Concept of Health Care Counseling for Pediatricians.

Health care counseling (HCC) is a relatively new concept that amalgamates human biology, human psychology and medical sociology principles, and applies the same in real-time clinical situations. In India, there is a real paucity of trained mental health personnel, and hence counseling services are restricted to few departments. HCC is especially important for the child population, as the pediatricians need to partner the parenting responsibilities in different illness care settings covering the period from newborn to adolescence. This paper proposes steps for further development of the concept, expertise and systematic training program for health personnel, as an activity of Centre for Health Care Counseling Studies under Kerala University of Health Sciences. Once the process is documented, we hope that the same would be made available to other states in India.

CDC Kerala 12: Socio-demographic factors among children (2-6 y) with autism--a case control study.

OBJECTIVES: To compare the socio-demographic factors among children between 2 and 6 y of age with autism and a control group of normal children. METHODS: One hundred forty three confirmed cases of 2-6 y-old children with autism, attending autism clinic of Child Development Centre, who had a CARS score of more than 30 were included in the study. Two hundred normal children in the same age group were recruited from the well-baby/immunization clinic of SAT Hospital, Thiruvananthapuram. Data was collected using a structured pre-piloted questionnaire consisting of 11 socio-demographic possible risk factors. RESULTS: The multivariate analysis on socio-demographic characteristics as possible risk factors for autism has shown that (i) upper and upper middle socioeconomic status (OR: 7.13; CI: 3.26-15.57) and (ii) male gender (OR: 3.95; CI: 2.22-7.04) were significant risk factors for autism, whereas place of residence, rural (OR: 0.41; CI: 0.24-0.68) is a protective factor. CONCLUSIONS: This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that upper and upper middle socioeconomic status and (ii) male gender are significant risk factors for autism, whereas place of residence, rule is a protective factor.

CDC Kerala 8: Effectiveness of a clinic based, low intensity, early intervention for children with autism spectrum disorder in India: a naturalistic observational study.

OBJECTIVE: To document the effectiveness of low intensity, clinic based intervention models for Autism Spectrum Disorders (ASD) in countries with low disability resources. METHODS: Thirty-nine participants with a mean (SD) of 36.03(11.15) mo were assessed before and after intervention with Childhood Autism rating scale (CARS), and at baseline with the Denver Developmental Screening Test for quantifying the effectiveness of the clinic-based intervention in ameliorating autism symptoms and studying the effect of developmental disability respectively. Developmental therapists in the clinic gave low-intensity group intervention for 45-60 min to the child through mother and encouraged to continue the training, for 3-4 h, at home to address the specific goals in the three ASD symptom clusters. Most of the children were also placed in play-schools. Follow-up support was given either on a weekly, fortnightly or monthly basis. Data was analyzed using appropriate bivariate and multivariate techniques. RESULTS: There was amelioration in the severity of autism after intervention, which was statistically and clinically significant. Intervention was useful to help children with mild to severe autism. CONCLUSIONS: Low-intensity, clinic-based intervention can be effectively used in situation where there is paucity of disability resources.

CDC Kerala 14: Early child care practices at home among children (2-6 y) with autism--a case control study.

OBJECTIVES: To compare early child care practices at home as possible risk factors among children between 2 and 6 y of age with autism and a control group of normal children without any symptom of autism, presenting at the well-baby/immunization clinic. METHODS: This case control study was undertaken at the autism clinic of CDC Kerala, comparing possible risk factors for autism among 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children of the same age from well-baby/immunization clinic of SAT hospital. The data was collected using a structured pre-piloted questionnaire, which included 11 questions administered by the same senior social scientist, on early child care practices at home that have been universally considered as important for child development. RESULTS: On multivariate analysis on early child care practices at home as possible risk factors for autism, it was observed that statistically significant high odds ratios were present for (i) no outings (OR = 3.36; 95% CI: 1.39-8.16; p 0.007); (ii) child does not play with children of same age (OR = 19.57; 95% CI: 9.50-40.32); (iii) do not tell stories/sing songs to the child (OR = 3.21; 9 % CI: 1.61-6.41); and (iv) breastfeeding duration nil/ < 6 mo (OR = 3.40; 95% CI: 1.28-8.99). CONCLUSIONS: This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that early child care practices at home, specifically breastfeeding duration nil/ < 6 mo, child does not play with children of same age, do not tell stories/sing songs to the child and no outings for the child are possible risk factors for autism.

