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Preliminary Report of Validity for the Infant Comprehensive Evaluation for Neurodevelopmental Delay, a Newly Developed Inventory for Children Aged 12 to 71 Months
J Korean Acad Child Adolesc Psychiatry 2022; 33(1): 16-23
Published online January 1, 2022
© 2022 Korean Academy of Child and Adolescent Psychiatry.

Minha Hong1, Kyung-Sook Lee2, Jin-Ah Park3, Ji-Yeon Kang3, Yong Woo Shin4, Young Il Cho5, Duk-Soo Moon6, Seongwoo Cho7, Ram Hwangbo7, Seung Yup Lee8, and Geon Ho Bahn9

1Department of Psychiatry, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
2Department of Rehabilitation, Hanshin University, Osan, Korea
3Sewon Infant and Child Development Center, Seoul, Korea
4Department of Psychology, Sungshin University, Seoul, Korea
5Division of Police Administration Dongguk University, Seoul, Korea
6Department of Psychiatry, Jeju National University School of Medicine, Jeju, Korea
7Likeminded Neuropsychiatry, Seoul, Korea
8Leemind Psychiatric Clinic, Seoul, Korea
9Department of Psychiatry, Kyung Hee University School of Medicine, Seoul, Korea
Correspondence to: Geon Ho Bahn, Department of Psychiatry, Kyung Hee University School of Medicine, 23 Kyungheedae-ro, Dongdaemungu, Seoul 02447, Korea
Tel: +82-2-958-8556, Fax: +82-2-957-1997, E-mail: mompeian@khu.ac.kr
Received November 29, 2021; Revised December 20, 2021; Accepted December 22, 2021.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objectives: Early detection of developmental issues in infants and necessary intervention are important. To identify the comorbid conditions, a comprehensive evaluation is required. The study’s objectives were to 1) generate scale items by identifying and eliciting concepts relevant to young children (12–71 months) with developmental delays, 2) develop a comprehensive screening tool for developmental delay and comorbid conditions, and 3) assess the tool’s validity and cut-off.
Methods: Multidisciplinary experts devised the “Infant Comprehensive Evaluation for Neurodevelopmental Delay (ICEND),” an assessment method that comes in two versions depending on the age of the child: 12–36 months and 37–71 months, through monthly seminars and focused group interviews. The ICEND is composed of three parts: risk factors, resilience factors, and clinical scales. In parts 1 and 2, there were 41 caretakers responded to the questionnaires. Part 3 involved clinicians evaluating ten subscales using 98 and 114 questionnaires for younger and older versions, respectively. The Child Behavior Checklist, Strengths and Difficulties Questionnaire, Infant-Toddler Social Emotional Assessment, and Korean Developmental Screening Test for Infants and Children were employed to analyze concurrent validity with the ICEND. The analyses were performed on both typical and high-risk infants to identify concurrent validity, reliability, and cut-off scores.
Results: A total of 296 people participated in the study, with 57 of them being high-risk (19.2%). The Cronbach’s alpha was positive (0.533–0.928). In the majority of domains, the ICEND demonstrated a fair discriminatory ability, with a sensitivity of 0.5–0.7 and specificity 0.7–0.9.
Conclusion: The ICEND is reliable and valid, indicating its potential as an auxiliary tool for assessing neurodevelopmental delay and comorbid conditions in children aged 12–36 months and 37–71 months
Keywords : Neurodevelopment; Developmental delay; ICEND; Infant; Comorbidity; Assessment
INTRODUCTION

Because infants and toddlers’ development differs from that of adults and is interdependent in each area, when development delays are evident, difficulties in each area may overlap [1]. When developmental delays in one area affect others, symptoms and signs become more convoluted, and treatment becomes challenging. Another characteristic of the infant development problem is that it is a continuous series of processes and dynamics, rather than a discrete event [2]. Some infants and toddlers develop swiftly at birth but later fail to acquire additional developmental abilities and are delayed, and vice versa. Although the features of development areas are interrelated, one area’s development does not guarantee or predict the development of another. Therefore, it is vital to review a wide variety of developmental areas on a regular basis over time [3].

