Abstract
This study aimed to investigate the functional and developmental outcomes in school age children diagnosed with global developmental delay before 2 years old and to verify the association between their final diagnosis and environmental and biological factors. Forty-five Brazilian children (26 boys), mean age 95.84 (7.72) months, who attended regular school and were diagnosed with global developmental delay before they were 2 years old had their functions evaluated. Children with global developmental delay were diagnosed with several conditions at school age. Students with greater chances of receiving a diagnosis were those whose mothers were younger at the time their children were born (OR = 1.47, CI = 1.04-2.09, P = .03), who had impaired motor performance, specially balance (OR = 1.33, CI = 1.01-1.75, P = .04), and who needed help during cognitive and behavioral tasks at school (OR = 1.08, CI = 1.00-1.17, P = .048). Interdisciplinary evaluation contributed to defining the specific diagnosis and to identifying the necessity of specialized support.
The generic term “global developmental delay” has been widely used within the field of infant and children’s health, and several physicians adopted this term to avoid labeling the child with a specific condition, and thus they used it temporarily until the child achieved an age when it was possible to make a more specific diagnosis. 1 This term now appears in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2 and it should be applied when the child does not meet the developmental milestones expected in the different areas of human development. According to the Diagnostic and Statistical Manual, this diagnosis is recommended for children younger than 5 years old, who are too young to participate in systematic assessments of intellectual functioning. 2,3 In Brazil, however, children who were born under vulnerable conditions or who have any type delay in their development process are said to have “global developmental delay,” and many of them remain with this diagnosis over the years. No further diagnosis is investigated, and often this initial diagnosis does not represent the actual condition of the child. 4,5 In addition, in Brazil there is still no standardized nomenclature (the most frequently used term is “neuropsychomotor developmental delay”), thus it is important to focus on well-documented follow-up of young children who are identified with any sort of developmental delay.
Recent studies have pointed out that global developmental delay is a complex set of symptoms that encompass a spectrum of problems of several types and severity. 6 -10 Kerstjens et al 11 found a higher frequency of problems regarding fine motor coordination, communication, and personal and social functioning among school children with history of global developmental delay. Perna and Loughan 12 found that school children with a history of global developmental delay had lower scores in their academic performance and were more likely to be diagnosed with attention-deficit/hyperactivity disorder compared to healthy children.
These studies reinforce the importance of determining the final outcome of the global developmental delay, so that families can be better informed about the child’s prognosis to seek proper intervention. Then, it will be more likely that these children will have better performance, skills and opportunities to develop successfully, consequently minimizing potentially severe problems. 13 -15
The present study aimed to investigate the final diagnosis of children with global developmental delay and to verify its association with early functional development and environmental and biological factors. The hypothesis that guided this study is that biological and environmental risk factors are associated with developmental outcome in school children who received early diagnosis of global developmental delay.
The participants of the present study were children assisted by a philanthropic institution in a Brazilian midsized city. This study presents data on the natural development of children with global developmental delay who received treatment in the 2 first years of life. This study thus contributes to the debate about the developmental outcomes of children with global developmental delay.
Method
This is a cross-sectional observational study, whose participants were 7- to 8-year-old children who received treatment at the Association of Assistance for Children with Disabilities, all initially diagnosed with “global developmental delay.”
Study Setting
Association of Assistance for Children With Disabilities
Located in Uberlândia, in the central area of Brazil, this is a private nonprofit organization that specializes in the rehabilitation of individuals with physical disabilities. Children with prenatal, perinatal, or postnatal and/or developmental problems are referred to the association by health care centers, hospitals or by their own parents. In the institution, they are assessed by a medical team that investigates whether or not intervention and monitoring are recommended. The global developmental delay diagnosis is based on clinical assessment and neurological semiology. In the present study, global developmental delay was defined as a definitive delay involving 2 or more developmental domains as compared to peers of the same age group. As “global developmental delay” is not listed in the International Classification of Diseases–10th Revision, 15 the classification system used in Brazil, children who meet the criteria are given the closest diagnosis, which is coded in Chapter VI (Diseases of the Nervous System) as G00-G99, specifically in the subcategory cerebral palsy unspecified, whose code is G80.9. Generally, children diagnosed with global developmental delay are referred to therapies at the Association of Assistance if they present motor delays. They usually attend weekly sessions of physiotherapy, hydrotherapy, and occupational therapy, and they are discharged when they achieve independent gait. These children are usually not followed up after discharge.