CDC Kerala 11: Diagnosis of autism among children between 2 and 6 y--comparison of CARS against DSM-IV-TR.

OBJECTIVES: To compare diagnosis of childhood autism using CARS cut off scores of ≥30 and the new Indian cut off scores of ≥33 against the gold standard DSM-IV-TR criteria available during the study period 2009-10. METHODS: The study was conducted at the autism clinic of Child Development centre (CDC), Kerala. Two hundred consecutive children between 2 and 6 y with symptoms suggestive of autism were administered both CARS by a trained developmental therapist and DSM-IV-TR by a developmental pediatrician on the same day, both blind to the test results of each other. Diagnosis of autism using CARS cut off scores 30 and above, as suggested in original tool administration manual and 33 and above, as suggested for diagnostic use in Indian population was compared with DSM-IV-TR diagnosis. Data was analyzed using SPSS (version 19.0) software. RESULTS: Against DSM-IV-TR diagnosis as gold standard, the new CARS cut off scores ≥33 had a higher Specificity (74.3%), Positive predictive value (PPV) (81.9%), Positive likelihood ratio (LR) (2.66) and Negative LR (0.43), but had a lower Sensitivity (68.3%), Negative predictive value (NPV) (57.9%) and accuracy (70.5%), as compared to the cut off scores of ≥30. CONCLUSIONS: The CARS prevalence of autism for cut off points ≥30 and ≥33 was 71.5 and 52.5% respectively against 63% prevalence by DSM-IV-TR.

CDC Kerala 2: Developmental intervention package for babies <1,800 g--outcome at 6 mo using DASII.

OBJECTIVES: To describe the experience of using developmental intervention package among low birth weight babies less than 1,800 g and developmental outcome at the end of 6 mo monthly intervention. METHODS: Babies below 1,800 g, discharged from neonatal intensive care unit (NICU) of Sree Avittom Thirunal (SAT) hospital, over the last 3 y, were followed at Child Development Centre (CDC) Kerala and offered monthly evaluation by different tools and developmental intervention using a package by trained developmental therapists and mothers were encouraged to continue the same at home. At the end of 6 mo the developmental outcome was assessed using Developmental Assessment Scale for Indian Infants (DASII). RESULTS: Out of a total of 821 babies enrolled for early stimulation program, 740 babies successfully completed 6 mo follow up and stimulation program. Comparing the outcome at 4 and 6 mo, both grading for head holding and gross motor part of DDST showed a statistically significant reduction in abnormal findings. At 6 mo assessment on DASII, motor DQ abnormalities were a high 80% for 600-900 g, as against 17.1% abnormalities for 1,500-1,800 g birth weight group. CONCLUSIONS: The results of this intensive early stimulation program for babies below 1,800 g have shown the importance of monthly early intervention using a mother oriented systematic developmental stimulation package.

CDC Kerala 13: Antenatal, natal and postnatal factors among children (2-6 y) with autism--a case control study.

OBJECTIVES: To compare antenatal, natal and postnatal factors among children between 2-6 y of age with autism and a control group of normal children. METHODS: One hundred and forty three confirmed cases of 2-6 y-old children with autism, attending autism clinic of Child Development Centre, who had a CARS score of ≥ 30 were included in the study. Two hundred normal children in the same age group were recruited from the well-baby/immunization clinic of SAT Hospital, Thiruvananthapuram. Data was collected using a structured pre-piloted questionnaire consisting of 21 antenatal, 8 natal and 6 postnatal risk factors. RESULTS: The multivariate analysis on antenatal, natal and postnatal possible risk factors for autism showed statistically significant high odds ratios for (i) excess fetal movement (OR = 11.44; 95% CI: 2.85-45.98); (ii) maternal respiratory infection/asthma (OR = 6.11; 95% CI: 1.56-24.02; (iii) maternal vaginal infection (OR = 5.20; 95% CI: 1.72-15.73); (iv) maternal hypothyroidism (OR = 4.25; 95% CI: 1.38-13.07) and (v) family history of neuro-developmental disorders (OR = 2.90; 95% CI: 1.72-4.88). CONCLUSIONS: This case control study involving 143 children between 2 and 6 y with autism as per CARS criteria and a control group of 200 normal children has shown that excess fetal movement, maternal respiratory infection/asthma, maternal vaginal infection, maternal hypothyroidism and family history of neuro-developmental disorders are possible risk factors for autism.

