EARLY DETECTION TOOLS FOR

CHILDREN WITH DEVELOPMENTAL

DELAYS AND DISABILITIES
IN THE MIDDLE EAST AND NORTH AFRICA

©UNICEF/Syria/UN0603137

JUNE, 2022
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Purpose
This technical brief was developed to support specialists in countries of the Middle
East and North Africa (MENA) region to select which early detection tools best
fit their needs and context by comparing various tools that have been used in the
region and lessons learned in using and adapting those tools to local contexts.

Background
Early detection of developmental delays and disabilities in children followed by early
childhood intervention, can greatly help children with better outcomes throughout
their life course. Since formal screening is essential to initiate early interventions,
there are various tools that exist and are being used in the world for detecting
developmental delays and disabilities and that target various professionals both
working at facilities and in the community, and for parents and caregivers to ensure
that children have the essential support needed to develop and thrive.1
While early detection and intervention are crucial for a child’s development, it is
also important to be aware of the risks of screening and the followings need to be
considered to mitigate risks: 1) review of tools and protocols by an authorised body,
2) accuracy and validity of tools, 3) referral pathway, and 4) protocols for the users
on how to address specific situation such as critical health and nutrition issues,
violence and abuse.1
Current research globally suggests that detection of developmental delays and
disabilities is lower than their actual prevalence, meaning that actions undertaken
in detection of developmental delays are not sufficient. In MENA, there is late
detection of developmental delays due to (1) the lack of policies and strategies
on early detection, (2) the lack of data on developmental delays and disabilities to
build evidence-based policies and strategies, (3) the scarcity of validated screening
tools in the languages used in the region including Arabic2, Farsi and French, (3) the
scarcity of socially and culturally adapted tools according to contexts 2 3, and (4) the
gaps in availability and capacity of specialized services and trained service providers
to support children and families with early diagnosis and intervention once a delay
and a disability have been identified.

1 A Toolkit for Measuring Early Childhood Development in Low- and Middle-Income Countries World Bank Document
2 The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study https://pubmed.
ncbi.nlm.nih.gov/31299551/
3 Screening tools for early identification of children with developmental delay in low- and middle-income countries: a systematic review
https://bmjopen.bmj.com/content/10/11/e038182
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Box 1. How this brief was developed

The UNICEF Middle East and North Africa Regional Office (MENARO)
collaborated with UNICEF headquarters and several country offices in the region
(Iran, Iraq and the State of Palestine), who have worked on early detection, to
discuss the tools and experiences they have had in their work. Additionally, the
MENARO contacted specialists at UNICEF Tanzania and UNICEF Lebanon, the
American University of Beirut in Lebanon, the University of Liverpool in the UK
and the New York University Global TIES for Children in the USA, who have in-
depth experience in this area on early detection tools used in the region and
globally.

To see the tools referenced in this technical brief, UNICEF employees can check
the ECD repository for MENA. If you have no access to UNICEF Intranet, please
kindly reach out to the authors.
There are 2 Annexes that give a summary of the tools, they are:
• Annex A - Tools used in Iran, Iraq, Jordan, Lebanon, and State of Palestine
• Annex B - Global tools for screening of developmental delays and disabilities used
and referenced in MENA

Overview of early detection tools used in the MENA region

This technical brief summarises five tools from five countries in the region (Annex A).

- Objectives of the tools

All five tools aim to screen for developmental delays and disabilities. When used
at different ages and stages of development, they are designed to identify various
difficulties including physical, motor, visual, hearing and learning difficulties or
delays, cognitive, social, emotional development, self-care, social adaptive skills
and neurodiversity, which are less obvious at birth including autism spectrum. The
screening tools are not diagnostic tools. Once a delay or disability is detected by
these tools, a child may need to be referred to a specialist or a specialised facility
for more detailed tests or interventions that are tailored to their needs and that
help their parents address the observed delays and disabilities with activities that
can be done at home.
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- Global tools that MENA tools are based on

The tools currently used in the MENA are all adapted from tools which have been
used globally. Annex B shows a brief summary of the global tools. Some of them
have Arabic version readily available and are free of charge and include:
1. Ages and Stages Questionnaire (ASQ)
2. Denver Developmental Screening Test
3. Malawi Developmental Assessment Tool (MDAT)

It is necessary to check whether the tools work appropriately in a local context. All
the tools which are currently used in MENA went through a process of translation,
local adaptation, and pilot before being implemented more widely. Lebanon has
documented this process in details when ASQ2 and ASQ3 were translated and
adapted1. The modification normally includes changing the words, phrases and
activities (e.g. children’s games, songs) to more socially and culturally appropriate.

Box 2. MDAT in Uganda

The Malawi Developmental Assessment Tool (MDAT) is a tool for early identification of
neurodevelopmental problems in young children. It was initially created through a series
of studies in Malawi to address the need of a simple, cheap and culturally appropriate
way to identify developmental delays. Now, it has been used over 20 countries including
low- and middle-income settings.
In Uganda, the early screening programme used the Delphi analysis to select the MDAT
tool from seven tools recommended by global experts due to its ease of use, being free,
wide age range covered and that the demonstration materials could be manufactured
locally. In a collaboration with the University of Liverpool, who is the original developer
of the tool, the Ministry of Health and UNICEF Uganda created a short version of the
questionnaire (called MDAT IDEC) which could be delivered by Health facility workers,
Community Healthcare Workers and the teachers of Early Childhood Development
Centres. It only takes around 10-20 minutes per session. The users of the tool need to
go through a 5-day training including practical hands-on training to work with children
and families. Currently, children are screened at 9 months and 18 months, but the tool
could be used up to 6 years of age. Parents and caregivers whose children are identified
with development delays are referred for Caregiver Skills Training (CST) (a tool jointly
developed by WHO & Autism-Speaks International) and Early Motor Development
Support (EMDS) (a tool jointly developed by WHO & Autism-Speaks International). All
children who are screened are also referred for mainstream Early Child Development
services (immunisation, nutrition, early learning, responsive care giving, safety and
security).

