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A Guide for Monitoring Child Development in Low- and Middle-Income Countries

^a Developmental-Behavioral Pediatrics Unit, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey
^b Department of Pediatrics, Baskent University School of Medicine, Ankara, Turkey
^c Child Study Center and Departments of Psychiatry, Epidemiology, and Public Health in Biometry, Yale University School of Medicine, New Haven, Connecticut

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
OBJECTIVE. In low- and middle-income countries, methods for clinicians to address difficulties in language, social-emotional, cognitive, behavioral, or neuromotor development during early childhood are lacking. To fill this gap, we designed, in Turkey, the Guide for Monitoring Child Development, which aims to aid clinicians in monitoring and supporting child development and the early detection and management of developmental difficulties. The Guide for Monitoring Child Development monitoring component is a practical, open-ended interview that catalyzes communication between clinicians and caregivers and obtains a portrayal of the child's development. We report on the development and psychometric properties of the Guide for Monitoring Child Development monitoring component for children aged 0 to 24 months.

METHODS. We examined the ages of attainment of Guide for Monitoring Child Development milestones and internal consistency in a cross-sectional study of healthy children receiving well-child care (study 1). In 2 clinical samples, we studied the interrater reliability between medical students and a child development specialist administering the guide (study 2), as well as the concurrent validity of the guide administered during a health visit and a comprehensive developmental assessment (study 3).

RESULTS. In study 1 (N = 510), item-total scale correlations ranged from 0.28 to 0.91. An age-dependent attainment pattern was seen in all of the milestones. In study 2 (N = 92), interrater reliability between medical-student pairs and between the child development specialist and students was high (kappa scores were 0.83–0.88). In study 3 (N = 79), the sensitivity, specificity, and positive and negative predictive values were 0.88, 0.93, 0.84, and 0.94, respectively.

CONCLUSIONS. The Guide for Monitoring Child Development is an innovative method for monitoring child development that is designed specifically for use by health care providers in low- and middle-income countries. Studies in Turkey provide preliminary evidence for its reliability and validity.

Key Words: child development • developing countries • surveillance and monitoring • developmental screening • screening tools

Abbreviations: LAMI—low and middle income • GMCD—Guide for Monitoring Child Development • WHO—World Health Organization • UNICEF—United Nations International Children's Education Fund

In low- and middle-income (LAMI) countries,¹ as childhood mortality has decreased, developmental difficulties, including disabilities, disorders, or delays in cognitive, language, social-emotional, behavioral, or neuromotor development that begin during early childhood are increasingly recognized as important contributors to morbidity across the life span.^2–6 In high-income countries, an important strategy for the early detection and management of developmental difficulties has been the integration of developmental monitoring of children (ie, standardized screening and surveillance) into health care.^7–12 In LAMI countries, health services are often the only professional services available to young children and offer, particularly during the first 2 years of life, important opportunities to address child development.^3,4,13 Interventions to enhance the development of young children are increasingly becoming available in developing countries and include low-cost strategies, such as addressing malnutrition and iron deficiency, improving caregiver-child relationships, increasing psychosocial stimulation, and establishing community-based rehabilitation.^13–17 To date, however, methods designed specifically for developmental monitoring of young children by health care providers in LAMI countries are lacking.^{2–6,13,14,18}

Research in Western countries has shown that children and their caregivers benefit from developmental monitoring during health visits in a number of ways: (1) if the child is developing typically, clinicians can provide reassurance, support parenting competence, and provide anticipatory guidance; (2) if the child is at developmental risk or has an established or emerging delay or difficulty, this can be detected early and addressed; and (3) in both situations, caregivers can be supported and informed about how to enhance their child's development.^7–12 At a population level, developmental monitoring can inform policy about rates of developmental difficulties so that existing interventions can be appropriately allocated, their effect can be monitored, and the need for further interventions can be determined.^{2,5–6,13,17}