CDC Kerala 15: Developmental Evaluation Clinic (2-10 y)--developmental diagnosis and use of home intervention package.

OBJECTIVE: To describe the last 5 years' experience of Child Development Centre (CDC), Kerala Developmental Evaluation Clinic II for children between 2 and 10 y, referred for suspicion of developmental lag in the preschool years and scholastic difficulty in the primary classes with specific focus on developmental profile and the experience of the home based intervention package taught to the mothers. METHODS: A team of evaluators including developmental therapist, preschool teacher with special training in clinical child development, speech therapist, special educator, clinical psychologist and developmental pediatrician assessed all the children referred to CDC Kerala. Denver Developmental Screening Test (DDST-II), Vineland Social Maturity Scale (VSMS) and Intelligent Quotient (IQ) tests were administered to all children below 6 y and those above 6 with apparent developmental delay. RESULTS: Speech/delay (35.9%), behavior problem (15.4%), global delay/ intellectual disability (15.4%), learning problem (10.9%), pervasive developmental disorders (7.7%), seizure disorder (1.7%), hearing impairment (0.7%), and visual impairment (0.7%) were the clinical diagnosis by a developmental pediatrician. Each child with developmental problem was offered a home based intervention package consisting of developmental therapy and special education items, appropriate to the clinical diagnosis of the individual child and the same was taught to the mother. CONCLUSIONS: The experience of conducting the developmental evaluation clinic for children between 2 and 10 y has shown that a team consisting of developmental therapist, speech therapist, preschool teacher, special educator, clinical child psychologist and developmental pediatrician, using appropriate test results of the child could make a clinical diagnosis good enough for providing early intervention therapy using a home based intervention package.

CDC Kerala 16: Early Detection of developmental delay/disability among children below 6 y--a district model.

OBJECTIVE: To develop a district model for establishing early detection of childhood disability below 6 y of age and to develop appropriate referral linkages for confirmation of the diagnosis and establish home based early intervention therapy to all needy children. METHODS: Trained Accredited Social Health Activist (ASHA) workers conducted the preliminary survey for identifying developmental delay/disability among children below 6 y of age using Trivandrum Developmental Screening Chart (TDSC) (0-6 y) and a team of experts assessed the screen positives in developmental evaluation camps conducted at primary health centres (PHCs). RESULTS: Community survey was carried out and 1,01,438 children below 6 y of age in Thiruvananthapuram district were screened by ASHA workers and 2,477 (2.45%) positive cases (TDSC two or more item delay) were identified and these children were called for the developmental evaluation camps conducted at 80 PHCs in the district. Among the 1,329 children who reached the evaluation camps 43.1% were normal. 24.98% children had speech and language delay and 22.95% children had multiple disabilities. Developmental delay was observed among 49.89% children and cerebral palsy in 8.43% and intellectual disability 16.85% were confirmed. Visual impairment in 3.31% and neuromuscular disorders in 1.35 were found among children evaluated in the camp. CONCLUSIONS: The results of this district wide early detection of disability survey by trained ASHA workers among children below 6 y of age showed a community prevalence of 3.08% observed, based on two or more item delay in TDSC and among these children, 43.1% were normal, 49.89% had developmental delay, 24.98% had speech and language delay and 22.95% had multiple disabilities.

CDC Kerala 17: Early detection of developmental delay/disability among children below 3 y in Kerala--a cross sectional survey.