1 Ages and Stages Questionnaires: Adaptation to an Arabic speaking population and cultural sensitivity - European Journal of Paediatric
Neurology (ejpn-journal.com)
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- Areas of development screened

All the tools screen motor (gross and fine), communication, social-emotional and
cognitive skills.

- Target age

Tools spanned from 1 month up to 6 years with various intervals. The intervals
tend to be shorter for younger age groups (1- 3 months) and longer for older age
groups (1-2 year or longer). The tools used in the State of Palestine have the widest
coverage from 1 month to 6 years.

Figure 1. Example of the tool (State of Palestine)

- Users

Except for the State of Palestine, healthcare providers primarily do the assessment
(general practitioners, paediatricians and Primary Health Care [PHC] healthcare
providers, and nurses). Kindergarten and nursery teachers and specialists at
academic institutions use the tool in the State of Palestine. Iraq may consider
training the pre-kindergarten teachers with a simplified screening tool in the future.
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- Settings

The health sector is the predominant entry point to conduct early detection
using the tools as they could be the first and earliest contact point with children
and families during their routine checkups, immunization session and/ or growth
monitoring. In the State of Palestine, screenings additionally take place in the
kindergartens, community centers and nurseries as well.

- Methods

Assessment methods include:

1. Observation (skill demonstration)
2. Interview with parents or caregiver using structured questionnaire or a set of
questions
3. Self-administered questionnaire parents can fill out

Most countries use a combination of these three methods. Iraq includes the
measurement of head circumference, length, height and weight as well.

The outcomes of the assessment are evaluated either:

1. Results are calculated using a scale (e.g. yes/ sometimes/ not yet) or
2. Results are classified into pre-set categories (e.g. red (referral), yellow (recheck
through follow-up visit) and green (routine follow-up)).
If the score is lower than the cut-off value or a child falls into red or yellow
categories, a follow-up visit or a referral is considered.
Persons administering the tools require training on the use of tools. The intensity of
the training depends on the methods used. If the assessment needs observation
(skill demonstration) and interview to parent/ caregivers, the duration of the training
tends to be longer as the users need to do hands-on training on how to work with
children and families. For example, in the State of Palestine, the duration of initial
training ranges from 3 to 7 days.

- Duration

The duration of the screening (onsite) takes a minimum of 15 minutes (Iraq) up

to a maximum of 60 minutes (State of Palestine). Time taken depends on the
experience of a user and mood of the child.
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- Users’ experiences

The users reported the tools were easy to use and feasible in the context even
though they can be time-consuming. User are required to have basic knowledge on
child development and receive trainings on how to administer tools.
To overcome the challenges mentioned above, countries are considering
developing a simplified version (e.g. a set of red flags) to reduce the duration of the
training and time constraint.

- Effectiveness

All countries except for Iran and Lebanon are in the early stage of implementing the
screening tools. Sensitivity, effectiveness and efficiency will need to be monitored
and evaluated in the future. Iran has 8 years of experiences implementing the
tool based on ASQ-2 before starting to use ASQ-3 and ASQ-SE and all data is
computerised in the nationwide electronic medical record. This dataset could
contribute to an evaluation of the tools and children could benefit from a continuum
of care by linking this data to other sectors like education and child protection.
Lebanon has done a rigorous study on psychometric properties of the ASQ3
(Arabic) and reported adequate reliability and validity for the children aged 4-33
months1. Comparing to a USA normative sample, significant differences on almost
all items and Lebanese children scored lower on communication and gross motor
items while higher on the problem solving and personal social items. This could be
due to environment and cultural norms1.

- Support and Referral

The countries in the region have varying degree of national policies on early
childhood development and strategies for early identification and intervention for
developmental delays and disabilities for children.

1 The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study - ScienceDirect
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Box 3. State of Palestine investing in developmental delays and disabilities in early

childhood development1 In Palestine, the number of children excluded from school
and affected by intellectual and physical disabilities has increased in the last
ten years. In addition, these children face stigma and exclusion due to societal
and environmental barriers. Technical support from international partners
contributed to the formation of a multi-sectoral partnership to address the
situation of children in a holistic manner involving the Ministry of Health, the
Ministry of Education and the Ministry of Social Development and United Nations
Relief and Works Agency (UNRWA). For example, the “Improvement of Early
Detection and Interventions for Children with Disabilities and Developmental
Delays” programme is coordinated by UNICEF and mainly was funded by the
Government of Japan in support of the National ECD Committee implementing
the National ECD/ECI Strategy. The program builds on the knowledge and
experience gained from past years, and with regards to the interdisciplinary ‘Child
Development Assessment Tool’ piloted in several locations in the West Bank and
the Gaza Strip. The targeted beneficiaries include service providers from health,
education and social protection sectors, NGOs and CSOs, as well as children,
their families and their communities. As part of a long-term focus, children with
disabilities are identified, receive assessment and support via an early childhood
Intervention programme including parenting counselling and education provide
early stimulation responsive care to children depending on age and development.
The aim is to fully include all families with children in society. A key driver of this
programme is to address the rights of children with developmental delays and or
disabilities in State of Palestine.