In the United States, the implementation of developmental monitoring and the early detection of developmental difficulties have made only limited progress without the use of standardized instruments and protocols; therefore, the American Academy of Pediatrics currently recommends that standardized instruments be used.^7,19,20 Such instruments have evolved in 2 areas in the past 40 years.^21–24 First, language, social-emotional, cognitive, and behavioral development, as well as functional capacity, have become essential constructs that are incorporated into instruments. Second, the importance of caregiver-clinician communication and partnership has been reflected in the methods used for developmental monitoring. Based on the family centered care initiative in pediatrics and advances in early intervention, models in which a parent watches while a clinician "tests" the child have evolved to models in which a caregiver and clinician use instruments to "talk" about the child's development. Many instruments that ask caregivers about their concerns regarding their child's development and/or whether their child has achieved certain developmental milestones have been shown to have appropriate psychometric properties as screening tools and are now recommended and widely used in Western countries.^22–24

Studies from LAMI countries suggest that caregivers^25–27 and health care providers^28–30 may not be well equipped with knowledge about early childhood development, and, therefore, the need for instruments in the monitoring process may be even more important than in high-income countries. Ideally, in both high-income and LAMI countries, methods used for developmental monitoring in health systems should (1) be based on well-supported current theories and conceptualizations of child development, (2) be reliable and valid, (3) be linked directly to frameworks for supporting development and managing developmental problems when they are detected, (4) be brief, easy to learn, and easy to administer, and (5) require minimal cost, equipment, and paperwork.

Several differences between high-income and LAMI countries need to be addressed, however, when adapting or developing instruments that can be used in LAMI countries. First, low caregiver literacy limits the use of written questionnaires and checklists. Second, in populations where developmental difficulties are prevalent, caregivers may not have an appropriate reference as to how children should typically develop. Although identifying caregivers’ concerns is of key importance in developmental monitoring, reliance on this method alone for early identification of developmental difficulties in LAMI countries requires further examination.^27,31 Third, the use of structured questions or checklists about milestones may also be problematic. Caregivers may not readily admit that their child has not reached a milestone and may provide socially desirable answers, particularly if they do not receive health care from the same trusted clinician at each visit, do not believe that interventions exist, or are concerned about stigma related to developmental difficulties. Fourth, the alternative reliance on "child testing" methods is neither practical nor desirable. Caregivers do know their children best, and even more so than in Western countries, they are the key resource to support children's development. Therefore, family centered methods for monitoring child development that have evolved in the West should be the methods of choice for developing countries as well. Testing of the child most often leaves the caregiver "watching" rather than participating in the evaluation, and, therefore, this approach does not capitalize on the partnership of clinicians with caregivers. Furthermore, it is difficult to elicit the optimal developmental functioning of young children during health care visits. When objects are needed to elicit children's skills, the cleanliness and maintenance of such objects may be a concern in LAMI countries. Fifth, instruments that are to be used across LAMI countries need to include universal and not culture-specific concepts in child development. Sixth, monitoring child development is a new concept for health care providers in LAMI countries, and methods that are to facilitate monitoring should build on existing protocols (such as growth monitoring and immunizations) and clinicians’ skills (such as clinician-patient communication).

A number of instruments that were designed to involve caregivers in the monitoring process and were developed in Western countries^32–36 have the potential to be adapted for use in developing countries. None of these instruments, however, has been designed specifically to address concerns in developing countries. Therefore, the Guide for Monitoring Child Development (GMCD) was developed for use by health care providers in LAMI countries to monitor the development of children 0.0–3.5 years of age. The GMCD has 3 components: (1) the monitoring development component, which is reported here; (2) the supporting development component, which is an expanded version of the World Health Organization (WHO)/United Nations International Children's Education Fund (UNICEF) Care for Development Intervention^15,37 and has been incorporated by the WHO into the newly launched International Growth Standards training package³⁸; and (3) the managing developmental difficulties component, which has been adopted by the Turkish Ministry of Health and UNICEF-Turkey to be used in a nationwide training program on child development for primary health care providers. We report here a description of the GMCD monitoring development component, referred to as the GMCD, and the results of research in Turkey on its development, interrater reliability, and validity for children aged 0 to 24 months.