OBJECTIVE: To conduct a community survey to understand the prevalence and type of developmental delay/disability among a representative state wide community sample of children below 3 y. METHODS: A state wide community based cross sectional survey was done with the help of the Integrated Child Development Services (ICDS) network in Kerala after giving one day training program at Child Development Centre (CDC), for one randomly selected anganwadi worker in each of the panchayath/municipal ward, from all districts of Kerala, to equip them to screen all children below 3 y in their anganwadi areas, using simple community screening tools like Trivandrum Developmental Screening Chart (TDSC) 0-3 and Language Evaluation Scale Trivandrum (LEST) 0-3. Those children with one or more item delay in TDSC or LEST were called to the developmental evaluation camps held at ICDS block level and trained pediatrician/medical officer re-evaluated the children with developmental delay. RESULTS: A total of 32,664 children below 3 y were screened across the state and overall 2.5% prevalence of developmental delay was observed using TDSC and 2.8% using LEST 0-3 y and 3.4% using TDSC and/or LEST positive. Out of the total 1,110 children clinically evaluated by a trained pediatrician, 69.3% children had developmental delay, 14.3% speech delay, 5.7% global delay, 5.3% gross motor delay and 3.6% suspected of hearing impairment. CONCLUSIONS: The study results showing 3.4% prevalence of developmental delay using TDSC and/or LEST by trained anganwadi workers or ASHA workers could be replicated in other states in India, under Rashtria Bal Swasthya Kariyakram.

CDC Kerala 7: Effect of early language intervention among children 0-3 y with speech and language delay.

OBJECTIVE: To assess the effect of systematic clinic and home based early language intervention program in children reporting to the early language intervention clinic with full partnership of specially trained developmental therapist and the parents. METHODS: All babies between 0 and 3 y referred to Child Development Centre (CDC) Kerala for suspected speech/language delay were assessed and those without hearing impairment were screened first using Language Evaluation Scale Trivandrum (LEST) and assessed in detail using Receptive Expressive Emergent Language Scale (REELS). Those having language delay are enrolled into the early language intervention program for a period of 6 mo, 1 h at the CDC clinic once every month followed by home stimulation for rest of the month by the mother trained at CDC. RESULTS: Out of the total 455 children between 0 and 3 y, who successfully completed 6 mo intervention, the mean pre and post intervention language quotient (LQ) were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant. The developmental diagnosis included developmental delay (62.4%), global developmental delay (18.5%), Trisomy and other chromosomal abnormalities (10.5%), microcephaly and other brain problems (9.9%), misarticulation (8.4%), autistic features (5.3%) and cleft palate and lip (3.3%) in the descending order. CONCLUSIONS: In the present study among 455 children between 0 and 3 y without hearing impairment, who successfully completed 6 mo early language intervention, the mean pre and post intervention LQ were 60.79 and 70.62 respectively and the observed 9.83 increase was statistically significant.

CDC Kerala 1: Organization of clinical child development services (1987-2013).

OBJECTIVE: The main objective of establishing the Child Development Centre (CDC), Kerala for piloting comprehensive child adolescent development program in India, has been to understand the conceptualization, design and scaling up of a pro-active positive child development initiative, easily replicable all over India. METHODS: The process of establishing the Child Development Centre (CDC) Kerala for research, clinical services, training and community extension services over the last 25 y, has been as follows; Step 1: Conceptualization--The life cycle approach to child development; Step 2: Research basis--CDC model early stimulation is effective; Step 3: Development and validation of seven simple developmental screening tools; Step 4: CDC Diagnostic services--Ultrasonology and genetic, and metabolic laboratory; Step 5: Developing seven intervention packages; Step 6: Training--Post graduate diploma in clinical child development; Step 7: CDC Clinic Services--seven major ones; Step 8: CDC Community Services--Child development referral units; Step 9: Community service delivery models--Childhood disability and for adolescent care counselling projects; Step 10: National capacity building--Four child development related courses. RESULTS: CDC Kerala follow-up and clinic services are offered till 18 y of age and premarital counselling till 24 y of age as shown in "CDC Kerala Clinic Services Flow Chart" and 74,291 children have availed CDC clinic services in the last 10 y. CONCLUSIONS: CDC Kerala is the first model for comprehensive child adolescent development services using a lifecycle approach in the Government sector and hence declared as the collaborative centre for Rashtriya Bal Swasthya Karyakram (RBSK), in Kerala.

