Cerebral palsy and developmental intellectual disability in children younger than 5 years: Findings from the GBD-WHO Rehabilitation Database 2019

Objective

Children with developmental disabilities are associated with a high risk of poor school enrollment and educational attainment without timely and appropriate support. Epidemiological data on cerebral palsy and associated comorbidities required for policy intervention in global health are lacking. This paper set out to report the best available evidence on the global and regional prevalence of cerebral palsy (CP) and developmental intellectual disability and the associated "years lived with disability" (YLDs) among children under 5 years of age in 2019.

Methods

We analyzed the collaborative 2019 Rehabilitation Database of the Global Burden of Disease (GBD) Study and World Health Organization for neurological and mental disorders available for 204 countries and territories. Point prevalence and YLDs with 95% uncertainty intervals (UI) are presented.

Results

Globally, 8.1 million (7.1-9.2) or 1.2% of children under 5 years are estimated to have CP with 16.1 million (11.5-21.0) or 2.4% having intellectual disability. Over 98% resided in low-income and middle-income countries (LMICs). CP and intellectual disability accounted for 6.5% and 4.5% of the aggregate YLDs from all causes of adverse health outcomes respectively. African Region recorded the highest prevalence of CP (1.6%) while South-East Asia Region had the highest prevalence of intellectual disability. The top 10 countries accounted for 57.2% of the global prevalence of CP and 62.0% of the global prevalence of intellectual disability.

Conclusion

Based on this Database, CP and intellectual disability are highly prevalent and associated with substantial YLDs among children under 5 years worldwide. Universal early detection and support services are warranted, particularly in LMICs to optimize school readiness for these children toward inclusive education as envisioned by the United Nations' Sustainable Development Goals.

Accelerating progress on early childhood development for children under 5 years with disabilities by 2030

The likelihood of a newborn child dying before their fifth birthday (under-5 mortality rate) is universally acknowledged as a reflection of the social, economic, health, and environmental conditions in which children (and the rest of society) live, but little is known about the likelihood of a newborn child having a lifelong disability before their fifth birthday if he or she survives. Available data show that globally the likelihood of a child having a disability before their fifth birthday was ten times higher than the likelihood of dying (377·2 vs 38·2 per 1000 livebirths) in 2019. However, disability funding declined by 11·4% between 2007 and 2016, and only 2% of the estimated US$79·1 billion invested in early childhood development during this period was spent on disabilities. This funding pattern has not improved since 2016. This paper highlights the urgent need to prioritise early childhood development for the beneficiaries of global child survival initiatives who have lifelong disabilities, especially in low-income and middle-income countries, as envisioned by the Sustainable Development Goals agenda. This endeavour would entail disability-focused programming and monitoring approaches, economic analysis of interventions services, and substantial funding to redress the present inequalities among this cohort of children by 2030.

The principles of Nurturing Care promote human capital and mitigate adversities from preconception through adolescence

A comprehensive evidence-based framework is needed to guide policies and programmes that enable children and adolescents to accrue the human capital required to meet the Sustainable Development Goals (SDGs). This paper proposes a comprehensive, multisectoral, multilevel life-course conceptualisation of human capital development by building on the Nurturing Care Framework (NCF), originally developed for the foundational period of growth and development through the age 3 years. Nurturing care (NC) comprises stable environments that promote children's health and nutrition, protect from threats, and provide opportunities for learning and responsive, emotionally supportive and developmentally enriching relationships. NC is fostered by families, communities, services, national policies and beyond. The principles apply across the life course, endorse equity and human rights, and promote long-term human capital. This paper presents an evidence-based argument for the extension of the NCF from preconception through adolescence (0-20 years), organised into six developmental periods: preconception/prenatal, newborn/birth, infancy/toddlerhood, preschool, middle childhood and adolescence. The proposed framework advances human capital within each developmental period by promoting resilience and adaptive developmental trajectories while mitigating negative consequences of adversities.Attaining the SDGs depends on strengthening human capital formation, extending throughout childhood and adolescence and supported by NC. Embedded in enabling laws, policies and services, the dynamic NCF components can mitigate adversities, enhance resilience and promote the well-being of marginalised groups. The life-course extension of the NCF is strategically positioned to enhance human capital, to attain the SDGs and to ensure that children or adolescents are not left behind in reaching their developmental potential.

Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments

BACKGROUND

Estimates of children and adolescents with disabilities worldwide are needed to inform global intervention under the disability-inclusive provisions of the Sustainable Development Goals. We sought to update the most widely reported estimate of 93 million children <15 years with disabilities from the Global Burden of Disease Study 2004.

METHODS

We analyzed Global Burden of Disease Study 2017 data on the prevalence of childhood epilepsy, intellectual disability, and vision or hearing loss and on years lived with disability (YLD) derived from systematic reviews, health surveys, hospital and claims databases, cohort studies, and disease-specific registries. Point estimates of the prevalence and YLD and the 95% uncertainty intervals (UIs) around the estimates were assessed.

RESULTS

Globally, 291.2 million (11.2%) of the 2.6 billion children and adolescents (95% UI: 249.9-335.4 million) were estimated to have 1 of the 4 specified disabilities in 2017. The prevalence of these disabilities increased with age from 6.1% among children aged <1 year to 13.9% among adolescents aged 15 to 19 years. A total of 275.2 million (94.5%) lived in low- and middle-income countries, predominantly in South Asia and sub-Saharan Africa. The top 10 countries accounted for 62.3% of all children and adolescents with disabilities. These disabilities accounted for 28.9 million YLD or 19.9% of the overall 145.3 million (95% UI: 106.9-189.7) YLD from all causes among children and adolescents.

CONCLUSIONS

The number of children and adolescents with these 4 disabilities is far higher than the 2004 estimate, increases from infancy to adolescence, and accounts for a substantial proportion of all-cause YLD.

The Rights of Children for Optimal Development and Nurturing Care

Millions of children are subjected to abuse, neglect, and displacement, and millions more are at risk for not achieving their developmental potential. Although there is a global movement to change this, driven by children's rights, progress is slow and impeded by political considerations. The United Nations Convention on the Rights of the Child, a global comprehensive commitment to children's rights ratified by all countries in the world except the United States (because of concerns about impingement on sovereignty and parental authority), has a special General Comment on "Implementing Child Rights in Early Childhood." More recently, the World Health Organization and United Nations Children's Fund have launched the Nurturing Care Framework for Early Childhood Development (ECD), which calls for public policies that promote nurturing care interventions and addresses 5 interrelated components that are necessary for optimal ECD. This move is also complemented by the Human Capital Project of the World Bank, providing a focus on the need for investments in child health and nutrition and their long-term benefits. In this article, we outline children's rights under international law, the underlying scientific evidence supporting attention to ECD, and the philosophy of nurturing care that ensures that children's rights are respected, protected, and fulfilled. We also provide pediatricians anywhere with the policy and rights-based frameworks that are essential for them to care for and advocate for children and families to ensure optimal developmental, health, and socioemotional outcomes. These recommendations do not necessarily reflect American Academy of Pediatrics policy.

Nurturing care framework for inclusive early childhood development: opportunities and challenges

The nurturing care framework (NCF) for early childhood development (ECD) launched at the 2018 World Health Assembly opens a range of opportunities and challenges for child neurodisability professionals. The United Nations Convention on the Rights of the Child and Convention on the Rights of People with Disabilities frame these pathways for collaboration and progress. This overview of the NCF and its contexts in inclusive ECD identifies avenues for innovation and collaboration in harmony with the field's clinical, scientific, and advocacy agendas. One avenue involves enhancing the alignment between health systems and human rights. A second avenue involves neurodisability professionals engaging with nurturing care as leaders, partners, and implementers. WHAT THIS PAPER ADDS: Participation and leadership by neurodisability professionals can enhance quality and impact. A rights-based framework that includes young children with disabilities and their families is widely encouraged.