Participants
The eligible children for the study were identified through medical records from August 2001 to August 2009 obtained from the Association of Assistance for Children with Disabilities in Uberlândia. The initial list had 329 records, which were analyzed according to the inclusion and exclusion criteria, resulting in 45 participants selected, as illustrated in Figure 1.
Sorting of records to select study participants.
Inclusion criteria were children of both genders, born from January 2003 to April 2006, currently living in Uberlandia, Minas Gerais, Brazil, diagnosed with global developmental delay, who had prenatal, perinatal, or postnatal problems with no evident neurological/orthopedic abnormalities, malformation, or visual/hearing impairments. We included in this study only children around the age of 2, who had already been assessed by physicians and discharged from therapy at the Association of Assistance for Children with Disabilities, those who had regular attendance at school and whose parents or guardians signed an informed consent form.
Exclusion criteria were children who had their final diagnosis changed to cerebral palsy, muscular dystrophy, autism, mental retardation, or other syndromes.
Procedures
Initially, data were extracted from the medical records of the 45 children selected for the study, by means of a semistructured questionnaire developed by the first author. We collected information about the therapies, period and length of intervention the children were submitted to in the first 2 years of life, and also data on initial and final evaluations made by the rehabilitation team. At the Association of Assistance for Children with Disabilities, evaluations were conducted by direct clinical observation and they included descriptions of the developmental status and a team-based discussion that defines (1) whether or not the child will benefit from intervention, (2) which therapies are needed, and (3) whether or not the child is ready for discharge. These clinical data were categorized into 3 components: (1) motor, for physiotherapy assessment; (2) activity, for occupational therapy assessment; and (3) participation, for psychological assessment. Information on each component was coded to indicate whether the child development was delayed, questionable, or appropriate. Data were gathered and categorized by 2 trained researchers, with kappa concordance index indicating good agreement (.63 to .79).
The participants were individually assessed at the Association of Assistance for Children with Disabilities by the first author, psychologists and neuropediatricians. The children, aged 7 to 8 years, attended the association for 3 visits. In the first visit, the first author evaluated the children with the Movement Assessment Battery for Children–2 16 and the parents filled in the Swanson, Nolan, and Pelham–IV and the Home Environment Resources Scale questionnaires.
The Movement Assessment Battery for Children–2 17 was used to identify motor skills problems in 3 different areas: manual dexterity, ball skills, and balance. The test is subdivided into 4 age groups from 3 to 16 years old. In the present study, age band 2 was used as it is specific for 7- to 8-year-old children. The sum of scores of each category provides a standardized score, and the sum of the 3 categories provides the total score. According to the test’s criteria, children with scores up to the 5th percentile were considered to have motor coordination problems or signs of developmental coordination disorder; children scoring from the 6th to the 15th percentiles were considered cases for further investigation, and those above the 15 percentile were considered to have age appropriate motor skills. The test has good test–retest and interrater reliability indexes. 16,18 For data quality control, the interrater reliability was verified prior to data collection and 2 raters scored 10 children independently, which yielded an interclass correlation coefficient of .80.
The Swanson, Nolan, and Pelham–IV questionnaire 19 identifies symptoms of attention-deficit/hyperactivity disorder in children and teenagers by summing the number of items marked by the parents: the higher the number of items, the more symptomatic the child is. It is often used with children at school age. For this study, children were categorized as either asymptomatic or with signs of either: inattention, hyperactivity, and inattention with hyperactivity. The Swanson, Nolan, and Pelham–IV questionnaire is considered to have good psychometric properties. 20
The Family Environment Resources 21 is a questionnaire answered by the parents. It is designed for the assessment of the quality of home environment according to 3 domains: material resources, activities indicating stability of the family environment, and parenting practices. It is often used to assess the resources available for children at school age. Following the author’s instructions, 22 the raw score was calculated in this study by adding the values of the marked items in each domain, except items 8, 9, and 10, which have specific scores. The instrument has satisfactory internal consistency and distinguishes families of children with different levels of school performance and behavioral problems. 22
During the second visit to the Association of Assistance, the child was assessed by a psychologist using the Wechsler Intelligence Scale for Children–III 23 and—at the same time—the first author interviewed the parents with the Pediatric Evaluation of Disability Inventory. The School Function Assessment 24 and information regarding school achievement were collected by means of an interview with the child’s teacher at school.