	METHODS

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Description of the GMCD
The GMCD aims to provide a method for developmental monitoring and early detection of developmental difficulties in LAMI countries and is rooted in the ecological and transactional conceptualizations of child development,^39,40 family centered care,⁴¹ and relationship- and strengths-based developmental assessment.²¹ To develop the GMCD, a comprehensive search of the literature was conducted, and consultations were held with experts on child development in both Western and developing countries. Core ideas were adapted from 3 seminal models: New Visions for Developmental Assessment of Young Children,²¹ Bright Future Guidelines,⁴² and the WHO International Classification of Functioning,⁴³ as well as 2 well-known and widely used instruments, the Parents’ Evaluation of Developmental Status³² and the Vineland Scales of Adaptive Behavior.³³ The open-ended interview technique was chosen as the administration method for the GMCD. This technique is based on the fundamental and universal principles of human communication and recall of information,⁴⁴ builds on patient-centered communication techniques,^45,46 avoids assumptions about what the child should be doing, lessens the possibility that caregivers will provide socially desirable answers, and is designed to be culturally neutral.

The GMCD is a brief, open-ended, precoded interview with the primary caregiver. The interview is administered in the following standard way. Caregivers are first provided with an explanation of the reason for the interview, and caregiver interest and cooperation are elicited. Table 1 shows examples of the questions of the GMCD and the way it is structured. The first question is adapted from the Parents’ Evaluation of Developmental Status³² and relates to identifying parental concerns. If the caregiver expresses concerns, these are explored further before the interview is continued. Next, the clinician explains the importance of obtaining a portrayal of the child's typical functioning and asks the 6 open-ended questions shown in Table 1. The questions (2–7) relate to the following developmental domains: (question 2) expressive language and communication, (question 3) receptive language, (question 4) gross and fine motor, (question 5) relationship (social-emotional), (question 6) play, and (question 7) self-help skills (for children older than 12 months). For each of the 6 questions, there are specific precoded milestones. Caregiver's spontaneous responses to the open-ended questions are applied to the milestones whenever possible. Additional questions are used when necessary to prompt responses to specific milestones. The GMCD does not include questions for the cognitive domain, because for young children it is difficult for a caregiver to narrate aspects of cognitive development separately from language, relating, and play skills. Cognitive development is addressed in the domains and in the first question, specifically asking if the caregiver is concerned about the child's cognitive development, using explanations such as "thinking," "using his mind," and "intelligence."

Three studies were conducted in Turkey on the construction and psychometric properties of the GMCD, for children aged 0–24 months. Study 1 aimed to determine the ages of attainment of the GMCD milestones, study 2 sought to examine ease of administration and interrater reliability, and study 3 served to examine concurrent validity of the GMCD with a comprehensive developmental assessment.

Study 1: Ages of Attainment of the GMCD Milestones
Participants
We used the WHO recommendations to select the study sample. The WHO recommends that, in populations with a high prevalence of conditions that are hazardous to child health and development (such as malnutrition, low birth weight, chronic infections including HIV/AIDS, parasitic infestations, iron deficiency anemia, and perinatal complications), references for monitoring growth and development should be based on what the WHO refers to as a "prescriptive sample" of healthy, thriving children without these risks rather than geographic, whole-population-based references.^50,51 The participants were children who, from birth onward, had received preventive health care at 2 university-affiliated community well-child care clinics in Ankara (Ankara and Baskent Universities). The intended sample size was 30 children of each gender in 8 age ranges under 25 months, resulting in a total of 480 children. All of the eligible children were enrolled and participated in the study. The pediatricians in the clinics who conducted the well-child visit examination completed the health record. At the end of the visit, a developmental-behavioral pediatrician reviewed the health records and applied the following inclusion criteria to identify the final sample that was used in the analyses. Children were included in the sample if they were born as healthy singletons with birth weight 2500 g and gestational age 37 weeks; their growth had been between fifth to 95th percentiles since birth; they had received and complied with the free iron prophylaxis available to children in Turkey after 6 months of age or their hemoglobin screens had been normal within 1 month of the study; and the pediatric evaluation and chart review concluded that they were healthy, growing normally, and had not had any health-related problems since birth apart from acute minor illnesses.

Procedures
Four researchers were trained in the administration of the GMCD and reached 95% interrater agreement on 25 consecutive administrations. At both sites, eligible caregivers were invited to participate in the study while they were waiting for their health visit or after the visit. Caregivers were informed that this was a study to obtain normative information about child development. The standard open-ended method of administration was used; 1 modification was made for the study. To avoid asking caregivers about milestones normally occurring much earlier or later than the age of the child, milestones were temporarily placed in age rows based on the following process. The 5 instruments^{33,34,47–49} used to construct the GMCD were examined, and the milestone was placed in the age column in which 90% of children in 1 of the instruments achieved this milestone. After the caregivers’ spontaneous responses were recorded, they were told that there may be other things that the child may or may not be doing. Milestones 1 below and 1 above the child's age range were read to the caregiver who was then asked whether the child had attained these milestones.

