**4. Promoting Children's Development: Assessment and Intervention in Health and Education**

Within an interactional framework, assessment, intervention, and evaluation activities should target key developmental indicators, in order to identify and address the specific delays in functioning an individual child may be experiencing. Each of these activities can significantly influence the developmental progress of children who are experiencing delays in development. The timing of assessment and intervention is critical.

Disparities in development can be enhanced or remediated based on the child's interactions within their environment. Risk factors are barriers and adverse influences on the development of the child. Protective factors are beneficial facilitating development. Exposure to risk and protective factors have cumulative effects [23] that occur when a child is exposed to the same factor repeatedly or different factors with fewer occurrences. Children who have accumulated more risk therefore need more protective factors to promote development. Greater protective factors are associated with better outcomes for children [24]. For example, children who experience multiple risk factors such as poverty, malnutrition, delayed motor development, and delayed speech are impacted by all of the

factors cumulatively. Early assessment and intervention practices are key for children facing increased risk, as they allow a mechanism to also increase protective factors during a critical time for child development. A time where gaps in delay can more easily be lessened. Evaluation of assessment and intervention practices allows for more target progress.

Assessment provides information about the level of current functioning, strengths, and deficits, which can then be used to drive the individual goals of an intervention. There are many key issues to consider when planning for developmental assessment. Assessment practices begin with instrument selection. An assessment plan should include gathering baseline information as well as measures to monitor progress. Instrument selection should be culturally relevant, valid, and reliable within the population context. When choosing an instrument, stakeholders should consider the benefits and risks of using a measure.

Although there is a range of developmental assessment measures, particularly in higher income countries, their applicability for use in low-resource countries is limited. Semrud-Clikeman et al. [25] compiled a comprehensive review of neurodevelopmental assessments and screeners for clinicians to determine the best instrument for their goals. In this review, the authors defined the additional considerations needed in order to choose an appropriate assessment tool in the context of low- and middle-income countries. Stakeholders need to determine whether they will use a formal assessment tool, an adapted version of a formal assessment tool, or a locally developed test. Administering a formal assessment tool allows for standardized data to be collected, with scores comparable to a norm reference group. This data provides a clear picture of how an individual child is performing in various domains, it also provides norm referenced scoring which is useful for determining delay. Using formal assessment tools are useful when they are assessing children who are represented in the norm referenced sample.

When assessing children who are in a different cultural context than where the assessment was developed, an approach that has been taken has been to develop an adaptation of the measure for the local context. To avoid overidentification due to cultural bias, and changes in reliability and validity, children should be assessed using data pre- and post- intervention to determine the change in functioning rather than focusing solely on norm referenced data to define delay. Developing local tests can be useful to determine a child's developmental functioning in the context of their community environment, which may have distinct priorities that shape the developmental trajectory of a child. Though Semrud-Clikeman et al. [25] provide a framework for thinking through the context of a developmental assessment, the bulk of their review provides a matrix of assessments for various neuropsychological domains with specific information about adaptations, training requirements, and test-specific information for practitioners. Their seminal work can be used as a guide for practitioners to begin choosing a specific measure within context of culture, disease, and area of development.

The lack of standardized measures suitable for use in assessment of young children in low-resource countries has been identified by Bhavnani [26] as a significant impediment for population-based screening and for assessing dimensions of child functioning for planning and monitoring interventions. The use of existing tools and measures is often not an option for a number of reasons. From a practical standpoint, the use of standardized, proprietary measures may not be feasible because of cost and the requirement for highly trained professionals to administer them. Lack of standardization with a reference population, concerns about cultural fit, specificity of content and mode of administration are additional constraints on developmental assessment of young children. Recognizing these constraints for valid developmental assessment, particularly of children in rural contexts, a gamified tool was developed to assess cognitive development using tablet technology that could be administered by non-specialists. Specifically, the Developmental Assessment on an E-Platform (DEEP) tool, uses games and narratives on tablets to assess cognitive development of three-year old children across six domains: response inhibition, divided attention, visual form perception, visual integration, reasoning and memory. The cognitive domains were assessed on the basis of the child's play of nine interactive games such as hidden objects, odd one out, jigsaw and location recall. In a phased testing of alpha and beta versions of the DEEP, the tool generated metrics that reflected individual differences in accuracy and completion of cognitive skills. In a subsequent proof of concept study, Mukherjee et al. [27] administered the DEEP to 200 three-year old children in a rural district in India to test the utility of derived scores to predict children's performance on a standardized tool, the Bayley Scales of Infant Development-III. Results indicated that DEEP scores were predictive of, and positively correlated with cognitive performance on the BSID-III. The potential utility of the DEEP for developmental assessment of children in low-resource countries is supported by the fact that it yielded reliable data in the context of a developmentally homogeneous study population (mean BSID-III cognitive score of 8), and physical limitations with one-third characterized by stunting and one-fourth being underweight.