Developmental disabilities among children younger than 5 years in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Sustainable Development Goals (SDGs) mandate systematic monitoring of the health and wellbeing of all children to achieve optimal early childhood development. However, global epidemiological data on children with developmental disabilities are scarce. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 provides a comprehensive assessment of prevalence and years lived with disability (YLDs) for development disabilities among children younger than 5 years in 195 countries and territories from 1990 to 2016.

METHODS

We estimated prevalence and YLDs for epilepsy, intellectual disability, hearing loss, vision loss, autism spectrum disorder, and attention deficit hyperactivity disorder. YLDs were estimated as the product of the prevalence estimate and the disability weight for each mutually exclusive disorder, corrected for comorbidity. We used DisMod-MR 2.1, a Bayesian meta-regression tool, on a pool of primary data derived from systematic reviews of the literature, health surveys, hospital and claims databases, cohort studies, and disease-specific registries.

FINDINGS

Globally, 52·9 million (95% uncertainty interval [UI] 48·7-57·3; or 8·4% [7·7-9·1]) children younger than 5 years (54% males) had developmental disabilities in 2016 compared with 53·0 million (49·0-57·1; or 8·9% [8·2-9·5]) in 1990. About 95% of these children lived in low-income and middle-income countries. YLDs among these children increased from 3·8 million (95% UI 2·8-4·9) in 1990 to 3·9 million (2·9-5·2) in 2016. These disabilities accounted for 13·3% of the 29·3 million YLDs for all health conditions among children younger than 5 years in 2016. Vision loss was the most prevalent disability, followed by hearing loss, intellectual disability, and autism spectrum disorder. However, intellectual disability was the largest contributor to YLDs in both 1990 and 2016. Although the prevalence of developmental disabilities among children younger than 5 years decreased in all countries (except for North America) between 1990 and 2016, the number of children with developmental disabilities increased significantly in sub-Saharan Africa (71·3%) and in North Africa and the Middle East (7·6%). South Asia had the highest prevalence of children with developmental disabilities in 2016 and North America had the lowest.

INTERPRETATION

The global burden of developmental disabilities has not significantly improved since 1990, suggesting inadequate global attention on the developmental potential of children who survived childhood as a result of child survival programmes, particularly in sub-Saharan Africa and south Asia. The SDGs provide a framework for policy and action to address the needs of children with or at risk of developmental disabilities, particularly in resource-poor countries.

FUNDING

The Bill & Melinda Gates Foundation.

Inclusive early childhood development (IECD): A twin-tracking approach to advancing behavioral health and social justice

As our American Orthopsychiatric Association (AOA) transforms into a Global Alliance for Behavioral Health and Social Justice (GABHSJ), early childhood development (ECD), and, particularly, inclusive early childhood development (IECD) persists as a prime pathway toward enhancing behavioral health and social justice. As we systematically and intentionally include consideration of the rights and needs of young children with disabilities and their families in our research, practice, and policy, a twin-track (TT) approach that simultaneously considers universal factors alongside disability-specific factors can enhance our conceptualization of problems and solutions. In the context of the sustainable development goals (SDGs) of the UN 2030 Agenda for Sustainable Development and its commitment to "leave no one behind," behavioral health and social justice enhancements derive from "mainstreaming" disability matters into diverse universal policies and programs. Elaborated in the triple-twin-track approach is a call for balancing child-centeredness, family focus, and community concerns as well as integrating the special and deepening knowledge of infants and young children with extant social policy and practice. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pioneers in Pediatric Psychology: Smashing Silos and Breaking Boundaries

As part of the Pioneers in Pediatric Psychology series, this article provides a brief personal account of my career as a pediatric psychologist. Educational and professional experiences often involved confrontations with silos and boundaries set by traditions limiting understanding and impact on children's healthy development. A pedigree in developmental psychology clashed with identity, guild, and loyalty dimensions of clinical psychology. A research emphasis challenged the emergent harmony of the scientist-practitioner models. The medical center and its silos collided with those of arts and sciences academia. Evolving as an applied developmental scientist specializing in pediatric psychology allowed for a gratifying and meaningful career with a range of scientific, pedagogical, and policy contributions. An abiding orientation toward human rights and social justice sustained progress and generativity.