Data Analysis
Internal consistency of the GMCD was examined by computing item-total score correlation for each milestone and Cronbach's for each domain and the total instrument. Item-total scale correlations of >.25 and Cronbach's of >.70 were considered appropriate.⁵² The presence of an age-dependent developmental pattern was examined using Pearson correlation coefficients for each domain score and age. The ² test was used to examine whether significant differences existed between girls and boys in the ages of attainment of developmental milestones. We computed the age at which >90% of the study sample performed each milestone, which was then placed in the corresponding age column.

Study 2: Ease of Administration and Interrater Reliability
In study 2, 1118 fifth-year medical students at Ankara University School of Medicine were trained in the use of the GMCD; the training involved a 1.0-hour seminar and a 1.5-hour practicum. Of these, 184 randomly selected fifth-year students were paired as partners. The paired students administered the GMCD to caregivers of 92 children aged 0–24 months who received health care at Ankara University School of Medicine Department of Pediatrics. While 1 student administered the GMCD, the other observed, and both completed the GMCD independently; administration time was recorded. A child development specialist with extensive experience on the GMCD administered the GMCD to the same caregivers within 48 hours of the medical students. The students completed a questionnaire related to ease of administration, and the child development specialist asked caregivers questions about the ease of responding to the GMCD. Percentage of agreement and were used to examine interrater reliability for the overall GMCD result. We used as our criterion for interrater reliability a value of 0.60, defining a level of "good" chance-corrected interrater agreement.⁵²

Study 3: Concurrent Validity
Preliminary criteria for interpreting the GMCD were developed to examine concurrent validity. If the child was reported to exhibit all of the milestones at age level, the GMCD interpretation was classified as "appropriate for age." If the child did not demonstrate 1 of the age-appropriate milestones, the GMCD interpretation was classified as "requires follow-up evaluation with or without intervention." In a cross-sectional study, we examined the concurrent validity of the GMCD. Infants aged 1–24 months who had been born with birth weight 1500 g, treated in the NICU at Ankara University, and who came for health visits to the follow-up clinic were enrolled consecutively over a 6-month period. A pediatrician with no specific training in child development but trained in the use of the GMCD administered the GMCD at the time of a clinic visit. An experienced developmental-behavioral pediatrician, "blinded" to the GMCD results, conducted a comprehensive developmental assessment within 48 hours. This evaluation included a developmental history, play observations, neurologic examination, and the Bayley II.⁴⁹ The comprehensive evaluation was considered positive if the clinician decided that the child needed developmental interventions or the Bayley Mental Index or Psychomotor Development Index was 2 SDs below the mean of the US reference (score < 70). , sensitivity, and specificity were used to examine concurrent validity.⁵³

For all 3 of the studies, data were analyzed using SPSS 11.0 (SPSS Inc, Chicago, IL).⁵⁴ Written, informed consent from caregivers was obtained for all 3 of the studies, which were approved by Ankara University School of Medicine Ethics Committee.

	RESULTS

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Study 1: Ages of Attainment of the GMCD Milestones
Of the 546 families invited to participate in the study, 18 were excluded because of iron deficiency anemia (n = 12), chronic illness (n = 2), or history of perinatal asphyxia (n = 4). Of the 528 families who met study inclusion criteria, 18 declined, resulting in a 97% response rate. The sociodemographic characteristics of the remaining sample of 510 children are shown in Table 2. The sample was 51% male, and 59% were 12 months of age. Most mothers had at least a secondary school education (97.6%) and worked (69.4%). Most were nuclear families (86.7%), and in 58.1%, the mother was the child's full-time caretaker.

Study 3: Concurrent Validity
The sociodemographic characteristics of the sample in study 3 are shown in Table 2. Most caregivers had a high school education or less (57%) and were unemployed (57%) mothers. The development of the former very low birth weight children was found to be "appropriate for age" in 68.4% with the GMCD and in 69.6% with the comprehensive evaluation. The average agreement on positive (developmental delay) and negative (no delay) cases was 21 (87.5%) of 24 and 51 (92.7%) of 55. The weighted sum of these 2 indices of average agreement produced the overall agreement of 72 (91.1%) of 79 and a of 0.79 (P < .001). The sensitivity and specificity rates were 21 of 24 (0.88; 95% confidence interval: 0.69–0.96) and 51 of 55 (0.93; 95% confidence interval: 0.83–0.97), respectively, which represent "good" and "excellent" levels of diagnostic accuracy.⁵³ Based on this clinic sample, we obtained a predicted positive accuracy value of 0.84 and a predicted negative accuracy value of 0.94.