Support to children with delays and disabilities and their families, as well as referral
pathways, differ among the five countries in this technical brief.
After the screening of developmental delays and disabilities, parents or caregivers
are normally given some counseling on exercises, stimulating activities, and play
activities which are appropriate to his/ her age and development. Iraq uses the
Care for Child Development package for counseling and identifying age-appropriate
activities. In State of Palestine, the results of the assessment would lead to the
development of early intervention education plans that could be implemented by
therapists or parents at home.

1 Compendium of Country Case Studies on ECD Programming in the MENA Region, Dr. Maria Raquel de Costa
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Iran has a comprehensive system with nationwide universal early detection and
referral pathway from health houses/posts (in rural/urban areas) to comprehensive
healthcare centres, who can then refer to interdisciplinary Child Developmental
centres (where available) or secondary health services that use the Bayley Scales
of Infant and Toddler Development (BSID) for a more detailed analysis. Overall,
it is still a challenge in the region to set up an early detection system with a
matching referral pathway due to a lack of universally available services for early
identification, and the lack of services, tools, specialists and specialised facilities to
support children and families for early interventions.

Conclusion
This technical brief sheds light on the tools for early detection of developmental
delays and disabilities that have been used in MENA. All the screening tools in this
brief are stemming from one or more tools used globally and have been translated
and adapted to local contexts. The translation and adaptation is recommended to
be done with interdisciplinary teams.1 The tools generally screen similar areas and
cover similar age groups. The health sector appears to be the main entry point
for early detection for now, and healthcare providers are the main user to do the
assessment, while parents are the key informants alongside their children. The
users of the tools normally need some level of training and the more experienced a
user on child development and screening, the less the duration of the screening. All
these factors will influence how rapidly an early detection programme can be scaled
up nationwide. Most countries in MENA are in the early stages of implementation of
such programmes; sensitivity, effectiveness and efficiency of early screening tools
should be monitored and evaluated in the long run. Adequate support for a child and
family and referral to appropriate services following detection is still a gap and needs
to take into account multisectoral, transdisciplinary and interdisciplinary coordination
among health, education, and child protection actors.2

1 https://pubmed.ncbi.nlm.nih.gov/33772410/
2 Vargas-Baron, Emily & Small, Jason & Wertlieb, Donald & Hix-Small, Hollie & Botero, Rocio & Diehl, Kristel & Vergara, Paola & Lynch,
Paul. (2019). Global Survey of Inclusive Early Childhood Development and Early Childhood Intervention Programs RISE Institute
10

For a way forward, one of the important considerations is that screening children
for developmental delays and disabilities can be inappropriate if there are not
enough resources to address those delays and disabilities in a given context as
this could end up being more stigmatizing for a child and family. As such, the
strengthening of multisectoral and multidisciplinary systems-level programmes for
diagnosis, intervention, follow-up, supporting and empowering a child and family
including humanitarian settings must be considered in parallel with starting an early
detection programme. The ultimate goal is that every child, including those at risk
and most vulnerable, survives and thrives to realise their full potential.1
We would like MENA countries to consider:
- Integration of strategy of early detection and interventions into a national policy on
early childhood development
- Implementation of early detection programme using tools which are locally adapted
and tested
- Monitoring and evaluation of the early detection tools on sensitivity, specificity,
effectiveness, efficiency and impact on children and families
- Providing the service providers with tools, skills and information on how to reach
and support children with developmental delays and disabilities and their families
especially those living in hard-to-reach areas
- Ensuring early detection is followed up with referral pathways to link with appropriate
and accessible support and services for children and families based on their needs
including those living in humanitarian settings. Where services are scarce or not yet
in place, early detection work to be used to help advocate for the establishment of
services to meet the needs of children and families.

1 https://bernardvanleer.org/ecm-article/2017/international-guide-monitoring-child-development-enabling-individualised-interventions/
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Box 4. Resources to support service providers, children with developmental delays and
disabilities and their families

Measurement Library: Inter-agency Network for Education in Emergencies

(INEE), in collaboration with New York University Global TIES for Children and
the International Rescue Committee (IRC), launched a “Measurement Library”
which contains a collection of measurement tools to assess children’s learning,
holistic development and service provider quality in crisis- and conflict-affected
contexts. It is a searchable and filterable database of measurement tools that
was developed through an extensive review of working papers and journal
articles in English and Arabic to identify and document the details of where, in
what language, and with what population measures have been used in MENA.
It does not provide access to the tools themselves, but is intended as a starting
point for users interested in finding measurement tools for their purpose and
context (Caires, R., Shankar, A., Diaz, P., Rafla, J., Tubbs Dolan, C., & Wuermli, A.
(2019, November). The MENAT CHILD measurement inventory. New York, NY:
NYU Global TIES for Children)
Care for Child Development: It is a training package for frontline workers. It
equips frontline workers with assessment and counselling skills on teaching
parents/ caregivers how to provide responsive and nurturing care to children
depending on age and development. The package has been implemented in
Egypt, Iran and Tunisia in MENA. The tutorial video for children with special needs
show how to counsel parents of children with disabilities in Arabic, English and
French.
Caring for the Caregiver: It is a new training package for frontline workers
to equip them with counselling skills to increase caregivers’ confidence and
help them develop stress management, self-care and conflict-resolution skills
to support their emotional wellbeing. Arabic and French version are under
development.
Parenting Resource Pack: It is a guide designed to give parents/ caregivers ideas
and supports on parenting so that they could make informed choices. Arabic
version is available.
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Parental Engagement Curriculum (PEC) for Parents of Children with Disabilities:

Lebanon has been quaked by multitude of events and continues to be unstable,
with extensive humanitarian and development needs. Families who are providing
care for children and especially those with disabilities have been greatly
affected by the crisis situation. They could find it challenging to find appropriate
services for support and referral. UNICEF Lebanon has recently developed the
parenting curriculum to provide skills and strategies for parents of children with
disabilities aged 0-18. The curriculum provides information on how to advocate
children’s rights, enhance development, encourage learning, protect from
violence and understand/ manage caregivers’ emotions. These resources aim
to provide parents with tools and strategies with the specialized content that is
targeted towards their specific needs that are not met through general parental
engagement programs; while also ensure to be gender responsive and child
protection components incorporated
Curriculum in English, Curriculum in Arabic, Facilitator guide in English, Facilitator
guide in Arabic
Bebbo: It is a free parenting application to support early childhood development
(0-6 years old) and it has inclusive sections for parents of children with disabilities.
It is not available for Arabic/ Farsi/ French. Bebbo - Apps on Google Play, ‎Bebbo on
the App Store (apple.com)
Cboard: It is an open-source communication application for children with
disabilities (speech and language impairment) and can be operated on desktops,
tablets and mobile phones. It is available in Arabic, English, and French. It is open
for customization and customization is very quick (few weeks max). Trainings
for professionals who should support use of Cboard with parents are part of the
intervention and on-line training in English is available. Cboard AAC - Google Play
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PEC for Parents of Children with Disabilities Bebbo Cboard

©UNICEF/Jordan/UN0276041/Herwig

Acknowledgements
The authors of this brief are Aferdita Spahiu [email protected], Shirin Kiani
[email protected] and Tomomi Kitamura [email protected] (UNICEF MENARO).
This brief is only possible due to the enormous contributions of: Lama Charafeddine
(American University of Beirut) [email protected], Melissa Gladstone (University of
Liverpool) [email protected], Joyce Rafla [email protected]
Roxane Caires [email protected] (New York University Global TIES for
children), Mohammad Eslami [email protected] Mahdis Daniali
[email protected] Bahar Azemati [email protected] (UNICEF Iran), Shaimaa
Ibrahim [email protected] (UNICEF Iraq), Selena Bajraktarevic
[email protected]/ Kanar Qadi [email protected]/ Fairooz Abu Warda
[email protected] (UNICEF State of Palestine), Amal El-Jabali
[email protected] (UNICEF Lebanon), Flavia Mpanga [email protected]
(UNICEF Uganda), Aleksandra Jovic [email protected] (UNICEF ECARO), and
Chemba Raghavan [email protected]/ Natalia Mufel [email protected]/ Erica
Wong [email protected] (UNICEF Headquarters).
 14
Annex A – Tools for screening of developmental delays and disabilities – used in MENA region
Tool name
References Support and Referral process
Developmental areas screened Target age User Settings Methods Implementation Characteristics
Country of after identification
useObjective

Country of use: Areas of development: 1 to 60 Users: Language: Arabic Time required: Support after screening:
State of 1. Speech/communication months, broken Healthcare providers Translation from English to Arabic. 20min minimum Following the results of the
Palestine 2. Social-emotional down into 10 (Pediatricians, general Back-translation from Arabic to 60 min maximum assessment, (whether the full
Tool name: 3. Motor skills (fine and assessment practitioners, nurses, English has also been done. Time includes a assessment or the short version of red
Child tools speech/physical Adaptation: child to demonstrate flags), parents/ caregivers are provided
gross)
development 1. 1-3 mo therapists), kindergarten/ Adapted to Palestinian contexts skills while playing with information/counseling and given
4. Cognitive development
behavioral (16 items) nursery teachers including words, lullabies, children’s (multiple attempts exercises if needed to do at home with
5. Self- help/ care
assessment 2. 3-6 mo (with bachelor’s degree), games, animal sounds/ names. may be needed), and children. For some service providers,
(adaptability) Social workers counseling to parents. where resources are available, an
scale (25 items) Also child protection elements have
General questions for parents Specialists in academic been taken into consideration by Duration depends on individual service plan is developed and
Global tool 3. 6-9 mo
are attached at end of the institutions (with PhD) changing the original questions. experience of users/ implemented for each child identified
referenced: (35 items)
assessment tools (not scored): Settings: West bank and (e.g. instead of asking ask child “to mood of child. to have a developmental delay.
DBS 4. 9-12mo
- Medical history (maternal Gaza take off clothes”, ask them “to put Users’ experiences Referral process:
developmental (33 items)
complications before/ 1. Mobile clinics on clothes” considering Protection User needs to 1. Need to retest child with low
behavioral 5. 12-18 mo
during/ after pregnancy, 2. Clinics against Sexual Exploitation and have some child score. Till a next retest, parents are
scales (28 items)
complications at birth Abuse). development given materials on stimulation of
(Pistolijevic, 6. 18-24 mo 3. Kindergarten/
(including prematurity), Training: knowledge in advance. specific activity
Zubcevic, (34 items) nursery
Users need to complete a 3-7 Duration of screening
Dzanko, 2016) history of childhood 2. If retest score is low and/or delay
7. 24-36 mo Methods: varies and it is possible
illnesses during early days training (including hands-on is confirmed, refer to:
Objective: (32 items) Observation/ skill to screen a maximum
infancy) practices). - Children with mild/moderate
Screening for 8. 3-4 y (43 demonstration of 5 children per day.
- Hearing In future, local expertise is needed
developmental (0-2 y.o.) ask parents to May need to repeat delays are referred to an institution
items) for a scale-up by identifying a
delays and - Vision help a child do skill, the screening when who can support family with early
9. 4-5 y (39 champion among the current users
disabilities - Touch (2 y.o. and older) a child is tired or not intervention plan focusing on
items) to be a trainer.
- Communication (verbal) demonstrate skills to a cooperative. specific skills (E.g. community
10. 5-6 y (42 Scale of implementation:
- Social and cognitive child and ask him/ her to centre, multidisciplinary clinics).
items) Around 375 professionals from Effectiveness:
development do skills
This is to be - If a child has severe delays and
The results are scored health, education and social
- Atypical behaviours determined as tool is a referral to a specialized service
using the 3-level scale: development sectors from eight
Additional Tools: governorates in the West Bank and new and Covid delayed is needed, then this is done if
1. Yes
- corrected age Gaza have been trained on the use full implementation. available. Colleagues in Palestine
2. Sometimes It appeared to be high.
- supervisory checklist of the tool. recognize there is not shared
3. No
- illustrations manual referral system and would like to
- rulebook strengthen this.
 Tool name
References Developmental areas Support and Referral process
Target age User Settings Methods Implementation Characteristics
Country of screened after identification
useObjective