The Ministry of Health and Welfare, Republic of Korea launched the National Health Screening Program for Infants and Children (NHSPIC) in 2007. The Korean Developmental Screening Test for Infants and Children (K-DST) was developed under the NHSPIC by researchers directed by pediatricians to assess infants and toddlers in Korea [4]. The KDST was developed in 2014 with support from Centers for Disease Control and Prevention in Korea, and with the collaboration of experts in related fields, the Korean Pediatric Society, the Korean Society of Pediatric Rehabilitation and Developmental Medicine, the Korean Academy of Child and Adolescent Psychiatry, and the Korean Psychological Association. Although the K-DST has the advantage of being tailored to the developmental features of infants and toddlers, it has limitations in that it cannot access all comorbid disorders, particularly socioemotional difficulties that go beyond physical development. This is because when developmental delays in mental health, such as cognition, language, and sociability, are found, parents are more concerned than when physical problems, such as height and weight, are detected [5].

Excessive pathological or medical considerations, such as normal mutations, individual differences, temporary changes, and relationship problems with babies and caregivers, are insufficient in diagnosing and classifying mental health in infants and toddlers [6]. To differentiate these variations, an approach focusing on family-centered preventive interventions based on developmental, environmental, and relationship- oriented data is needed [7]. It is important to approach and evaluate the mental health of infants and toddlers, in contrast to the psychiatric diagnostic technique used in adults. For example, infant development should not only focus on the impairment of children’s functions and relationships, but also on the impairment of family functions and relationships. By assessing the environmental aspects of infants and toddlers, it can help to comprehend the overall condition. In particular, evaluation of risk variables that can have a detrimental impact on infants and toddlers allows for the prediction of unfavorable consequences [8]. In addition to risk factors, assessing a child’s competence or creating a healthy parentchild relationship might be valuable resources for establishing a coping strategy in the event of a future impairment.

In this regard, the authors developed a comprehensive and practical screening tool for neurodevelopmental delay, as well as assessing its validity.

METHODS

Tool development

Multidisciplinary specialists, including child psychiatrists, child developmental psychologists, language pathologists, developmental education specialists, and statisticians, formed a team as part of the Korea Mental Health R&D Project to develop a new scale to assess neurodevelopmental delay and comorbidities in infants, toddlers, and young children under the age of seven. To establish the practical contents required for the new scale, we conducted focus group interviews (FGI) with 12 experts [5]. Based on FGI results, authors made a draft version of the new scale. We had sent a draft with Delphi questionnaires to 77 specialists and got feedback from 36 replies. The authors had monthly seminars and two interim public hearings with translational experts over the research period of 2015–2017 to verify the work’s performance.

The Infant Comprehensive Evaluation for Neurodevelopmental Delay (ICEND) developed two versions, one for children aged 12–36 months and the other for children 37–71 months (Table 1). The ICEND comprises three parts. Part 1 includes risk factors, such as prematurity, low birth weight, domestic violence with child abuse, maternal depression, and maternal alcohol abuse. Competence and parent-child relations are two resilience components discussed in Part 2. Part 3 presents clinical symptoms and signs with eight subscales that include cognition, language, autism spectrum disorder, attention-deficit/hyperactivity disorder, internalizing symptoms, externalizing symptoms, trauma, attachment issues, maladjustment, and others. Part 1 and Part 2 each feature 41 questionnaires for both age groups, which caretakers can report. Part 3 contains 98 questionnaires for children aged 12– 36 months and 114 for children aged 37–71 months. Part 3 questionnaires will be graded by raters who were trained for the execution of the ICEND.