Psychosocial predictors of acute complications of diabetes in youth

In this paper we determine whether individual and family psychosocial functioning predicts the risk for recurrent acute diabetic complications. An onset-cohort of 61 children and adolescents with Type 1 diabetes received conventional diabetes care. Episodes of ketoacidosis and of severe hypoglycemia were recorded for 8 years, and glycaemic control was measured by glycohaemoglobin. Measures of psychosocial functioning of the patient and parents were obtained during the first year. Over 8 years, 28% of subjects had at least one episode of ketoacidosis, and 21% had at least one episode of hypoglycaemia. The odds of observing recurrent hypoglycaemia versus recurrent ketoacidosis was 14 times greater in boys than in girls (Fisher's exact test p < 0.05). Girls with recurrent ketoacidosis had more behaviour problems and lower social competence, they reported higher levels of family conflict, and their parents reported lower levels of family cohesion, expressiveness and organization in year one. These relationships were independent of any association with poor glycaemic control. Recurrent hypoglycaemia in boys was generally unrelated to individual and family functioning or glycohaemoglobin. Despite our small sample size, our findings are suggestive of relationships that may lead to early identification of patients who are prone to recurrent ketoacidosis, and to the development of early intervention strategies.

Family environment and glycemic control: a four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus

An onset cohort of children and adolescents with insulin-dependent diabetes mellitus (IDDM) and their parents were studied. Aspects of family environment were evaluated at study inception, and their influence on the initial level of, and change in, glycemic control over 4 years was examined. Family measures of expressiveness, cohesiveness, and conflict were linked to differences in the longitudinal pattern of glycemic control. In particular, the encouragement to act openly and express feelings directly (expressiveness) seemed to ameliorate deterioration of glycemic control over time in both boys and girls. Boys were especially sensitive to variations in family cohesiveness and conflict; those from more cohesive and less conflicted families showed less deterioration in glycemic control. This study demonstrated the important influence of family psychosocial factors present at diabetes onset on glycemic control in children and adolescents over the first 4 years of IDDM.

Self-perception and adolescent psychopathology: a clinical-developmental perspective

The relationship between self-perception and adolescent psychopathology was examined on nine domains of self-perception in a group of adolescent psychiatric inpatients and a comparison group of nonpatients. Inpatients rated themselves significantly lower in four domains, and correlations between symptom reports and domains of self-perception supported a relationship between negative self-perception and psychopathology. Further analysis suggested less differentiated self-perceptions among inpatients than among nonpatients. Implications for developmental assessments and clinical interventions are discussed.

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: I. The influence of patient coping and adjustment

An onset cohort of adolescents and children with insulin-dependent diabetes mellitus was studied over a 4-year period. Individual patient psychosocial and demographic factors were assessed at study inception and used to examine aspects of adherence over the follow-up. We found that initial assessment of patient coping (defense level, adaptive strength, and locus of control) and adjustment at study inception were predictive of the level of patient adherence to diabetic regimen over the 4 years of study. Psychosocial variables predicted adherence outcomes independent of patient age. This was found for three domains of adherence, i.e., diet, insulin adjustment, and metabolic monitoring, and for the composite index derived from the separate adherence scales. Preadolescents (ages 9-12) at study entry were more adherent than patients who were already adolescent (ages 13-16) when diagnosed. Using multiple regression, three factors (age, adjustment, ego defense level) accounted for 47% of the variance in adherence. No factors were predictive of change in adherence during the follow-up. Thus, psychosocial characteristics of diabetic children assessed shortly after diagnosis predicted typical or average adherence over a 4-year period. Identification of such characteristics may be useful in developing strategies for intervention early in the course of illness.