Country of use: Areas of 21 questionnaires Users: Language: Farsi Time required: Support after screening:
Iran development: with following month: Parents: Consultant who was expert in Up to 30 min General instructions are
1. communication 2, 4, 6, 8, 9, 10, 12, fill out the questionnaires before early detection tool supported Users’ experiences provided in the PHC
Tool name: 2. gross motor 14, 16, 18, 20, 22, 24, vising the health facilities translation. Fairly easy to use and At the interdisciplinary Child
ASQ-2/ ASQ- 27, 30, 33, 36, 42, 48, Healthcare providers (Primary Health Adaptation: feasible for Iranian context. Developmental centre, parents/
3. fine motor
3/ ASQ-SE 54, 60 months Care (PHC) level): The same consultant The Iranian gov’t seems caregivers of children with
4. problem solving
(Currently support parents when the questions contextualized the tool (e.g. to satisfy with the ASQ-2 developmental delays or
5. personal-social
using ASQ-3 & Due to time are not clear for them. traditional beliefs/cultures, to screen various delays disabilities receive counseling
skills and how to give appropriate
ASQ-SE) constraints with using review and score the questionnaires urban/rural). It should be noted and disabilities. It has been
21 questionnaires and record scores on Electrical that same questionnaire and used for 8 years now. The stimulation and responsive/
with universal Medical Record. cut offs are used for both rural government has started nurturing care.
Global Tools coverage, Iran has explain the results to parents. and urban areas. the use of ASQ-3. Referral process:
referenced: selected used 5 Pilots have been done after Effectiveness: 1.Based on Red Flags and ASQ
Ages and (6,12,24,36,60 Settings: translation and adaptation. The tool is proven effective screening test (computerised),
Stages months) of the Primary Health Care centre (during The cut-off points were globally, however, there a child is referred to
Questionnaire questionnaires for regular check-up/ immunizations). determined by calculating 1SD may be under-reporting comprehensive healthcare
(ASQ) Home ASQ-2 for routine ‘Health Houses’ in rural/ Health Post and 2SD below mean. The of disability by parents center doctor for Bayley Scales
- Ages and monitoring. However, in urban areas latter representing the main who fear stigmatization assessment.
Stages if a child has been cut-off point and the interval for the child. Due to self- 2. If doctor at comprehensive
identified as “needs between the two representing healthcare center has
further assessment” Methods: administration nature of
Objective: the monitoring zone according concern, then a referral is
through Well child Self-administer questionnaire filled a tool, there may be false
Screens for to the ASQ3 technical manual. made to an interdisciplinary
programme, he/ out by parents positives and negatives.
developmental Child Developmental centre
she will undergo Scoring by healthcare providers Training: According to ”The
delays and or hospitals. The centres
ASQ3 and ASQ SE using the 3-level scale for ASQ3 MoHME provides specific situation analysis of the
disabilities are equipped with early
appropriate to his/her (Yes/ Sometime/ Not yet) and 3-level protocols, guidelines and Developmental Status
age. scale (Often or always/ Sometimes/ trainings for healthcare (Draft)”, 5% of the children intervention tools and various
Healthy children born Rarely or Never) for ASQ-SE. workers to follow when using under the age of 3 required rooms to support various skill
ASQ-SE has an option for parents/ the questionnaire and to referral based on the ASQ development.
with prematurity
will undergo the caregivers to check “if this is a answer the questions from (overall items).
concern” (currently digitalised and caregivers. For children with severe
appropriate ASQ tests disabilities/delays, referrals to
appropriate for 2, 6, 9, stored in a nationwide electronic Scale of implementation:
medical record system): specialized facilities are made,
12, 18, 24, 36, 48, 60 Nationwide where available.
months.
15
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Tool name References Country Developmental areas Support and Referral process
Target age User Settings Methods Implementation Characteristics
of useObjective screened after identification

