability in Low-Income Countries: Enhancing Prevention, Promoting Child Development, and Investing in Economic Well-being

Michael E. Msall, MD^a and Dennis P. Hogan, PhD^b

^a Section of Developmental and Behavioral Pediatrics, Kennedy Center and Institute of Molecular Pediatric Sciences, Pritzker School of Medicine, Comer and LaRabida Children's Hospitals, University of Chicago, Chicago, Illinois
^b Population Studies and Training Center, Brown University, Providence, Rhode Island

Abbreviations: ICF, International Classification of Functioning

There has been increased recognition that strategies to address women's and children's health require comprehensive approaches of reproductive, prenatal, neonatal, and both early- and middle-childhood public health and educational interventions.^1–3 Several preventive themes have been highlighted, including prenatal nutrition, attendants at delivery, antiviral treatment for those with HIV, tetanus prophylaxis, breastfeeding during the first year, aggressive immunization campaigns, prevention of malnutrition and vitamin and trace-element deficiencies (folate, vitamin A, vitamin D, iron, zinc, iodine), oral rehydration, and community safety.⁴ The scope of this problem is daunting: 4 million of the 130 million infants born each year around the world die during the first 4 weeks of life.⁵ In addition, there are 6 million preventable child (<5 years old) deaths each year in developing countries.⁶ Major associations with these neonatal deaths include preterm birth, severe infections, and asphyxia, which in aggregate contribute to 80% of these deaths.^5,7

The historic assumption has been that if one sequentially applies advances in preventive health, then the presence of child disability will be substantially reduced. In the preschool years, this has happened with reductions of motor disability from polio and cerebral palsy from iodine deficiency; deafness from rubella, measles, mumps, and bacterial meningitis; blindness from gonococcus and vitamin A deficiency; and mental retardation from vaccine-preventable encephalitis and meningitis.^8,9 In the United States, medical, community, and public health advances have resulted in 98% of children entering kindergarten without neurodevelopmental disability.¹⁰ However, in developing countries in south Asia and sub-Saharan Africa, 200 million children under 5 years of age fail to reach their cognitive potential because of poverty, poor health and nutrition, and suboptimal home environments.¹¹ These disadvantaged children are likely to do poorly in school and subsequently have low incomes, high fertility, and difficulty meeting the health and developmental needs of their own children, which results, in turn, in intergenerational transmission of poverty and compromised developmental potential.¹²

Because of these challenges, the article by Maulik and Darmstadt in the supplement to this month's Pediatrics is important.¹³ The authors undertook a comprehensive meta-analysis to understand current knowledge on child disability in low-income (less than $875 gross national income) and middle-income ($875–$3465 gross national income) countries. What else did they discover?

First, despite the large impact on child health, family life, and economics, research in childhood disability has been woefully inadequate. Several reasons are readily apparent. They include the difficulty in counting children when there is limited public health infrastructure or community-based preventive pediatric systems. In addition, this situation is compounded if there are gaps in educational access and no formal arrangements exist for collaboration between health and education for evaluating children who are blind, deaf, mobility challenged, unable to follow directions, or unable to learn to read and calculate.¹⁴

Second, the Ten Questions survey was the most commonly used screening tool.¹⁵ This instrument was designed to identify children (in any culture) with sensory, motor, seizure, or severe communicative or intellectual disabilities. Although there has been success with this screening tool in several developing countries, use of the Ten Questions survey in other countries, especially with the goal of detecting mild-to-moderate intellectual disability, is far from ideal.¹⁶ A key requirement here is what might be done to promote stimulation and development in early childhood and have measures of communication and learning competencies that reflect the diverse cultural contexts of childhood. In this context, the emphasis of the Ten Questions survey on mobility, lifting, self-care, communicating, seeing, hearing, and following directions is quite good.^17,18 The key need in survey research and developmental surveillance evaluation is to understand and frame indicators for social roles at key ages across elementary and secondary school experiences.¹⁹ In a developmental perspective, prevention is not a 1-age or 1-stage undertaking. In this respect, measuring functioning and activity is a promising approach and would benefit from the World Health Organization's International Classification of Functioning (ICF) model.²⁰