Composition and number of questions of ICEND depending on the age of the subjects and raters

Rater Part and subscales 12-36 months 37-71 months
Caretaker Part 1. Risk factors
Prematurity and low birth weight 10 10
Domestic violence 7 7
Maternal depression 10 10
Maternal alcohol abuse 4 4
Part 2. Resilience factors
Competency 5 5
Parent-child relationship 5 5
Subtotal (Part 1+Part 2) 41 41
Trained raters for ICEND Part 3. Clinical subscales
Cognition 15 15
Language 16 16
Autism spectrum disorder 13 13
Movement symptoms 0 8
Attention-deficit/hyperactivity disorder 5 10
Internalizing symptoms 14 14
Externalizing symptoms 9 12
Post-traumatic stress disorder 5 5
Attachment issues 5 5
Maladjustment and other behaviors 16 16
Subtotal 98 114

Total 139 155

ICEND, Infant Comprehensive Evaluation for Neurodevelopmental Delay



Study participants

Subjects were recruited from a variety of institutions (including hospitals such as Kyung Hee University Hospital, Myongji Hospital, Seoul Metropolitan Children’s Hospital, and Sewon Infant Child Development Center) between February 2017 and March 2019. Those whose primary caregiver(s) voluntarily signed the consent form were included, once the study was explained to them. A total of 296 people participated in this research. The individuals’ primary caregiver(s) completed Part A, and the researcher assessed Part B with them. Caregivers also completed Korean version of the Child Behavior Checklist (K-CBCL), Korean version of Strengths and Difficulties Questionnaire (SDQ-K), Korean version of Infant-Toddler Social Emotional Assessment (ITSEA-K), and K-DST for the validity test with ICEND. Correlation between ICEND and ITSEA-K was investigated with only the aged 12–36 month.

Measures

Korean version of the Child Behavior Checklist for ages 1.5–5 (K-CBCL 1.5–5)

The CBCL 1.5–5 [9] is a 100-item assessment tool completed by a child’s primary caregiver. It evaluates seven subareas: emotional responsiveness, anxiety/depression, somatic complaints, withdrawal behavior, sleep problems, attention problems, and aggressive behavior, as well as two factor scores of internalizing and externalizing problems, and a cumulative behavioral problems score, based on the frequency of behaviors over the past two months. The Korean version has been translated and standardized [10]. In terms of Cronbach’s α, the internal consistency and reliability of the K-CBCL 1.5–5 between syndrome indices and total score internalizing and externalizing was 0.56–0.94, while the Cronbach’s α for the total score encompassing all items was 0.94.

Korean version of Strengths and Difficulties Questionnaire (SDQ-K)

The SDQ, which Goodman developed in 1997 [11], was standardized in Korean by Ahn et al. in 2002 [12], and its reliability and validity were verified. It comprises four difficulty subscales (emotional symptoms, conduct problems, hyperactivity- inattention, and peer problems) each with five items, and one strength subscale (prosocial behavior). It is graded on a 3-point scale, with subscale scores determined by adding the scores on relevant items (range 0–10). The total difficulty score can be calculated by adding the scores from the four subscales of difficulty (range 0–40).

Korean version of Infant-Toddler Social Emotional Assessment (ITSEA-K)

The ITSEA is a 169-item assessment tool with four behavioral domains: externalizing, internalizing, dysregulation, and competence [13]. The ITSEA items were evaluated on a scale of 0 (not true/rarely), 1 (somewhat true/occasionally), and 2 (very true/often). It required approximately 30 minutes to complete. The Korean version was found to be reliable and valid [14].

Korean Developmental Screening Test for Infants and Children (K-DST)

The K-DST is a Korean-developed nationwide screening instrument with good reliability and validity [4]. There are eight questions in each of the six domains: gross motor, fine motor, cognition, language, sociality, and self-care. Each question is scored on a scale of 0–3, with a maximum attainable score of 24 points for each domain. It is completed by caregivers and is indicated for infants and children aged 4–71 months.

Statistical analysis

SPSS 23.0 (IBM Corp., Armonk, NY, USA) was used to conduct the analyses. The internal consistency of the ICEND scale was assessed using Cronbach’s alpha. An alpha of 0.70 or higher is considered acceptable. Concurrent validity was evaluated using Pearson correlations between ICEND and CBCL scale scores, ICEND and SDQ, and ICEND and K-DST. Concurrent validity is hypothesized to be expressed in large positive correlations between the ICEND scales and the CBCL, SDQ, and K-SDT. We looked for the best cut-off point with the maximum area under the curve (AUC) and sensitivity/ specificity.