Adherence among children and adolescents with insulin-dependent diabetes mellitus over a four-year longitudinal follow-up: II. Immediate and long-term linkages with the family milieu

Cross-sectional and longitudinal findings drawn from a 4-year longitudinal study of an onset cohort of preadolescents and early adolescents with insulin-dependent diabetes and their families are presented. Patient and parent perceptions of the family environment near the time of diagnosis are used to examine patterns of adherence in the first year of illness as well as over the four follow-up years. We found that family conflict, cohesion, and organization were strongly associated with independently rated first-year adherence levels. The strongest predictor of longer term adherence was family conflict, as experienced by the patients. In addition, parents' and youngsters' perceptions of family cohesion predicted improved adherence as well as overall higher levels of patient adherence. The findings are discussed with respect to the clinical implications of discovering those family characteristics that can, shortly after diagnosis, predict short- and long-term adherence. In addition, we present planned investigations intended to further clarify paths from family perceptions to individual diabetes behaviors.

Perceptions of control, competence, and contingency as influences on the stress-behavior symptom relation in school-age children

Analyzed data from 154 school-age children and their mothers to examine the relations between stress, perceived competence and contingency, and behavior symptoms. Analyses focused on the relative merits of unidimensional vs multidimensional measures of control in predicting symptoms. The stress of undesirable life events and behavior symptoms were related in the expected direction. Multiple regression models with R2 ranging from .11 to .14 (all ps less than .0002) included significant main effects for stress, competence, and control. Analyses supported the relative superiority of the multidimensional measure of control. Models containing main effects and interaction terms were of equivalent magnitudes in accounting for variance in symptom scores. Findings support the idea of perceived control as a moderator of the stress-illness relation and are consistent with earlier suggestions that simple main effects models may be the most useful in examining these relations.

Perceptions of control, competence, and contingency as influences on the stress-behavior symptom relation in school-age children

Analyzed data from 154 school-age children and their mothers to examine the relations between stress, perceived competence and contingency, and behavior symptoms. Analyses focused on the relative merits of unidimensional vs multidimensional measures of control in predicting symptoms. The stress of undesirable life events and behavior symptoms were related in the expected direction. Multiple regression models with R2 ranging from .11 to .14 (all ps less than .0002) included significant main effects for stress, competence, and control. Analyses supported the relative superiority of the multidimensional measure of control. Models containing main effects and interaction terms were of equivalent magnitudes in accounting for variance in symptom scores. Findings support the idea of perceived control as a moderator of the stress-illness relation and are consistent with earlier suggestions that simple main effects models may be the most useful in examining these relations.

Measuring children's coping

Using a transactional model of stress and coping, a measure of children's coping is offered and applied in a semi-structured interview in which specific coping styles are assessed. Data from 176 school-age children yielded findings on age and gender differences along with other preliminary suggestions of the validity of the instrument.

Psychologic predictors of compliance in children with recent onset of diabetes mellitus

A group of 57 children with recent onset of insulin-dependent diabetes mellitus was studied over 18 months. Compliance with the prescribed diabetic treatment deteriorated over this period. Adolescents (aged 13 to 15 years) were less compliant than preadolescents (aged 9 to 12 years). Initial patient reports of self-esteem, perceived competence, social functioning, behavioral symptoms, and their adjustment to diabetes predicted subsequent compliance behaviors. The findings highlight the linkage of child personality and adjustment with self-care of diabetes, and suggest that psychosocial assessment soon after diabetes is diagnosed may help identify patients at risk for later compliance problems.

Psychological adjustment of children with recently diagnosed diabetes mellitus

Children with recent onset of insulin-dependent diabetes mellitus (IDDM) were compared with a sample of children with a recent acute medical problem. No differences were found in terms of self-esteem, locus of control, behavioral symptoms, or social functioning. A separate assessment of adjustment to diabetes was strongly correlated with each of these general personality, behavioral symptom, and social functioning measures. Sociodemographic factors such as age, gender, and social class did not predict the level of adjustment to diabetes. This study suggests that onset of diabetes does not necessarily lead to major disruptions of psychological adaptation. It also affirms the view that early adjustment to diabetes is embedded in a context of overall personality development and adaptation.