Country of use: Areas of Well-child Users: Language: Arabic Time required: Support after screening:
Iraq development: care and Early Healthcare providers (PHC level, Translation from English to 15 min Please refer to “When a child falls
Tool name: 1. Social/ Childhood mainly doctors, either family Arabic was straightforward Users’ experiences into “yellow” category”.
No specific name emotional Development physician doctors or general due to simplicity of Very easy and Referral process:
It is integrated in the child monitoring are practitioners) questions. rapid, 4 questions
2. Language/ - When a child falls into “yellow”
health care recording file scheduled as Settings: Adaptation: embedded in a
communication category, counselling using
used during immunizations following months. Primary Health Care centre As the four key milestones comprehensive form
3. Cognitive Care for Child Development is
and growth monitoring (Ones in bold (during regular check-up/ per age group were mostly
(learning, Effectiveness: provided to parents on how to
align with the immunizations and growth straightforward and universal
Global Tools referenced: thinking, immunization Yet, to be give responsive stimulation to
Monitoring Child monitoring). skills, no localization process determined as
problem- schedule) a child
Development in the IMCI Methods: was needed. project is new.
solving) During the - When a child falls into ”red”
context (PAHO/WHO) 4. Movement/ screening, 4 key Interview with structured Training;
category, two pediatric
(Four development scales developmental questions (risk factors), The users need to receive a
physical hospitals are available in 1st
referenced: milestones are Measurement (head, height/ 4-day specific training course.
development pilot phase to be referred to, in
Bayley Scales of Infant checked. length, weight) They are trained on the
and Toddler Development Observation/ skill demonstration ECD concept and guideline Baghdad (tertiary hospitals).
(BSID), Classification by pre-set criteria including how to do the - Tools used by pediatricians for
<1 (1 week and 1
Denver Developmental 1. red (referral) screening and how to provide further asesssment of delay
month), 2, 4, 6, 9,
Screening Test 2. yellow (counsel and follow- responsive care. vary and up to a pediatric
12, 15, 18, 24, 30,
(DDST), 36, 42, 48, 54, 60 up visit) Scale of implementation: specialist.
Exame neurologico do months 3. green (counsel and routine In January 2022, a pilot has - There seems to be little
recemnascido de termo, been started at 12 PHC publicly available specialized
visits)
and Diagnostico del centres. centres for children with
desarrollo normal y anormal After evaluation, a plan severe delays/limitations
del nino: metodos clinicos y is to expand to 3 more (speech, motor, intellectual).
aplicaciones practicas) governorates (5 PHC centres - Some private centres may
Objective: per governorate) be available to support on
Screens for developmental
developmental delays for those
delays and disabilities
who can afford it.
 Tool name Support and Referral
Developmental areas
References Country Target age User Settings Methods Implementation Characteristics process after
screened
of useObjective identification

Country of use: Areas of 21 Users: Language: Arabic Time required: Support after screening
Lebanon development: questionnaires Parents: ASQ3 has been translated as follows in Lebanon. For parents/ and Referral process:
with following fill out the questionnaires before vising *ASQ has been easily administered for 4-36 caregivers to fill The current form of
Tool name: 1. communication
month: the facilities, Healthcare professionals months age groups but not for 4-5 years old due out questionnaire: universal screening
ASQ-3 2. gross motor at American University of Beirut (AUB): to cultural differences2 around 10 minutes for developmental
*Translation 2, 4, 6, 8, 9,
3. fine motor support parents when the questions 1) A skilled translator who is a communication delays is a checklist
10, 12, 14, 16, Users’ experiences:
and adaptation 4. problem solving are not clear, review and score the skills expert did a translation from English to very easy to use, included in the child’s
have been done 18, 20, 22, 24,
5. personal-social questionnaires, explain the results to Arabic. it only takes a health record that is
in Lebanon for 27, 30, 33, 36, parents. (2) Another bilingual translator, blinded to the offered by the MOPH
skills short time and
a part of the 42, 48, 54, 60 * Early ECD educators (World Vision) original translation, did the back translation into to every newborn at
flexible. It can be
questionnaires1, months have used the tool for Syrian refugee English, administered easily birth. This health record
however, children. (3) Arabic translations were reviewed and over the phone. contains developmental
The questions Settings: compared with the original English questionnaire milestones’ checklists
currently, the Effectiveness:
are either yes/ AUB neonatal continuity clinics for high- by two specialists (medical doctors) to detect that the physician or
Arabic version *Comparison with
no or yes/ risk infants (The clinic is for babies born any misunderstanding, mistranslations or the parent can fill at
available from a USA normative
sometimes/not in AUB or those born outside of AUB inaccuracies. different ages. The
the official sample by ASQ3
and referred for checkup and follow-up) (4) All items on the questionnaires were reviewed checklists are based on
website has yet to choose (0-3) 3:
and discussed with a child psychologist, a the Center for Disease
from. Methods: Lebanese children
been used for paediatric occupational therapist, and an early Control and Prevention4.
Self-administer questionnaire filled scored lower on
consistency. child education expert till a consensus was It is not known how
out by parents (at AUB, parents fill out communication
reached. Items that were found to be culturally widely these checklists
Global Tools during their visits to clinic (during the and gross motor
sensitive were modified. are used. In case of
referenced: COVID restriction, screening has been items across age
(5) Cutoff points of each domain were generated developmental delay, a
Ages and Stages done through a phone interview). groups.
for each age group by subtracting two standard child is usually referred
Scoring by healthcare providers Lebanese children
Questionnaire-3 deviation from the mean score to a pediatrician or
Paper format scored by hand. Compare scored significantly
(ASQ-3): Home - Adaptation: pediatric neurologist
child’s scores to Lebanese cutoff points. higher on problem
Ages and Stages Face-to-face interviews with consenting parents for further assessment.
Discuss results with parents and solving and
were held to check the ease of readability and There are many
Objective: determine next steps. (e.g follow-up, personal social
clarity of the questions. Questions were modified services available (ex.
Screening for monitoring, or further assessment. items. This could
based on the feedback. Special kids clinic at
developmental Share activities with parents if delays be due to a child
AUBMC, Sesobel,
delays and noted. Trainings: For the specialists working at AUB, rearing takes
I’dad, ARC en Ciel
Results- 3 levels the training guidelines/ manuals are used (going place in extended
disabilities among others) however
1. Pass over the questionnaires and calculation of scoring family environment
a comprehensive
2. Suspect (Above threshold but to ensure understanding. Then, practicing with extensive
mapping of those
below the normal range in >= 1 administering the questionnaires) interactions.
services is highly
domain) Scale of implementation: Health facility (tertiary/
needed.
3. Referral (Below threshold in at least referral level: AUB) for follow up high-risk infants
1 domain)