Research ethics

The Institutional Review Boards at the institutes from which participants were recruited, including Kyung Hee University Hospital, approved the study’s protocol (KHU 2016-11-071). The study was conducted in compliance with the Helsinki II Declaration’s ethical requirements for informed consent, voluntariness, and anonymity.

RESULTS

Demographic characteristics

A total of 108 people from the 12–36 months age group and 188 people from the 37–71 months group participated in the study (Table 2). The proportion of high-risk patients in the 12–36 months group was 13% (n=14), whereas it was 23.1% (n=43) in the 37–71 months group (Supplementary Table 1 in the online-only Data Supplement).

The demographic characteristics of participants and caregivers depending on the age

Characteristics 12-36 months (n=108) 37-71 months (n=188)
Sex
Male 60 (55.6) 96 (51.1)
Female 48 (44.4) 92 (48.9)
Parental status
Natural pregnancy 91 (91.9) 169 (91.4)
Vitro baby 8 (8.1) 14 (7.6)
Adoption 0 (0) 2 (1.1)

Data are presented as n (%).



Validity

The correlations between CBCL, SDQ, K-DST, and ITSEA (only 12–36 months) were investigated to determine the ICEND’s concurrent validity. The results are presented in Tables 3 and 4. Although several subdomains of ICEND (P1- A, P1-B, P1-D, P3-G, and P3-H of 12–36 months, and P1-A and P2-B of 37–71 months) did not demonstrate statistical significance, the overall correlations between all measures were significant. Person coefficients of 0.31 (P1-A), 0.29 (P2- A), 0.30 (P3-A), 0.21 (P3-B), 0.24 (P3-F), 0.26 (P3-G), and 0.24 (P3-J) were found to be positive correlations between the ICEND 12–36 months scale and the CBCL. Person coefficients of 0.24 (P1-C), 0.35 (P3-A), 0.47 (P3-B), 0.39 (P3-C), 0.19 (P3- D), 0.41 (P3-E), 0.51 (P3-F), 0.38 (P3-G), and 0.41 (P3-J) were found to be positive correlations between the ICEND 37–71 months scale and the CBCL. Similar patterns of correlations between ICEND and SDQ or ICEND and K-DST were found for the 12–36 months and 37–71 months subgroups.

The validity of ICEND for the aged 12-36 months

P1-A P1-B P1-C P1-D P2-A P2-B P3-A P3-B P3-C P3-E P3-F P3-G P3-H P3-I P3-J
CBCL -0.00 0.11 0.31** -0.02 0.29** 0.10 0.30** 0.21* 0.16 0.18 0.24* 0.26* -0.06 0.08 0.24*
SDQ (2-4 years old) 0.24 0.10 0.23 0.04 -0.12 -0.13 -0.23 -0.21 -0.22 -0.09 0.01 0.14 -0.20 -0.30*
ITSEA -0.33 -0.20 -0.25 -0.18 -0.40 -0.68 -0.19 -0.31 -0.34 -0.01 -0.17 -0.30
K-DST (12-13 months)
K-DST onths)
K-DST (16-17 months)
K-DST (18-19 months) 0.34 0.09 -0.19 0.39 0.29 0.54 0.40 0.02 -0.61 0.11 0.33 -0.54
K-DST (20-21 months) -0.91 0.97 -0.09 -0.91 0.82 -1.00* -0.91 -0.85 1.00 -0.99
K-DST (22-23 months) 1.00 -0.11 0.03 -0.85*** -0.67* -0.78** -0.92*** -0.67* -0.70* -0.29 -0.41 -0.54 -0.26
K-DST (24-26 months) -0.07 -0.86** -0.47 -0.92*** -0.09 -0.92*** -0.53 -0.77* -0.77* -0.32 -0.53 -0.77 -0.22 -0.36
K-DST (27-29 months) -0.87 -0.19 0.42 -0.76* -0.14 -0.66* -0.80** -0.54 -0.68* -0.33 -0.12 -0.54 -0.15
K-DST (30-32 months) -0.18 -0.47 0.53 -0.33 -0.58 -0.59 -0.61* -0.54 -0.60 -0.50 -0.10 -0.06 -0.54
K-DST (33-35 months) -0.40 0.26 0.16 -0.29 -0.88*** -0.44 -0.74** -0.86*** -0.65* -0.34 -0.64* -0.26 0.22 -0.62*
K-DST (36-41 months) 0.83 -1.00 -0.99* -0.90 -0.99* -0.99* -0.99* -0.83 0.56 -0.01 -1.00 -0.83