The Wechsler Intelligence Scale for Children–III 23 is an intelligence test translated and standardized to be used in Brazil. The test consists of 13 subtests that are combined into 3 intelligence coefficients (total, verbal, and execution) and 4 factorial indexes (verbal comprehension, perceptual organization, resistance to distraction, and processing speed). It is a clinical instrument for individual application to assess the intellectual ability of children and teenagers aged between 6 and 16 years and 11 months old. The coefficients have a mean of 100 points and standard deviation of 15. The test has good reliability coefficients and is considered a valid measure of children’s intellectual functioning. A psychologist from the Association of Assistance with extensive experience in cognitive assessment evaluated the children.
The Pediatric Evaluation of Disability Inventory 25 is a functional inventory adapted to Brazilian Portuguese. 26 The instrument items provide information on functional aspects of the development of 6- to 7-year-old children, but it can also be used with children older than 7.5 years old. It consists of an interview with parents concerning their children’s functional skills in 3 domains: self-care, mobility, and social function. For each domain, there are 3 scales: (I) capacity, (II) level of caregiver assistance, and (III) need for environmental adaptations. In this study, only scale I—capacity for self-care and mobility—was used. The sum of the items of each scale results in the total score, which is then converted into normative and continuous score. The normative score was used to rate the performance as within or below the expected for the age. The continuous score, which provides information about the children’s ability on a scale ranging from 0 to 100, was used for statistical analysis. Several studies support both reliability and validity of this test.
The School Function Assessment 24 was used to assess the children’s functional performance and participation in the school environment in 3 dimensions: participation in different school environments, assistance during tasks, and activity performance. The content addressed by this instrument is adequate for registering the functional profile of 5- to 12-year-old children. The raw score, which is obtained by summing up the points in each scale of the questionnaire, is converted to a total score that ranges from 0 to 100, with the highest score indicating full level of functioning in the assessed area.
The School Function Assessment results may be interpreted in 2 ways: basic level and advanced level. For the present study, the basic level was used to inform whether the child’s functioning in the school environment was within what is expected for both children at the same age and academic year. The School Function Assessment has evidence of reliability and validity, 27 and although it has not been validated and standardized for Brazilian children, the translated version has been clinically used in Brazil.
A ranking of the children’s performance regarding the academic content was developed by the first author based on information collected with the teacher about the child’s classroom performance. In Brazil, 7- to 8-year-old children are not given specific grades, but they receive qualitative assessment—such as excellent, good, and regular—or a report describing the development of their skills. 28 The teacher also assesses the children throughout the year to identify reading and writing levels (ie, alphabetic, syllabic-alphabetic, syllabic, and presyllabic) or to grade the level of their skills in specific content areas (ie, A: excellent, B: good, and C: fair). These data were combined and categorized into 3 levels: (I) alphabetic level and/or qualified as excellent—consolidated acquisition of expected abilities for the school year; (II) syllabic-alphabetic or syllabic level and/or qualified as good—acquisition of expected abilities in development for the school year; and (III) presyllabic level and/or qualified as regular—no acquisition of the expected abilities for the school year. In addition, information about attendance to specialized educational service was also collected.
At the end of the assessment process, the child was referred to a third visit to the Association of Assistance for Children with Disabilities, when the neuropediatricians conducted a clinical neurological evaluation and defined the final diagnosis. The neuropediatricians had access to all the test results and questionnaires.
Although the evaluation process was structured according to the International Classification of Functioning, Disability and Health 29 (Figure 2), the International Classification of Diseases–10th Revision was used to determine the clinical diagnosis, as recommended by the World Health Organization.