CDC Kerala 4: TDSC items based developmental therapy package among low birth weight babies--outcome at 18 months using DASII.

OBJECTIVE: To assess the effectiveness of Trivandrum Developmental Screening Chart (TDSC) items based intervention package developed at Child Development Centre, Kerala on the developmental outcome of children at 18 mo of age using Developmental Assessment Scale for Indian Infants (DASII) and compare the same in different birth weight groups. METHODS: Five hundred consecutive discharges from the Neonatal Intensive Care Unit (NICU), Sree Avittam Thirunal hospital, were recruited and followed up till 18 mo of age including 240 low birth weight (LBW;<2,500 g) babies and 260 normal birth weight babies. All 240 LBW babies were offered early intervention at monthly intervals till 12 mo of age, whereas the normal birth weight (NBW) group received only immunization service as per the routine of the hospital. The early intervention package for the low birth weight group was designed based on Trivandrum Developmental Screening Chart (TDSC 0-2 y) items delay. At 18 mo of age both the groups were offered developmental assessment using DASII by specially trained and experienced developmental therapists who were blind to the intervention status of the babies. RESULTS: It was observed that the LBW (<2,500 g) group, who received intervention had a DASII mental age of 18.31 as against 18.16 in the NBW (≥2,500 g) group and mental DQ 101.84 (LBW group) and 98.65 (NBW group) and the observed differences were not statistically significant. Similarly, the LBW, who received intervention group had a DASII motor age of 18.68 as against 18.47 in the NBW group and motor DQ 139.40 (LBW group) and 135.39 (NBW group) and the observed differences were not statistically significant. CONCLUSIONS: The results of this TDSC based intervention package among low birth weight babies showed that at 18 mo of age there was no statistically significant difference in the developmental outcome using DASII, between low birth weight babies on intervention and the normal birth weight babies without any intervention.

CDC Kerala 6: Validation of Language Evaluation Scale Trivandrum (0-3 y) against Receptive Expressive Emergent Language Scale in a developmental evaluation clinic population.

OBJECTIVE: To validate Language Evaluation Scale Trivandrum (LEST) 0-3 y against the reference standard, Receptive Expressive Emergent Language Scale (REELS) in a population of children attending CDC developmental evaluation clinic 0-3 y. METHODS: All the children clinically diagnosed as having speech and language problem in the developmental evaluation clinic of CDC Kerala over a period of 3 y were assessed using LEST (0-3) by trained developmental therapist and REELS by a speech therapist, both blind to the results of each other. RESULTS: Out of a total of 761 children between 0-3 y diagnosed as having speech problems by a Developmental Pediatrician in the developmental evaluation clinic (0-3 y) of CDC Kerala, both LEST and REELS could be administered among 679 children. The screening tool LEST 0-3 had a high sensitivity (84.4%), specificity (80.3%), Positive Predictive Value (PPV) (91.5%), Negative Predictive Value (NPV) (67.1%) and accuracy (83.2%) against the reference standard REELS. CONCLUSIONS: The observation of this study that LEST 0-3 had a high sensitivity, specificity and accuracy against REELS, suggest that in a developmental/speech evaluation clinic LEST could be effectively used in resource poor settings.

CDC Kerala 9: Effectiveness of low intensity home based early intervention for autism spectrum disorder in India.

OBJECTIVE: To validate effectiveness of low intensity, home based early intervention (EI) models in autism for countries with low disability resources. METHODS: Fifty-two toddlers and young children were assessed before and after intervention with Childhood Autism Rating Scale, Vineland Social Maturity Scale, and Receptive-Expressive Emergent Language Scale. Developmental and speech therapists helped mothers assemble low-cost training kits based on the developmental age of the child, gave initial training in the basic behavioral technique to address the three autism symptom clusters at home. Follow-up support was given either on a weekly, fortnightly or monthly basis. Most of the children were also placed in play-schools. Data was analyzed using appropriate bivariate and multivariate techniques. RESULTS: There was statistical and clinical amelioration in the severity of autism, with acquisition of social skills and language skills (all P = 0.001) after intervention in children with mild to severe autism. Gender showed a trend in becoming a significant predictor for intervention response. CONCLUSIONS: Low-intensity, home-based EI can be effectively used in situations where there is paucity of disability resources in countries like India, especially in primary-care and community settings.