*p<0.05; **p<0.01; ***p<0.001. ICEND, Infant Comprehensive Evaluation Neurodevelopmental Delay; CBCL, Child Behavior Checklist; SDQ, Strengths and Difficulties Questionnaire; ITSEA, Infant-Toddler Social Emotional Assessment; K-DST, Korean Developmental Screening Test for Infants and Children; P1-A, prematurity and low birth weight; P1-B, domestic violence; P1-C, maternal depression; P1-D, maternal alcohol abuse; P2-A, competency; P2-B, parent-child relationship; P3-A, cognition; P3-B, language; P3-C, autism spectrum disorder; P3-E, attention-deficit/hyperactivity disorder; P3-F, internalizing symptoms; P3-G, externalizing symptoms; P3-H, post-traumatic stress disorder; P3-I, attachment issues; P3-J, maladjustment and other behaviors


The validity of ICEND for the aged 37-71 months

P1-A P1-B P1-C P1-D P2-A P2-B P3-A P3-B P3-C P3-D P3-E P3-F P3-G P3-H P3-I P3-J
CBCL -0.25 -0.19 0.24** -0.03 -0.47*** -0.40*** 0.35*** 0.47*** 0.39*** 0.19* 0.41*** 0.51*** 0.38*** 0.003 0.02 0.41***
SDQ (4-17 years old) 0.24 -0.02 -0.36*** 0.004 -0.27** -0.07 -0.39*** -0.38*** -0.17* -0.07 -0.13 0.29*** 0.16 0.10 -0.02 -0.07
K-DST (36-41 months) -0.13 0.19 -0.19 -0.12 -0.45 -0.15 -0.52* -0.56* -0.28 -0.17 -0.24 -0.19 0.24 0.12 -0.35
K-DST (42-47 months) -0.05 0.13 -0.06 -0.03 -0.51* -0.66** -0.81*** -0.89*** -0.74** -0.58** -0.55* -0.17 -0.21 -0.49 -0.25 -0.42
K-DST (48-53 months) 0.67* 0.47 0.10 0.03 -0.55** -0.55** -0.87*** -0.92*** -0.70*** -0.38* -0.71*** -0.39* -0.16 -0.22 0.15 -0.45*
K-DST (54-59 months) -0.28 0.47 -0.15 -0.82** -0.62* -0.52 -0.92*** -0.94*** -0.49 -0.32 -0.56 -0.03 -0.09 0.47 -0.30
K-DST (60-65 months) -0.14 -0.01 0.08 0.04 0.63** -0.12 -0.82*** -0.86*** -0.72*** -0.82*** -0.54** -0.52* -0.07 0.13 -0.10* -0.13*
K-DST (66-71 months) -0.26 -0.18 -0.37 -0.22 -0.64** -0.60** -0.86*** -0.88*** -0.72*** -0.47* -0.57* -0.64** -0.16 -0.58** -0.25** -0.56**