Children with recently diagnosed diabetes: Interactions within their families

Cross-sectional findings drawn from the first year of a 4-year longitudinal study of preadolescent and early adolescent insulin-dependent diabetics and their families are presented. Using direct observation techniques and a specially designed coding system, the family interactions of 56 families with a recently diagnosed diabetic child are compared with those of 49 families with a child of similar age and sex, who has had a recent, serious acute illness. The two samples are contrasted in terms of each family member's (mother, father, and child) enabling and constraining interactions, controlling for social class differences. The findings reveal that the diabetic children and their parents expressed significantly more enabling (e.g., focusing, problem solving, active understanding) speeches than comparable members of the acute illness group. In addition, there are indications of particular constraining interactions (devaluing) occurring between fathers and diabetic children. Several alternative interpretations are offered to account for these results, together with plans for future research directions to investigate these hypothesized explanations.

Marital separation and health: stress and intervention

Marital separation is a stressful life event implicated in much current thinking and practice in mental health, health psychology and psychosomatic medicine. This study examines marital separation in a controlled, prospective design. The participants were 314 Health Maintenance Organization (HMO) subscribers followed over a two year period. Marital separation was experienced by 127 of these participants early in the two-year study period. A stratified random half of these separated individuals participated in a short-term psychoeducational group intervention, "Seminars for the Separated." Measures of psychosocial adjustment and medical utilization were analyzed to describe correlates of marital separation and to evaluate the intervention. Statistically significant increases in medical utilization by people experiencing marital separation were observed in comparisons with married control subjects. Much of this increased utilization occurred in the year surrounding the actual separation and may be accounted for by mental health visits as well as nonmental health contacts with the health plan. The effects of the intervention were not evident until controls for baseline levels of medical utilization were introduced into the multivariate analysis. Even then, intervention effects were slight. Methodological problems and implications for further study are presented.

The stress of marital separation: intervention in a Health Maintenance Organization

Relationships between life stress and illness form the basis of much current thinking and practice in psychosomatic medicine. This study examines a particular life stress, marital separation, in a controlled, prospective design. Participants are 237 Health Maintenance Organization [HMO] subscribers followed over a two-year period. Marital separation was experienced by 117 of these participants early in the two-year study period. A stratified random half of these separated individuals participated in a short-term psychoeducational group intervention, "Seminars for the Separated." Measures of psychosocial adjustment and medical utilization were analyzed to describe correlates of experiencing marital separation and to evaluate the intervention. Statistically significant increases in medical utilization by people experiencing marital separation were observed in comparisons with married control subjects. Much of this increased utilization is in the year surrounding the actual separation and is accounted for by mental health visits. Effects of the intervention were not evident until controls for baseline levels of medical utilization were introduced. Even then, intervention effects were slight. Methodological problems and implications for further study are presented.

Children with recently diagnosed diabetes: interactions within their families

Cross-sectional findings drawn from the first year of a 4-year longitudinal study of preadolescent and early adolescent insulin-dependent diabetics and their families are presented. Using direct observation techniques and a specially designed coding system, the family interactions of 56 families with a recently diagnosed diabetic child are compared with those of 49 families with a child of similar age and sex, who has had a recent, serious acute illness. The two samples are contrasted in terms of each family member's (mother, father, and child) enabling and constraining interactions, controlling for social class differences. The findings reveal that the diabetic children and their parents expressed significantly more enabling (e.g., focusing, problem solving, active understanding) speeches than comparable members of the acute illness group. In addition, there are indications of particular constraining interactions (devaluing) occurring between fathers and diabetic children. Several alternative interpretations are offered to account for these results, together with plans for future research directions to investigate these hypothesized explanations.