CDC Kerala 3: At-risk baby clinic service using different screening tools--outcome at 12 months using Developmental Assessment Scale for Indian Infants.

OBJECTIVES: To describe CDC Kerala experience of establishing an at-risk baby clinic and the comparison of different developmental screening tools at 12 mo against the gold standard Developmental Assessment Scale for Indian Infants (DASII). METHODS: At risk baby clinic of CDC, Kerala was established as a facility for follow up of NICU graduates from Sree Avittam Thirunal Hospital at 2, 4, 6, 8 and 12 mo corrected age and during each visit the mother is taught the CDC model early stimulation by developmental therapists and encouraged to continue to do the same at home. At 12 mo, assessment results of four simple developmental tools were compared with the gold standard DASII administered by a senior developmental therapist. RESULTS: Out of a total of 800 babies, outcome measurements at 12 mo were available for 604 infants. The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and using DASII, a diagnostic tool (13.3%). Also the combination of Amiel Tison angles, CDC standing grading and DDST gross motor against DASII motor DQ had high specificity (94.15%) and negative predictive value (NPV) (70.18%) but with a very low sensitivity of 14.58% and low positive predictive value (PPV) of 53.85%. It was observed that a significant odds ratio for DASII mental deviation quotient (DQ) was seen for neonatal seizures (2.34) and low birth weight (1.49). CONCLUSION: The prevalence of developmental delay using the screening tools, CDC grading for standing, Amiel Tison angles and DDST II (Denver II) gross motor were 24.8, 24 and 24.3% respectively and together they had a high specificity, NPV and accuracy against DASII motor DQ as gold standard at one year assessment.

CDC Kerala 5: Developmental therapy clinic experience--use of Child Development Centre grading for motor milestones.

OBJECTIVES: To document the experiences of the intervention given to children who attended the developmental therapy clinic of Child Development Centre (CDC) Kerala, a specialized clinic for providing developmental intervention/therapy for babies less than two years with developmental delay/disability. METHODS: All the babies referred to this speciality clinic from developmental screening/evaluation clinics of CDC were registered in the clinic and re-evaluation was done using CDC grading for head holding, sitting, standing, Amiel Tison passive angles, and Trivandrum Developmental Screening Chart (TDSC) 0-2 y. RESULTS: Out of a total of 600 consecutive babies below 2 y with developmental delay/disability referred to developmental therapy clinic, on comparing the test results at enrollment and after 6 mo of intervention, a statistically significant reduction was observed (i) in the 2-4 mo age group with regard to abnormal TDSC (25.5%), (ii) in the 4-8 mo age group with regard to abnormal head holding grade (87.1%) and abnormal TDSC (19.4%), (iii) in the 8-12 mo age group, with regard to abnormal sitting grade (71.7%) and (iv) in the above 12 mo age group with regard to abnormal sitting grade (35.3%) and abnormal standing grade (78.8%). CONCLUSIONS: The experience of organizing the developmental intervention/therapy clinic at CDC Kerala has shown that therapy services by developmental therapists in a centre and supportive therapy by mother at home is useful in improving the developmental status of children with developmental delay.

Development and validation of Trivandrum Development Screening Chart for children aged 0-6 years [TDSC (0-6)].