*p<0.05; **p<0.01; ***p<0.001. ICEND, Infant Comprehensive Evaluation Neurodevelopmental Delay; CBCL, Child Behavior Checklist; SDQ, Strengths and Difficulties Questionnaire; K-DST, Korean Developmental Screening Test for Infants and Children; P1-A, prematurity and low birth weight; P1-B, domestic violence; P1-C, maternal depression; P1-D, maternal alcohol abuse; P2-A, competency; P2-B, parent-child relationship; P3-A, cognition; P3-B, language; P3-C, autism spectrum disorder; P3-D, movement disorder; P3-E, attention-deficit/ hyperactivity disorder; P3-F, internalizing symptoms; P3-G, externalizing symptoms; P3-H, post-traumatic stress disorder, P3-I, attachment issues; P3-J, maladjustment and other behaviors



Reliability

Domain internal consistencies were calculated for each age group 12–36 months and 37–71 months (Table 5). The Cronbach’s alpha correlation coefficients of ICEND 12–36 months varied from 0.533 to 0.928 except for P1-A -0.271, while those of ICEND 37–71 months ranged from 0.334 to 0.951 (Table 5), and were well within Nunnally and Bernstein’s acceptable range [15].

The reliability of ICEND

Ages Part Subscales Cronbach’s α
12-36 months Risk factors Prematurity -0.271
Domestic violence 0.662
Maternal depression 0.796
Maternal alcohol abuse 0.451
Resilience factors Competency 0.831
Parent-child relationship 0.662
Clinical subscales Cognition 0.864
Language 0.917
ASD 0.770
ADHD 0.698
Internalizing symptoms 0.778
Externalizing symptoms 0.771
PTSD 0.928
Attachment issues 0.533
MAL 0.568
37-71 months Risk factors Prematurity 0.114
Domestic violence 0.720
Maternal depression 0.798
Maternal alcohol abuse 0.546
Resilience factors Competency 0.872
Parent-child relationship 0.724
Clinical subscales Cognition 0.896
Language 0.951
ASD 0.884
Movement symptoms 0.538
ADHD 0.786
Internalizing symptoms 0.670
Externalizing symptoms 0.734
PTSD 0.453
Attachment issues 0.334
MAL 0.643

ICEND, Infant Comprehensive Evaluation Nneurodevelopmental Delay; ASD, autism spectrum disorder; ADHD, attention-deficit/hyperactivity disorder; PTSD, post-traumatic stress disorder; MAL, maladjustment and other behaviors



The detection ability of ICEND

As indicated in Table 6, receiver operating characteristics (ROC) analysis was used to distinguish young children with a high risk of developmental delay. The cut-off, sensitivity, and specificity for each domain are presented in Table 6. According to the results of ROC analysis, the cutoff numbers for ICEND 12–36 months ranged from 0.5 to 3.5, and ICEND 37–71 months ranged from 0.5 to 4.5. Both ICEND 12–36 months and 37–71 months demonstrated satisfactory levels of sensitivity with a range of 2.3%–81.4% and satisfactory levels of specificity with a range of 68.8%–100% using this new criterion.

The AUC, cut-off, sensitivity and specificity results of ICEND depending on the age

Ages Part Subscales AUC Cut-off Sensitivity Specificity
12-36 months Resilience factors P2-A 0.832 3.5 0.071 0.968
P2-B 0.802 2.5 0.500 0.883
Clinical subscales P3-A 0.727 2.5 0.500 0.742
P3-B 0.857 3.5 0.786 0.772
P3-C 0.827 1.5 0.786 0.849
P3-E 0.792 1.5 0.714 0.753
P3-F 0.741 1.5 0.643 0.688
P3-G 0.780 1.5 0.714 0.731
P3-H 0.609 0.5 0.250 0.967
P3-I 0.738 0.5 0.727 0.708
P3-J 0.720 2.5 0.714 0.688
37-71 months Resilience factors P2-A 0.737 4.5 0.023 1.000
P2-B 0.832 3.5 0.116 0.972
Clinical subscales P3-A 0.737 0.5 0.721 0.699
P3-B 0.845 4.5 0.814 0.832
P3-C 0.837 1.5 0.744 0.874
P3-D 0.701 1.5 0.488 0.825
P3-E 0.762 2.5 0.744 0.699
P3-F 0.584 1.5 0.512 0.650
P3-G 0.570 1.5 0.419 0.636
P3-H 0.529 0.5 0.120 0.935
P3-I 0.550 0.5 0.120 0.935
P3-J 0.752 3.5 0.605 0.755