Organization of the assessment process of children with developmental delay based on the International Classification of Functioning, Disability and Health model. Abbreviations: HER, Home Environment Resources Scale; MABC-2, Movement Assessment Battery for Children–2; PEDI, Pediatric Evaluation of Disability Inventory; SFA, School Function Assessment; SNAP-IV, Swanson, Nolan, and Pelham–IV; WISC-III, Wechsler Intelligence Scale for Children–III).
The Research Ethics Committee from both the Federal University of Minas Gerais and the Association of Assistance for Children with Disabilities approved this study. The children’s parents or guardians signed an informed consent form after being informed about the research goals and method.
Statistical Analysis
Data were analyzed with the Statistical Package for Social Sciences SPSS, version 17.0, Minitab 16, and Excel Office 2010. The dependent variable—medical diagnosis—was defined as a dichotomous variable (ie, “typical” and “with diagnosis”) and the others (tests, questionnaires, and family, personal and rehabilitation data) as independent variables. Typical children are those presenting a level of development compatible with age expectation. Whereas children with diagnosis are those presenting 1 or more diagnoses in the final medical assessment. Descriptive analysis of the frequency distribution of categorical variables and analysis of the measurements of central tendency and dispersion for continuous variables were performed. Univariate analysis was also performed by using ANOVA (continuous variables) and binomial tests for 2 proportions (categorical variables) to determine whether there were significant differences between children with and without medical diagnosis regarding the variables. Variables with P ≤ .05 in the univariate analysis were included in the initial logistic regression model. This model was used to predict the probability that the children receive the diagnosis “with diagnosis.” Significant variables with good prediction for the final model of logistic regression were selected. The analysis was completed by calculating the probability of risk, by estimating the probability of occurrence of a “not normal” diagnosis, given the combination of variables included in the predictive model., The quality of the model was assured by the Hosmer-Lemeshow test. Finally, survival analysis was performed by using the Kaplan-Meier method to estimate the time elapsed between the initial diagnosis of developmental delay and the specific medical diagnosis.
Results
In all, 329 children had initial diagnosis of global developmental delay. Approximately 80% of them had their diagnosis changed over the first 3 years of life to cerebral palsy, muscular dystrophy, and genetic syndromes, all representing more severe conditions. The remaining 20% of the children received their “final” diagnosis after they entered school, with their participation in the present study, and, therefore, they were considered milder cases. The average time for setting the final diagnosis was 63.712 months (CI = 59.85, 67.56) (Figure 3).
Kaplan-Meier curve of the time to obtain a specific diagnosis for all children with an initial diagnosis of developmental delay.
Demographic Characteristics and Neonatal Conditions of the Participants
In this study, the authors evaluated 45 children (26 boys) with average age of 95.84 (±7.72) months at the time of the assessment, all with diagnosis of global developmental delay. The children were born with mean gestational age of 35.49 (±4.88) weeks, with an average weight of 2.289 (±1116.17) grams and, among the neonatal complications, the most common were jaundice (17), need for oxygen at birth (14), seizures (13), and signs of perinatal hypoxia (12).
Characteristics of the Rehabilitation Process in the Early Years of Life
The participants started the rehabilitation process when they were, on average, 12.75 (±7.93) months old, with minimum and maximum ages of 2 and 24 months old, respectively. They were referred to therapies mainly due to the occurrence of motor delay (24), which was identified during the initial evaluation by the rehabilitation team. Combined therapies involving the team as a whole (ie, physiotherapy, occupational therapy, psychology, hydrotherapy, speech therapy, and music therapy) were the most common mean of intervention (25). The duration of the rehabilitation process was, on average, 2.61 (±1.96) years and discharge was recommended mainly due to the fact that motor development had been considered adequate (41) for the child’s age.
Functional Developmental Outcome of the Participants
Regarding the developmental outcomes, 22 children had total Wechsler Intelligence Scale for Children–III score for intelligence quotient within average, whereas 13 were below and 10 above average. On the Movement Assessment Battery for Children–2, 32 children showed motor abnormalities, 28 had motor difficulties, and 4 were at risk for difficulties. As for the functional profile, which was assessed with the self-care, mobility and social function domains of the Pediatric Evaluation of Disability Inventory, 39, 43 and 27 children performed within the average, respectively. On the Swanson, Nolan, and Pelham–IV scale, the majority of children (26) did not present symptoms of attention-deficit/hyperactivity disorder. According to the School Function Assessment, 10 children (22.2%) presented effective participation in different school environments and required assistance in cognitive and behavioral tasks, just as their peers from the same group. As for the development in academic tasks, although 24 (53,3%) managed to comprehend academic content, as assessed by the teacher, most of them presented limited participation, especially in activities that required positive interaction (26), behavioral control (26), and completion of tasks (28). There were no records of attendance to specialized educational services.