Optimal intervention occurs as early as possible, recognizing that disparities in early childhood have long lasting consequences. These consequences can be mediated by early intervention programs in which long-term effects have been noted related to cognitive development, as well as behavioral and emotional development in children [28]. In higher income countries, early intervention focuses increasingly on preparing for educational readiness through programs such as preschool, head start, or home visit interventions. In low- and middle-income countries, additional consequences of health and environmental factors, such as increased risk for malnutrition or infection and disease, may require the creation of different types of intervention feasible in low-resource settings.

Interventions to facilitate improved developmental outcomes for children may involve implementing community-based programs or processes that promote children's development in low- and middle-income countries. Interventions may target the child directly or aim to involve the interactions between the child and their environment. Eickmann et al. [29] described a community-based intervention program implemented in Brazil in which the intervention program was designed to improve cognitive and motor development by targeting the interaction between the child and their mother. Mothers were trained to implement simple interactions that promote motor and cognitive development within the home environment. Children who received the intervention showed significant improvements in both cognitive and motor development. Children who showed greater initial delays made larger overall gains from the intervention. Children who received the intervention maintained their developmental progress when measured 12–18 months later, while children who did not receive the intervention showed scoring decline.

The intervention included a workshop component as well as home visits. The intervention was designed to increase the mother's skill through demonstration, practice, skill building, and reinforcement in the home environment. The intervention was intensive, with three workshops and ten home visits occurring over a period of five months. This study highlighted several key factors for optimal intervention, including early assessment leading to targeted intervention for children most at risk. The study also promoted a process that changed the social and environmental interactions of children to increase stimulation.

In upper middle- and high-income countries, intervention priorities may shift toward the developmental risk factors present in the population served to also include school readiness behaviors as part of developmental outcomes. In the U.S., children with developmental delays or other disabilities can begin receiving early intervention services beginning at birth, and eventually provided through the public-school system beginning at age three. Elbaum [30] investigated the developmental outcomes of children with delays (*n* = 17,828) who participated in preschool special education. Children received services to support the development of communication, cognitive, adaptive, motor, and social development. Using the Battelle Developmental Inventory, Second Edition (BDI-2), children were categorized into severity of delay (no delay, mild/moderate delay, and severe delay). Children with a mild or moderate delay (24.2% of the sample, upon entry) made significant gains, with over half (57.6%) exiting the preschool program functioning at age level development. Of the children with a severe delay (60% of sample, upon entry), developmental gains were made as well with 23% exiting the program meeting age level developmental expectations.

Children with more complex delays (including delays across multiple measured categories) showed higher level of risk upon entry and less age expected developmental progress upon exiting the program [30]. This outcome speaks to the importance of considering the complex nature of supporting children with multiple areas of delay or children with special healthcare needs, as their developmental needs are unique. These groups of children benefit from early developmental intervention, but may not experience the same immediate gains in developmental progression as children with fewer domain areas of delay or children without special healthcare needs.

Early childhood interventions in Turkey [31] and Austria [32] have structures similar to those in the U.S., beginning at birth with early intervention services which transition to school-based services around 36 months. Early intervention programs in each of these countries are structured by legislation and public policy. They also illustrate similar challenges in cohesiveness across sectors. For example, integrating health and nutrition programs into early intervention services require an integration of intervention from multiple stakeholders. These three countries also face challenges of public awareness of intervention programs as well as limitations with diagnostic requirement for services and lack of opportunities for inclusive programing with typically developing children.