AUC, area under the curve; ICEND, Infant Comprehensive Evaluation Nneurodevelopmental Delay; P2-A, competency; P2-B, parent-child relationship; P3-A, cognition; P3-B, language; P3-C, autism spectrum disorder; P3-D, movement disorder; P3-E, attentiondeficit/ hyperactivity disorder; P3-F, internalizing symptoms; P3-G, externalizing symptoms; P3-H, post-traumatic stress disorder; P3-I, attachment issues; P3-J, maladjustment and other behaviors


DISCUSSION

This study aimed to investigate the psychometric properties of the ICEND, a recently designed screening tool for developmental delay. Validity and reliability were both favorable. The corresponding domain of the ICEND yielded satisfactory results. The AUC of 0.609–0.857 in each domain revealed superior detection ability in the ROC analysis. The cut-offs for each domain effectively distinguished the high-risk group with reasonable sensitivity and specificity.

The tools, CBCL, SDQ, ITSEA, and K-DST were used to evaluate early childhood the development, which included infancy, toddlers, and preschool. Because they have distinct qualities and applicable age groups, it is difficult to assess their validity correlations directly. While CBCL is a caregiver rating scale, clinical subscales of ICEND is rater-rating scale. As ICEND has clinical subscales and subscales for environmental factors, it is advantageous compared with symptomsoriented domains only of ITSEA. The K-DST is a screening tool for the assessment of the development for the infant, toddler, and young child, mostly physical health. The ICEND is expected to be employed as a complementary or secondary screening tool to the K-DST, which is currently used by the NHSPIC, after its psychometric properties are confirmed. In order to apply ICEND to larger group, it is necessary to have further trials for an equal group of children across the country. ICEND is also necessary to evaluate whether it is appropriate to divide the target group into only two age groups unlike K-DST, which subdivided the target age group into 2–3 months units.

This study had several critical limitations. First, the test-retest validity was not evaluated. It should be conducted again in the near future to ensure the tool’s reliability. Second, although the age and gender distributions were matched, the sample size of 296 was insufficient for analysis.

Despite the abovementioned limitations, it is the first tool developed independently in Korea to try to distinguish highrisk groups for developmental delay, considering various mental disorders in infancy and early childhood as defined by ICD-10, DSM-5, and Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0–5) [16]. This was reflected in a panel of multidisciplinary experts’ discussion of clinical subscales. It also included information on potential risk factors that could affect development, such as prematurity, child abuse, maternal depression, or alcohol abuse, as well as potential strength factors that could operate as protective factors, such as parental relationships or competency.

In summary, the ICEND exhibits good psychometric characteristics, including reliability, validity, and detection ability, according to this study. The ICEND is a valuable secondary screening tool to detect high-risk developmental delay groups in kindergarten, center, or clinical settings.

Availability of Data and Material

The datasets generated or analyzed during the study are not publicly available due to containing information that could compromise research participant privacy/consent but are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Minha Hong, Geon Ho Bahn. Data curation: Kyung- Sook Lee, Jin-Ah Park, Duk-Soo Moon. Formal analysis: Young Il Cho, Yong Woo Shin. Funding acquisition: Geon Ho Bahn. Investigation: Kyung-Sook Lee, Jin-Ah Park, Duk-Soo Moon. Methodology: Young Il Cho, Yong Woo Shin. Project administration: Ji-Yeon Kang, Seongwoo Cho, Ram Hwangbo, Seung Yup Lee. Writing—original draft: Minha Hong, Geon Ho Bahn. Writing—review & editing: Minha Hong, Geon Ho Bahn.

Funding Statement

The Republic of Korea’s Korea Mental Health R&D Project funded this research (Grant No. HM15C1084). We also thank Dr. Kyung Hoon Suh for his contribution to project management.

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