	DISCUSSION

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The GMCD is a novel method with the ultimate goal of facilitating developmental monitoring and the early detection of developmental difficulties of children in LAMI countries. The theoretical conceptualization of the GMCD is anchored in family centered, relationship, and strengths-based developmental assessment theory,^{21,24,39–41} and the techniques used are adapted from currently used strategies in screening and surveillance.^32,33,42 The GMCD advances the field conceptually by introducing a new and practical method of using an open-ended interviewing technique to obtain comprehensive information about the child's developmental functioning. Brevity of the training, administration, and scoring and the 1-sheet instrument offer a practical approach to developmental monitoring. The 3 studies in Turkey have provided promising results on the psychometric properties of the GMCD. Internal consistency was high, as measured by item-total score correlations and Cronbach's for the domains and total score. The sample size of 64 children in each of the 8 age ranges was adequate to demonstrate a stable, age-dependent attainment of the milestones. The 90th percentile cutoff point was used for placing milestones in age ranges; the percentile method has been used previously in other instruments, such as the Denver II.⁴⁷ Medical students with no previous background on child development were able to learn the GMCD after a brief training and administer it reliably. Sensitivity and specificity were in the range that is considered good to excellent for the diagnostic accuracy of developmental screening tests.⁵³

In high-income countries, different instruments have been standardized and validated for developmental monitoring and the early detection of developmental difficulties.^7,22,23 In LAMI countries, research on child development is extremely limited.^2,5,6,13,14 Instruments such as the Ten Questions Questionnaire,^55–57 Access Portfolio,⁵⁸ and Disability Screening Schedule⁵⁹ have been developed but are designed to question caregivers about whether a child has a severe disability and do not provide a framework for monitoring the development of young children. The Denver test⁴⁷ has been used in many countries, but decades after large standardization and restandardization studies in many different LAMI countries, research on the use of the Denver test in promoting developmental monitoring and child development is lacking. The Denver test relies on "child testing" and "structured questions," both of which are not ideal in LAMI countries. The training does not stress the importance of developing partnerships with caregivers or of promoting child development and does not have a component that can be used for planning interventions. Furthermore, the Denver II test is less commonly used in the West than it was previously because of research demonstrating its inadequate screening accuracy.⁶⁰

Each of the 3 studies has limitations in sampling and methodology. The study on the ages of attainment of GMCD milestones (study 1) is only generalizable to healthy children receiving well-child care in Ankara. In Turkey, 4 risk factors that are associated with developmental difficulties in young children are prevalent: malnutrition, iron deficiency anemia, low birth weight, and chronic illness.⁶¹ In study 1, therefore, we used the "prescriptive sample" approach recommended by the WHO.^50,51 In the United States, most instruments on cognitive development have standards based on general populations where no attempts are made to exclude children with health conditions that pose risks to development. However, because children in developing countries have much higher rates of such health-related problems that increase the likelihood of developmental problems, the WHO recommends using "prescriptive samples" to construct standards. This approach was applied by the WHO in the construction of the newly launched WHO International Growth Standards and the WHO Motor Development Study.^50,51 These studies have shown that, when child health is homogeneous and optimal, child growth and motor development are similar across diverse countries. The "prescriptive sample" approach enables LAMI countries to have standards for child development that are independent of major health-related risk factors for child development, more comparable between countries, and similar to those of Western children. This approach is now being applied in developing countries as exemplified by the population-based standardization study for developmental milestones in Argentina.⁶² As suggested by our study and that from Argentina, when healthy subjects are recruited, the sample may be skewed toward children whose caregivers have higher educational levels than national averages. Population-based studies are needed to examine the diagnostic accuracy of instruments, such as the GMCD, that have used healthy samples to construct standard references. Particular attention should be directed to whether this approach leads to high false-positive rates or whether it enables the identification of children who have delayed development but would be considered to be developing normally if population-based standard references were used.