OBJECTIVE: To develop and validate a simple screening tool for identifying developmental delay among children of 0-6 y of age in the community. METHODS: The 51-items of Trivandrum Development Screening Chart for children of 0-6 y [TDSC (0-6 y)], were carefully prepared from the norms in various existing developmental charts/scales, by experts keeping in mind the face validity and content validity. The criterion validity was assessed in a community sample of 1,183 children of 0-6 y with a mean age of 35.38 mo (SD of 19.25) including 597 (50.46%) boys and 586 (49.54%) girls. TDSC (0-6 y) was validated against Denver Developmental Screening Test (DDST) as the 'Reference Standard'. RESULTS: When one item delay in TDSC (0-6 y) was considered as 'TDSC delay' (test positive), the sensitivity and specificity of TDSC (0-6 y) was found to be 84.62% (95% CI: 71.92-93.12) and 90.8% (95% CI: 88.97-92.43) respectively with a Negative Predictive Value of 99.23% (95% CI: 98.48-99.67) and LR (negative) of 0.17(95% CI: 0.09-0.32). The test-retest and inter-rater reliability [an interclass correlation (ICC) of 0.77 for test-retest and ICC of 0.97 for inter-rater] were good and acceptable. CONCLUSIONS: TDSC (0-6 y) is a simple, reliable and valid screening tool for use in the community to identify children between 0 and 6 y with developmental delay, enabling early intervention practices.

ARSH 1: Reproductive and sexual health problems of adolescents and young adults: a cross sectional community survey on knowledge, attitude and practice.

OBJECTIVE: To understand the problems faced and the difference in knowledge, attitude and practice of young people across the age group of 10-24 y on reproductive and sexual health issues and to get their suggestions regarding adolescent care services. METHODS: This cross sectional community survey involving three districts in Kerala was conducted among adolescents and young adults of 10-24 y using a population proportion to sample size technique. RESULTS: The main problems faced by the young people between 10 and 24 y of age were financial, substance abuse in family, poor academic performance, difference of opinion, disease in self/family, mental problems, lack of talent, strict parents, difficulty in mingling, love failure, broken family, loneliness and problems at school/office in the descending order. As the age advances higher percentage of both boys (43.4%) and girls (61.7%) discuss reproductive sexual health issues among themselves. There was a statistically significant difference in personal hygiene practices like changing napkins/cloths more than once a day (94.3%), cleaning genital organs with soap every day (71.7%), washing after urination (69.2%), washing from front to back after defecation (62.2%) and washing hands with soap after defecation (73.2%) between 10-14, 15-19, and 20-24 y age group with higher percentages in the older groups. In order to make the service more useful, more of the older group participants suggested giving information on adolescent services to parents, adolescents and society as a whole by creating better societal acceptance and keeping confidentiality in service delivery. CONCLUSIONS: This study has shown an overall inadequacy in reproductive health knowledge in all age groups, but increasing knowledge gain and better attitude and practices on reproductive and sexual health as the age increases. The suggestions made by the group regarding need for adolescent reproductive sexual health (ARSH) and counseling services with privacy and confidentiality ensured, is useful for planning ARSH services under National Rural Health Mission.

ARSH 9: Lower reproductive tract infections among unmarried girls (15-24 y) - a clinic based validation study.

OBJECTIVE: To compare clinical and laboratory diagnosis of lower reproductive tract infections (RTIs) in a clinic setting, among unmarried adolescents and young adults between 15 and 24 y and to validate clinical diagnosis of lower RTIs against the microbiological diagnosis as gold standard. METHODS: A structured questionnaire was administered among the participants to assess symptoms of lower reproductive tract infections and associated known risk factors. A qualified gynecologist conducted the visual inspection of the external genitalia for any clinical evidence of lower RTIs and took cotton tipped swab from the vulva (outside the hymen) for laboratory examination. The swabs were examined by a qualified Laboratory Technician for evidence of candidiasis, and bacterial vaginosis. RESULTS: Out of the total of 427 unmarried girls enrolled in the study, 344 (80.6%) belonged to the age group 15-19 y and 83 (19.4%) to 20-24 y. The results of this clinic based study validating clinical diagnosis against laboratory diagnosis as gold standard have shown 62.69% sensitivity, 97.78% specificity, 0.76 positive predictive value, 0.96 negative predictive value and 92.27 overall accuracy. CONCLUSIONS: The results of this clinic based study on unmarried adolescent lower reproductive tract infections validating clinical diagnosis against laboratory diagnosis as gold standard have shown a high 0.96 negative predictive value, suggesting that external genital examination is enough to rule out lower reproductive tract infections among unmarried adolescents.