1 The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study - ScienceDirect
2 Ages and Stages Questionnaires: Adaptation to an Arabic speaking population and cultural sensitivity - European Journal of Paediatric Neurology (ejpn-journal.com)
3 The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study - ScienceDirect
4 CDC’s Developmental Milestones | CDC
17
 18
Tool name Support and Referral
Developmental areas
References Country Target age User Settings Methods Implementation Characteristics process after
screened
of useObjective identification

Country of use: Areas of From 0 to 5 Users: Language: Arabic Time required: Support after screening:
Jordan 1 2 development: years old Trained enumerators with some Translated from English to Modern Standard 30-40 min Referral process:
Tool name: 1. gross motor (34 background in Child Protection, Arabic (MSA) and adapted to local Levantine depending on age Information not
MDAT items) Education and Health sectors dialects by translators, specialists and of child, available
Settings: psychometric experts Users’ experiences
Global Tools 2. fine motor (34
Syrian refugees and Jordanian Backtranslation was done as well. It has been
referenced: items)
3. language (34 caregivers under pilot/ research purpose Adaptation: reported by the
Malawi
items) Methods: Adaptation process was conducted after enumerators that
Developmental
Using the toolkit, translation to MSA. Adaptation included linguistic the caregivers
Assessment Tool 4. social
The users observe a child (skill adaptation and adaptation of images and local appeared to enjoy
(MDAT) development
demonstration) and ask questions to materials that are required to test the child’s the use of MDAT.
Objective: (34 items)
parent/ caregiver whether a child can abilities. Effectiveness:
To identify
*Original version perform skills. Trainings: The expected
children with
of MDAT has been Scoring system is used to see whether It seems to require relatively intense training on correlations
neurodisabilities
used in Lebanon a child is “pass” or “fail”. the use of the tools (e.g. how to ask questions, with caregiver
or delayed
(Different from a record the results, etc.) measures were
development.
short version used Scale of implementation: not obtained,
in Uganda) Syrian refugee settings who participated in a pilot however further
research study investigation is
needed.

1 As the documentation of the implementation is ongoing, only the limited information is available for now.
2 irc-rul-reportapril27-2020.pdf (inee.org)
Annex B - Global tools for screening of developmental delays and disabilities

This table is not an exhaustive list of screening tools used globally, but listed those used/ referenced in MENA.
Tool / Objective Developmental areas Target age User / Methods / Trainings Available language
screened
Ages and Stages Questionnaire Areas of development: 21 questionnaires User: Permission from publisher required for translation.
(ASQ) 1. communication with following Parents/ caregivers Arabic/ English/ French and other languages
2. gross motor month intervals: Professionals, paraprofessionals or clerical staff These can be purchased from ASQ website
3. fine motor 2, 4, 6, 8, 9, 10, 12, Methods: Translations of ASQ - Ages and Stages
Objective:
14, 16, 18, 20, 22, Parents/ caregivers fill out a self-administer *How the Arabic translation has been done?
To detect delays early to 4. problem solving
24, 27, 30, 33, 36, questionnaire ASQ3 has been translated into a standardised Arabic and
improve child outcomes 5. personal-social skills
42, 48, 54, 60 Professionals score the questionnaire, review reviewed by experts from different Arabic-speaking countries
while encouraging parent
months child’s scores and compare to standardised cut-offs including KSA, Kuwait and Egypt.
involvement and education
If scores fall in the category for follow-up, schedule Adaptations have been made include: a) language to reflect
the next screening and provide Arabic grammar, b) cultural experiences, c) motor skills.
ASQ-3 Arabic uses the same cutoffs as the English version.
Trainings: Research projects conducted to study the psychometric
Required. Can be purchased from Training - Ages properties of ASQ-3 Arabic are not comprehensive enough
and Stages to provide separate normative data on Arabic children at this
time and should be reviewed with consideration especially in
the communication and personal-social areas.
Bayley Scales of Infant and Areas of development: 16 days to 42 User: Permission from publisher required for translation.
Toddler Development (BSID) 1 1. cognition months Professionals English
BSID 4 published in 2019 2. motor (Psychologists, neuropsychologists, or Global TIES for Children have translated into Arabic, however
3. language developmental paediatricians are the common it has not been tested.
users.
Objective: 4. socio-emotional
Occupational therapists, speech and language
To diagnose developmental 5. adaptive behaviour
pathologists, and paediatric nurse practitioners also
delays in early childhood and
con utilise in practice.)
plan management 2
*Considered to be Methods:
standardised screening Parents/ caregivers to complete questionnaires
instruments and a gold Professionals observe and facilitate skill
standard diagnostic tool for demonstration. Then, professionals summarise
developmental delay for standard and score
infants and young children 3 4. Trainings:
Required (webinars and workshops)