Relation Between Neonatal, Familiar, and Rehabilitation Characteristics and Final Diagnosis
There were statistically significant differences between groups (typical and with a diagnosis) on the following variables: mother’s gestational age (P = .005), mother’s education (P = .034), father’s education (P = .018), initial motor assessment (P = .014), and therapies attended during the rehabilitation process (physiotherapy + occupational therapy + psychology) (P = .018), and orientation to parents or caregivers (P = .019). Tables 1 and 2 present the results of univariate analysis, which reveals the association between neonatal, family and rehabilitation characteristics and the medical diagnosis given to children at school age.
Neonatal and Sociodemographic Characteristics and Their Association With the Final Medical Diagnosis of Children With Developmental Delay.
Abbreviations: BW, birth weight; GA, gestational age; MW, minimum wage; SD, standard deviation.
*ANOVA. **Binomial for 2 proportions.
Rehabilitation Characteristics and Their Association With the Final Medical Diagnosis of Children With Developmental Delay.
Note: OT, occupational therapy; Physio, physiotherapy; Pyscho, psychology; SD, standard deviation.
*ANOVA. **Binomial for 2 proportions.
Relation Between Developmental Outcome and Final Diagnosis
There were statistically significant differences regarding children with and without medical diagnosis in the distribution of the scores from the Movement Assessment Battery for Children–2, Wechsler Intelligence Scale for Children–III, School Function Assessment, Pediatric Evaluation of Disability Inventory, Swanson, Nolan, and Pelham–IV scale, and school performance. No association was found between developmental outcome and home environment as measured by the Home Environment Resources scale. Table 3 presents the results of the univariate analysis, which showed the association between medical diagnosis and developmental outcomes at school age.
Functional Development Outcome at School Age and Its Association With the Final Medical Diagnosis of Children With Developmental Delay (Continuation).
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; IQ, intelligence quotient; MABC-2, Movement Assessment Battery for Children; PEDI, Pediatric Evaluation of Disability Inventory; SD, standard deviation; SFA, School Function Assessment; SNAP-IV, Swanson, Nolan, and Pelham–IV; WISC-III, Wechsler Intelligence Scale for Children–III. *ANOVA. **Binomial for 2 proportions.
Likelihood of Receiving Diagnosis From the International Classification of Diseases–10th Revision According to the Logistic Regression
The variables used to create the logistic regression model to predict the likelihood of receiving a specific diagnosis were those which had univariately presented a “diagnosis” effect. These variables with their respective P values are in bold in the last column of Tables 1, 2, and 3. Table 4 presents the final logistic regression model, indicating that the younger the mother, the greater the chance the child might be given a diagnosis. Moreover, the worse the performance in the motor area of “balance,” the greater the chances the child might be given a diagnosis as well. The chance of being given a diagnosis was higher in children who required additional assistance in “cognitive and behavioral tasks” at school. The statistical significance of the adjustment test was .796 (P > .05), indicating that the model is adequate and has good adhesion.
Functional Development Outcome at School Age and Its Association With the Medical Diagnosis of Children With Developmental Delay (Continuation).
Abbreviations: HER, home environment resources; SD, standard deviation.
aRaw score.
*ANOVA. **Binomial for 2 proportions.
Final Diagnosis of Children with Developmental Delay
Thirty children (66.7%) received a formal diagnosis and the remaining 15 were considered free of developmental disorders. From the 30 children with diagnosis, half received only 1 diagnosis code from the International Classification of Diseases–10th Revision, whereas the other half received more than 1 diagnosis code. The most frequent diagnoses were a combination of other unspecified coordination disorders conditions (R27.8) + activity and attention disorders (F90.0) + unspecified developmental disorder of scholastic skills (R27.8), whereas 7 (23.3%) children received diagnosis code F81.9, that is, unspecified developmental disorder of scholastic skills (6; 20%). Table 5 presents the diagnosis codes and the number of children diagnosed according to the International Classification of Diseases–10th Revision.
