Methodology for the early identification of neurodevelopmental disorders in the primary and preschool children in rural India by applying intervention module developed for teachers

Study design

This study design is an quasi–experimental study.

Study setting

Department of Health Research, Government of India, has established one of the Model Rural Health Research Unit (MRHRU) in Tirunelveli District, South India. This unit is linked to Tirunelveli Medical College and is mentored by the National Institute of Epidemiology, Chennai. The field practice area of this unit is the study setting with 30 government and government-aided primary schools, 46 Anganwadi Centres (AWC)/preschools, 2892 children, and 107 primary and 46 preschool teachers.

Inclusion criteria

All primary (107) and preschool teachers (46) from government and government-aided primary schools and AWCs in the study setting who are willing to participate will be included in the study. In addition, all 2892 children enrolled in the same schools with parental permission will be included in the study.

Exclusion criteria

We exclude teachers on transfer, on a 3-month leave such as maternity leave, or teaching in private schools and children with severe NDD who cannot attend school.

Methods

We will conduct the study in two phases. In the first phase, we will develop and validate a training module and train the teachers as per the groups assigned to identify the children with NDD over 2 months. In the second phase, the neurologists will assess the children over 1 year.

To train the teachers, the investigators will develop a module in the vernacular (Tamil), based on the neurodevelopmental screening tool (NDST) of the National Institute of Epidemiology (NIE). The training module will comprise of a booklet with an introduction, clinical features of NDD, identification using the NDST, early detection advantages, and teachers’ directions on completing the NDST. Tirunelveli Medical College and NIE will peer-review and validate the module.

After obtaining administrative approval from the District Chief Education Officer and Project Officer of Integrated Child Development Services, we will initiate the study. Line listing of the government and government-aided primary schools and AWCs, teachers, and children will be done.

We randomly assign the teachers into two groups: before identifying the students using the NDST, the teachers in Group A will get training using the module. Group B is the control group, in which untrained teachers administer the NDST to the children and then will be trained. The scheduling of training sessions will consider the teachers’ feasibility. The teachers will be communicated, and written informed consent will be obtained.

The principal investigator (neurologist) will conduct a 1-day interactive training session at Model Rural Health Research Unit for Group A teachers utilizing a power point presentation based on the module and clarify their queries. Pre- and post-session questionnaires will be collected. The training module booklet, informed written consent forms for parents, and NDST assessment tools will be provided to the teachers to identify children with NDD. After the session, Group A teachers will screen each child under their direct supervision over 2 months. Meanwhile, the Group B teachers will assess the children under supervision for 2 months using the same NDST without training. At the end of 2 months, the investigator will train Group B teachers using the same module as Group A. The investigators will randomly supervise teachers in both groups to see how they use NDST.

After 2 months of screening by teachers, investigators will examine children for NDD over 1 year at the respective schools and Anganwadi centers. Children with NDD will be referred to Tirunelveli Medical College [Flow Charts 1 and 2].

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Flow Chart 1:

Proposed activities.

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Flow Chart 2:

Time line of proposed activities.

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All ethical guidelines will be followed at each phase of the study. As indicated, we will get administrative approval. Teachers’ written informed consent will be obtained. The teachers will get the parents’ written informed consent before assessing the children for NDD. As the children are vulnerable, the study permits timely and appropriate rehabilitation referrals.

Data collection and analysis

The data will be captured using the individual paper-based NDST forms filled by the teachers and the investigators. The data will be entered in a Microsoft Excel worksheet and analyzed using SPSS software version 23.0. The prevalence of NDD among pre and primary school children in the study area will be estimated. Pre- and post-test scores will assess the teachers’ existing knowledge of NDD and the same imparted by the intervention, respectively. The significance of the session on imparting knowledge to teachers will be calculated by paired student t-test.

Outcome

The study is the first of its kind to assess the prevalence of NDD among rural India’s pre- and primary school children. As a result of the study, the effectiveness of teacher training for early detection of NDD will be assessed. Thus, the validity of the screening for NDD by the teachers as a result of the training will be estimated.

Implications

We propose the study as a potentially cost-effective strategy for the timely identification of children with NDD. Early diagnosis of NDD will aid in determining the most appropriate disorder-specific intervention and rehabilitation for children. With the help of trained teachers, the parents will be informed and made aware of the problems their children face due to NDD.

Thus, we have the opportunity to channel children based on their strengths and limitations, which increase the children’s well-being and has a positive effect on the family and society.

Limitations

Children with severe NDD who cannot attend school will represent a limitation. Since only government and government-aided schools are included in the study, the results may not be applicable beyond the setting.