In the ICF model, a child's health and well-being are described in terms of 4 components: (1) body structures, (2) body functions, (3) activities, and (4) participation. Body structures are anatomic parts of the body such as organs and limbs, as well as structures of the nervous, visual, auditory, and musculoskeletal systems. Body functions are the physiologic functions of body systems, including psychological functions such as being attentive, remembering, and thinking. Activities are tasks performed by children and include walking, climbing, feeding, dressing, toileting, bathing, grooming, communicating, and socially interacting with peers and adults. Participation means involvement in community life, such as playing with peers, helping with chores, and attending family activities such as visiting relatives, attending religious services, or going on errands. The ICF model also accounts for contextual factors in a child's life, including environmental facilitators and environmental barriers as well as personal factors. Environmental facilitators include information, transportation, education accessibility, and comprehensive health services. Environmental barriers include limited health services, negative attitudes of others, lack of legal protections, and discriminatory practices. Personal factors include age, gender, interests, and sense of self-efficacy; these factors can be facilitators or barriers. Table 1 illustrates application of the ICF model for 3 children with preschool disability in developing countries. One can understand from this model community-based strategies for primary, secondary, and tertiary prevention.

View this table: [in this window] [in a new window]   TABLE 1 ICF Model Scenarios in Preschool Children With Physical Disability in Developing Countries

 
Third, diagnostic advances for hearing screening using transient otoacoustic emissions and automated auditory brainstem response²¹ had not been systematically implemented. This could be combined with nutrition and community-wide growth, health, and developmental surveillance at key preschool and school ages.²²

Fourth, in a model randomized clinical trial of service delivery for mothers of children with cerebral palsy, a comparison of health advice and play, distance training and mother-child group activities were undertaken.²³ Both the distance-training package and the mother-child group activities were beneficial in improving maternal knowledge about disability-related services, reducing maternal stress, and improving interactions between parent and child. Thus, this pilot study demonstrated how one might link isolated populations via use of information, training, and community networks.

Fifth, protein-energy malnutrition manifested by stunting and iodine deficiency resulting in cretinism or hypothyroidism were major preventable causes of intellectual disability. In this context, it is critically important to understand rural and urban roles whereby other etiologies of intellectual disability are recognized.²⁴

Sixth, there is increasing recognition of having cooperation and systems integration between health, social, and educational systems.^25–28 It is in this context that interventions such as providing safe water, preventing burns and unintentional injuries, preventing food insecurity, and promoting parents and communities as teachers can be used as opportunities to implement systematic developmental surveillance and early childhood supports.²⁹

Seventh, combining school vaccinations with screening of nutritional, vision, hearing, dental, and developmental status is not routine.

Eighth, the problems of stigma are real. This holds both for visible impairments (motor, blindness, sensory) and less obvious impairments (hearing, intellectual).

Ninth, gender disadvantage and discrimination against girls are also important. These issues bring us full circle to the high payoff of increasing maternal educational attainment and health literacy.

Tenth, information about severity of disability across different age groups and longitudinal studies that examine factors that promote child functioning and participation, as well as family well-being, have not taken place.

As expected, these substantial gaps in epidemiology make our prevention strategies more difficult. However, there are several points worth considering for population research:

1. What media strategies can be used to promote parents’ awareness of development? In this respect, educating parents about feeding, immunization, injury prevention, and indicators of illness can be coupled with educating them about child development.
   
2. How might health and education systems collaborate in preschool years and in understanding how to promote basic literacy and numeracy?
   
3. What survey methodologies at what ages might be useful for linking indicators of maternal health, infant health, child health, developmental status, and family well-being?
   

Finally, if we are to go beyond 1 disorder (eg, measles, HIV, tuberculosis) or 1 strategy (eg, oral rehydration, prenatal vitamins, vaccine preventable disorders) at a time, what key regional priorities might be implemented for enhancing prenatal, neonatal, and early childhood health and the environments of women and children? By working together to improve the status of women and children, our interventions will be an investment that enhances human capital and economic development, optimizes health and functioning, and has high payoffs in all of our futures.

	ACKNOWLEDGMENTS

 
This article was supported in part by the Brown University Office of the Vice President for Research Seed Fund Award entitled "Exceptional Children—Exceptional Challenges: Developing an Interdisciplinary Multinational Project for Studying Work-Family Dilemmas Among Parents Raising Children With Disabilities."

	FOOTNOTES

 
Accepted Apr 13, 2007.

Address correspondence to Michael E. Msall, MD, University of Chicago Pritzker School of Medicine, 5841 S Maryland Ave, MC0900, Chicago, IL 60637. E-mail: mmsall{at}peds.bsd.uchicago.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Msall, M. E. Articles by Hogan, D. P. Search for Related Content PubMed Articles by Msall, M. E. Articles by Hogan, D. P. Related Collections Office Practice Related AAP Red Book topics: Tetanus (Lockjaw) Rubella Pneumococcal Infections Mumps Measles Human Immunodeficiency Virus... Social Bookmarking                         What's this?