Final Logistic Regression Model.
Abbreviations: CI, confidence interval; MABC-2, Movement Assessment Battery for Children; OR, odds ratio; SFA, School Function Assessment.
Discussion
The results of this study show that the global developmental delay can determine a wide range of possible outcomes. Some elements, such as mother’s age at birth, poor balance and need for assistance in cognitive and behavioral tasks in the school context, can be valuable in determining the developmental outcomes of school children diagnosed with “global development delay.”
It is known that risk factors for developmental delay are multifactorial and that the accumulation of conditions can magnify the impact on the child’s development. Children with global developmental delay who were included in the present study were mostly boys from low-income families, most of them with motor delay at the initial evaluation and 51.1% with history of prematurity and low birth weight, and also neonatal neurological complications. Similarly to this study, Shevell et al 30 analyzed the profile of children with global developmental delay who attended a pediatric hospital in Canada. They found a higher frequency of developmental issues in boys, with different degrees and subtypes of delay: more severe cases involved global delay whereas mild cases involved motor delay only. Chen et al 31 also analyzed the risk factors and clinical characteristics of children with global developmental delay and reported a higher frequency (62.8%) of biological factors associated with the delay observed. Motor delay was the most frequent condition in children who had prenatal, perinatal, and postnatal problems, whereas genetic defects and congenital anomalies were more commonly observed in those with global delay.
In the present study, the treatment of children in the rehabilitation center began, on average, at their first year of life, and lasted for about 2.5 years. Furthermore, the present findings show that the type of intervention that children received during this period was associated with their outcomes, which means that children with a diagnosis from the International Classification of Diseases–10th Revision also received more than 1 type of intervention (physical therapy, occupational therapy, and psychology) during the rehabilitation process. These children probably had more severe forms of delay at the beginning and received no follow-up after discharge. These findings are consistent with the literature, which states that there is low investment in the long-term follow-up of this population. 6 Although children benefit from therapies, which result in significant improvements in their development, there is evidence that the benefits of intervention decrease over time when monitoring is interrupted earlier than expected. 32
Regarding the developmental outcomes, these data indicate that children who were diagnosed with global developmental delay have difficulties both in motor skills and school participation, although they are more independent in daily activities. As in the present study, Shevell et al 6 also found that the frequency of motor problems (96%) were higher than functional difficulties (70%) in children with global developmental delay. They argue that the presence of favorable predictive variables, such as parent’s school level and employment, were associated with good functional performance. This suggests that these factors may have contributed to children’s access to more resources, which might minimize future problems related to their developmental process. Families with more resources, for example, can make adjustments to daily tasks or to their environment in such way that the child’s ability to perform tasks independently can be maximized.
However, it is important to recognize that other factors may be related to good academic performance found in children with developmental delay, such as greater cognitive reserve. As for intelligence assessment, there were children with total intelligence quotient within, 22 below 13 and above the average range. 10 It was also observed that 13 children in the group that received a final diagnosis had total intelligence quotient below average. Tang et al 33 investigated the cognitive development of preschoolers with global developmental delay and also found variations, but children with below average intelligence were those with history of more significant delay. In a similar study, Riou et al 10 assessed the intelligence of children diagnosed with global developmental delay as they entered school and also found a wide distribution of intelligence scores, which was justified by the presence of children with autism and mental disorders in their sample. In the present study, no child with autism was identified due to the exclusion criteria, and also because the Association of Assistance for Children with Disabilities is an institution specialized in motor rather than mental/cognitive disorders.
As identified in this study, the outcome of global developmental delay presents a variety of profiles, ranging from those with normal development (n = 15; 33.3%) to those with significant problems (n = 30) (Table 6). The variables that were determinant for indicating this outcome were mother’s age at child’s birth, motor performance regarding balance, and need of assistance during cognitive and behavioral tasks at school. As for the mother’s age, it was observed that the younger the mother is at child’s birth, the greater the chances the child might have a diagnosis. Liaw and Brooks-Gunn 34 also found an association between maternal young age and cognitive impairment in children. According to Fraga, 35 this association may be related to the following 2 factors: biological risk of early pregnancy that might affect the newborn development and issues associated with the interaction between young mothers and their children.