A specific example of an early intervention program implemented in the context of a school-based service, is the Tools of Mind (Tools) program. Recognizing the importance of environmental interactions in intervention, Diamond et al. [33] investigated the impact of Tools on individual and environmental factors in Canadian kindergarten classrooms. The Tools curriculum is designed to teach strategies to support executive functioning skills by teaching contextually based attentional control and self-control strategies. The authors built on previous studies of the Tools intervention to further investigate the impact of the intervention on the environment by measuring the child's prosocial behavior, academic performance, classroom stress, and teacher burnout. Results of the study, as measured by standardized academic assessment tools and teacher surveys, indicated the contextually based Tools intervention resulted in individual and environmental impacts. Children who were enrolled in a classroom where the teacher used Tools had improved self-regulation skills and performed better academically. Environmental impacts in the classroom included less bullying, increased helping behavior of students, and increased enthusiasm, and decreased burnout among teachers.

In defining replicable strategies of intervention for low-income countries, Engle et al. [34] examined the effectiveness of cross sector programs to optimize the health and the environment of children through intervention. Factors associated with effective intervention included: direct services provide to children, early intervention- especially to those most disadvantaged, and longer or more intensive exposure to the intervention. Additionally, structure and establishing processes were associated with program quality. Though early intervention provides significant benefits strategies to minimize environmental, health, and social risks are also key. This can be challenging as it requires investments beyond direct child intervention, and into other sectors of public policy, research, and governmental programming working together to support comprehensive early child development interventions.

Evaluation of implemented interventions should be considered at both the systemic and individual level. Promoting optimal functioning for children requires the facilitation and coordination of assessment, intervention, and evaluation efforts. Evaluation should include systemic indicators as well as individual indicators. Framed within the lens of transactional theory, Black and Dewy [35] emphasized the importance of integrated interventions, while also magnifying challenges in evaluation. Integrated interventions across health and education target a child's developmental needs across sectors (i.e., early child development and nutrition). Integrating nutrition programs into early education programs intuitively makes sense, as better nutrition is linked to cognitive development and functioning. Research is needed to demonstrate that nutrition and early child development programs are more effective than early education programs alone [35]. This perspective is

elaborated by Lipina and Posner's [36] comprehensive review demonstrating the relationship of cognitive, linguistic and behavioral development with nutrition and underlying development of brain networks. Within this perspective, interventions, particularly for children in poverty need to address the associated risk factors of malnutrition, inadequate housing, and limited access to health care, support and early education.

Given the importance of integrated interventions to promote children's developmental potential, meaningful evaluation becomes a key priority. Systematic efforts to evaluate interventions that combine cross-sector programs are challenging in that they require multiple stakeholders to coordinate, organize, and monitor programming. In providing combined health and educational services emphasizing child-environment interactions, there is a need for collaborative initiatives across sectors serving young children, particularly children at risk and with disabilities. Studies focused on child-environment interactions in the educational or health settings. For example, Sanches-Ferreira M et al. [20] described special needs assessment in the Portuguese educational system. Interestingly, the authors' findings support the need for an expanded focus on person-environment interactions, considering students' participation in different domains of life—besides learning—as well as the impact of environmental barriers over students' participation. In addition, they highlight the need for training programs centered on a biopsychosocial understanding of human functioning, the establishment of a transdisciplinary collaborative culture and the use of dynamic assessment tools to equip professionals with appropriate conditions to use the ICF-CY within an interactive perspective. Moreover, Batorowicz et al. [19] proposed a model for research and clinical practice that directs researchers and practitioners working in rehabilitation of young children toward interventions that address the mechanisms of child-environment interaction and that can build capacity within both children and their social environments, including families, peers' groups and communities. In this service provision approach, the authors highlight that health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love [19].

Table 1 shows the key findings of the studies included in this section applying a child-environment interaction framework. Promoting early child development, we have identified children's factors, environmental factors, and interaction factors facilitating child development and functioning in different settings (Table 1).


**Table 1.** Promoting early child development: a child-environment interaction framework.