The findings of the reliability study (study 2) were limited to medical students in a research setting. This study has provided evidence that medical students who have minimal clinical experience can be rapidly trained to administer and score the GMCD. Future studies must address whether the reliable administration of the GMCD can be sustained in real-life clinical practice. In this study, the sociodemographic characteristics of the sample were similar to national census data: 64% of the caregivers had <5 years of education, and 12% were illiterate. Those caregivers with low education could communicate their child's development in the GMCD process and provide information for the GMCD. was lower but still within the excellent range for caregivers with primary school education or less.⁵² Future population-based studies in real-life settings are needed to determine the reliability and validity of the GMCD for caregivers with different levels of education.

The study on validity (study 3) did not use a population-based sample, and, therefore, the information on positive predictive accuracy and negative predictive accuracy only pertains to the clinical sample on which it is based. Future research is required to test whether similar results will be obtained for a population-based sample. The sample size was not adequate to determine whether validity was appropriate for all of the age ranges; the sample size for the 0- to 6-month range was particularly small. Until further evidence is available on the validity of the scoring criteria in large, population-based samples and different cultures, the GMCD should be used to guide clinicians in monitoring and supporting child development and should not be used as a cross-sectional screening test. Furthermore, in study 3, the validity of the GMCD was examined using a cutoff point for the Bayley II of –2 SD and a 90% cutoff point for the milestones. In future studies, so as to avoid missing children with mild delays, it will be important to determine which cutoff points for the milestones are accurate in comparison with a 1.5-SD cutoff point for the gold standard assessment.

The GMCD training program developed by the authors consists of written materials, slides, and demonstration videos and has been adopted by the Turkish Ministry of Health and UNICEF-Turkey to be used in a nationwide training program on child development for primary health care providers. The training involves 1 day for each of the 3 GMCD components. The training includes interpreting the result of the GMCD together with all of the other existing clinical information, giving feedback starting with the child's specific strengths and using the following components to develop a plan with the caregiver to support the child's development and to manage developmental difficulties if they are detected. In future research it will be important to: examine psychometric properties in population-based samples in diverse countries and to examine the efficacy and effectiveness of the GMCD training program in the early detection and management of developmental difficulties within health care systems.

This study also raises an important question related to international research on measures for monitoring child development in LAMI countries: if, as suggested by the WHO, healthy "prescriptive" samples are used to develop standard references for instruments such as the GMCD, are the ages of attainment of key developmental milestones of healthy children similar across countries? Comparisons of our data with other studies^62,63 suggest that, during the early ages, children from different populations may attain developmental milestones at similar ages. If milestones with similar ages of attainment across populations can be included in instruments for developmental monitoring, such as the GMCD, this may have important implications for eliminating the need to standardize and validate instruments in each country.

	CONCLUSIONS

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As an effective strategy to enhance child development, many developed countries have redefined health care and have incorporated efforts to monitor and support the development of young children. As childhood mortality continues to fall in LAMI countries, there is an emerging interest in introducing models to optimize child development and to reduce the burden of developmental difficulties beginning in early childhood. The GMCD developed specifically to address some of the challenges in LAMI countries offers a practical new method for developmental monitoring and the early detection of developmental difficulties within health systems in such countries.

	ACKNOWLEDGMENTS

 
This study was supported by a grant from the National Institutes of Health and Fogarty International Center titled "Brain Disorders Across the Lifespan" (NIH R21 TW006678-01; CFDA No. 93.9899 "Promoting Child Development: Yale-Ankara Collaboration").

We deeply appreciate the contribution of Drs John M. Leventhal and Brian Forsyth for mentoring on the studies and preparation of the article; Drs Frances Page Glascoe, Sirel Karakas, and Sedat Isikli for suggestions on the data analysis; Drs Meena Cabral, Mercedes de Onis, and Jose Martines of the World Health Organization for suggestions and support; William Storandt for editing; and Nermin Sezer for data entry.

	FOOTNOTES

 
Accepted Jul 31, 2007.

Address correspondence to Ilgi O. Ertem, MD, Developmental-Behavioral Pediatrics Unit, Department of Pediatrics, Ankara University School of Medicine, Cebeci, Ankara, 06100 Turkey. E-mail: ertemilgi{at}yahoo.com

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

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