Diagnosis according to ICD 10, children with delay history of global development.
Abbreviation: ICD-10, International Classification of Diseases–10th Revision.
*Code given to children who were diagnosed as normally developing.
Data also indicate that children that are given a diagnosis have poor performance with regard to balance and need more assistance in cognitive and behavioral tasks at school. There is little evidence on the developmental outcome of children with developmental delay, 6 but retrospective studies have documented the co-occurrence of learning difficulties among children with motor coordination problems. 36 -38 The exact cause of these associations is still a target of speculation. 39 The cerebellum, however, has been shown to play an important role in reading and writing skills; 40 it also contributes to the development of language and motor control, 41 and even to cognitive modulation. 42 Thus, problems in these areas may have a common biological substrate, which operates through the cerebellum, 38 and therefore would be shown externally by balance problems.
Most children in this study (66.7%) received diagnosis codes that represent several conditions, according to the International Classification of Diseases–10th Revision, which demonstrates that the developmental delay for most of them does not have a positive outcome. This also shows that with a more precise and thorough evaluation of children at school age it is possible to better define the type of developmental disorder. It is important to define the “final diagnosis” of global developmental delay as this may entitle access to special services. Although no children assessed in this study benefitted from special educational services, they could have access to specialized support, which is granted by law in Brazil, when the child has a formal diagnosis.
Among the limitations of this study, the authors can highlight the use of foreign tests, which limits the interpretation of the cutoff points of each instrument, and also the use of teachers’ reports to assess children’s academic performance. However, the tests were very carefully selected. We opted for those with high reliability and also for those that were commonly used in Brazil. The teacher’s report should be considered an important piece of information to support the specific diagnosis. In this study, the authors verified that academic performance assessed by the teacher was related to the child outcome, which means that children who did not master the academic content (level II) tended to be in the group that received a diagnosis. In addition, children with a final diagnosis had lower intelligence quotient, more symptoms of attention-deficit/hyperactivity disorder and, consequently, required more attention by the teacher in the classroom than those without a diagnosis.
It is important to clarify that the sample was obtained from an institution whose focus is to treat children at risk for neurological deficits. Therefore, there are limitations to the generalization of results due to the possibility of bias regarding the number of children with motor problems. Further studies should be carried out in institutions for treatment of young children in general (eg, health care centers), preferably before they start school, to identify outcomes such as autism and other developmental disorders, which were underestimated in the present study.
Conclusion
At school age it is possible to make more accurate diagnosis of children with global developmental delay. Interdisciplinary assessment of multiple domains of development, with the presence and participation of parents, contributes to the diagnosing process and to the identification of need of specialized support. The development of children with global developmental delay should be monitored, because this process can help professionals and parents understand what is happening until a “final diagnosis” is made, as the term “global developmental delay” should be used only as a temporary diagnosis.
Footnotes
Acknowledgments
This study was carried out at the Association of Assistance for Children with Disabilities, Uberlândia, Minas Gerais, Brazil.
Author Contributions
LFD: elaboration of the study project, contact with the participants, application of questionnaires and tests, except the Wechsler Intelligence Scale for Children–III, interpretation of data, manuscript writing, including revision and formatting. NMCD: diagnostic evaluation of the subjects. NMOM: diagnostic evaluation of the subjects. RMCP: assistance and revision of data statistical analysis. RRHA: application of the Wechsler Intelligence Scale for Children–III to the subjects. SAP:. LCM: interpretation of data and manuscript writing, including revision and formatting.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Council of Technological and Scientific Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq) and the Foundation for Research Support of the State of Minas Gerais (Fundação de Amparo à Pesquisa do Estado de Minas Gerais—FAPEMIG).
Ethical Approval
This study was approved by the Research Ethics Committee of the Association of Assistance for Children With Disabilities (number 09/2010) and the Research Ethics Committee of the Federal University of Minas Gerais (OEP/UFMG number ETIC 0482.0.203.000-10).