1 Bayley N. Bayley scales of infant and toddler development. PsychCorp, Pearson; 2006.
2 Bayley Scales Of Infant and Toddler Development - StatPearls - NCBI Bookshelf (nih.gov)
3 Nelson Textbook of Pediatrics. 19th Edition
4 The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study - ScienceDirect
19
 20
Tool / Objective Developmental areas Target age User / Methods / Trainings Available language
screened
Denver Developmental Areas of development: From birth to 6 User: English
Screening Test motor (gross and fine) years Professionals Arabic in limited use as follows:
language Methods: Revised Denver Pre-Screening Developmental Questionnaire
(DDST)
personal-social skills Using Denver Development Screening forms and has been translated and adapted for Madinah children in KSA
1
kit, the users identify the chronologic age of child .
Objective: Denver II has been administered by physicians in the Middle-
and draw age line on scoring sheet.
To identify young children at Eastern countries, but not being widely used 2.
Test a child with items on the form along age line
risk for developmental delays
and then to the right of the age line until a child
and disability.
fails items
Trainings:
Required
Malawi Developmental Areas of development: 0 to 5 years old User: Arabic,
Assessment Tool (MDAT)3 gross motor Anyone with a high school education English,
fine motor Can be used at primary health care level French, and other languages
language Methods: Translations | Local MDAT
Objective:
social development Using the toolkit, the users observe and facilitate Tools can be requested from Get your toolkit | Local MDAT
To use as a clinical tool
a child to demonstrate skill and ask questions to for free of charge.
in early identification of
*Cognitive development parent/ caregiver whether a child can perform Implemented in over 20 countries
neurodevelopmental problems
is measured within the skills. In Low- and middle-income settings in Sub-Saharan Africa,
and as an outcome measure
domains of fine motor and Scoring system is used to see whether a child is South East Asia and South America
(e.g. in clinical trials of
language. “pass” or “fail”. Global Influence | Local MDAT
perinatal interventions)
I Global Influence | Local MDAT
Trainings:
Required (at least 3 days to 7 days)

1 Translation and Adaptation of the Revised Denver Pre-Screning Developmental Questionnaire for Madinah Children, Saudi Arabia (annsaudimed.net)
2 The standardization of the Denver Developmental Screening Test on Arab children from the Middle East and north Africa. - Abstract - Europe PMC
3 pmed.1000273 1..14 (nih.gov)
 21

Other screening tool for a resource-limited setting

(not currently used in MENA)
The Guide for Monitoring Child Development (GMCD) 1 2 is a tool for monitoring and
early detection of development difficulties of children aged 0-3.5 years in low- and
middle-income countries. It was originally developed in Turkey. Training required to
use the tool and it takes 1 to 3 days depending on the background of the trainees.
Community workers, nurses, family physicians, paediatricians and early intervention
providers in 25 countries have been trained in the use of the tool. The tool has three
components: 1) monitoring of development component, 2) supporting development
and 3) managing developmental difficulties and integrate the concept of Care
for Child Development and the WHO International Classification of Functioning,
Disability and Health framework. It is a brief, open-ended, precoded interview with
primary caregiver and it assesses language (expressive and receptive), motor skills
(gross/ fine), relating, playing and self-help.

Development Screening Questionnaire (DSQ)/ Rapid Neurodevelopment

Assessment (RNDA) 3 4 are tools developed in Bangladesh. DSQ is administered
to mothers of children aged 0 to 24 months of age to screen neurodevelopmental
status with 24 age sets with 8 questions per set. It screens motor (gross/
fine), vision, hearing, cognition, socialisation, behaviour and speech. RNDA was
developed to assess neurodevelopmental status of children aged less than 2
years with limited access to health screening. It can be conducted by semi-skilled
health workers. It is meant to provide neurodevelopmental evaluation equivalent
to a scale like BSID 3. The tool is now available to screen children up to 9 years old
with domains: motor (gorss/fine), vision, hearing, speech, cognition, behaivour,
seizure, and self-help (only for 5-9 years old). Training can be accessed from Rapid
Neurodevelopmental Assessment (RNDA) Training (rnda-bd.org).

1 A Guide for Monitoring Child Development in Low- and Middle-Income Countries | Pediatrics | American Academy of Pediatrics (aap.
org)
2 The international Guide for Monitoring Child Development: enabling individualised interventions - Bernard van Leer Foundation
3 Screening tools for early identification of children with developmental delay in low- and middle-income countries: a systematic review
| BMJ Open
4 https://www.researchgate.net/publication/280868267_Validation_and_adaptation_of_Rapid_Neurodevelopmental_Assessment_
Instrument_for_Infants_in_Guatemala
22

Parents’ Evaluation of Developmental Status (PEDS) is a tool to provide

developmental screening and behavioral screening plus ongoing surveillance for
children aged 0 to 8 years old. The tool screens language (expressive/ receptive),
motor (gross and fine), behaviour, self-help and school and social skills (PEDS-R will
include psychosocial challenges and health problems). Parents are asked to answer
10 questions on the PEDS Response Form and it is scored using the Score Form.
On the back of the Score Form, PEDS Interpretation Form is attached and shows
an algorithm for deciding whether to refer, screen further, observe, counsel parents
or simply reassure them. The form also has the spaces for recording and tracking
decisions and actions. It is available in Arabic, English, Farsi and French.

Free screening tools with the languages used in MENA:

Caregiver-Reported Early Development Instruments (CREDI) is a an open-source
tool and being used for population-level early childhood development assessment
from birth to 3 years old (not for an individual screening tool to detect early
developmental delays or disorders). The caregiver answers a questionnaire (short
or long form). The CREDI Short Form creates a summary score for children’s overall
developmental status and the long form creates domain-specific developmental
scores. It is available in Arabic, English, and French.
© United Nations Children’s Fund (UNICEF)
JUNE, 2022