Knowledge, attitude, and practices of parents regarding the red flags of developmental milestones in children aged 0–5 years in Karachi, Pakistan: a cross-sectional study

Children are screened for developmental delays in 4 basic domains, gross motor, and fine motor, social and verbal. Once the delays are identified, further detailed evaluation is carried out in cognition, language, motor skills, and social and emotional behavioral domains. The term “development” is defined as the progress of a child in all areas of human functioning [1]. Early years of life play a crucial role in the mental and physical development of a child and the two most important pillars in the proper development of children are parents and doctors [2].

Generally, parents are the ones who spend most of the time with their children and are involved in raising them so they should have the best knowledge related to developmental signs as parental concern about a child’s development can be used as a reliable predictor of actual developmental delays [3]. There are three channels for red flags in developmental milestones to get noticed, either via parents, physicians during routine check-ups, or if teachers notice [4].

Parents must recognize the need to take their child for routine check-ups to a physician and immediately, in case they notice a red flag. One study from 2017 showed that without routine screening, only 29% of children with developmental issues were identified before kindergarten [5]. This allows us to assume that a large number of children with developmental issues were not identified before kindergarten due to parents being unable to identify the red flags. Although the major responsibility of recognizing developmental milestones and any delay in them is the responsibility of the healthcare system, cases, where parents fail to get their children routinely monitored for growth and development by healthcare professionals and not being able to recognize major red flags of development by themselves, can lead to serious consequences in a child’s health.

Studies report that early recognition of red flags in the social, motor, and cognitive aspects of development helps in better and proactive management and therapies of children for example autism. There is, therefore, a need for early intervention. Early intervention and treatment can be very beneficial for the child and the family, according to research done in the USA in 2015, about 3.5% to 15% of children have developmental disabilities who need early intervention but only 2.8% of these toddlers and infants receive early interventional services [6].

Meanwhile, there is a lack of validated and reliable measurement tools to monitor the developmental progress of the younger age groups that can be easily adapted to regions that may be culturally, socially, and economically very diverse from the Western world. Assessment tools that were designed for resource-rich countries cannot really be used to make generalizations elsewhere. This poses a great challenge to the enforcement of programs to support childhood development which can be the reason why in low- and middle-income countries, such as Pakistan, over 250 million children are at risk of not reaching their developmental potential by 5 years of age. Moreover, the first alarm that children are not developing as they should is noticed usually when they join school which is already too late for intervention [7]. Hence, parents’ early recognition of developmental delays may result in earlier diagnosis and early intervention. With an ever-increasing population and a high birth rate (3.51 births per woman), it is the need of the hour in Pakistan, to know how to improve the conditions for children in which they are brought up so that they can become healthy and socially productive members of society. According to UNICEF's Early Childhood Development Index (ECDI), reports of nearly 100,000 caregivers show that 36.8% of children aged 3 and 4 years in LMICs do not achieve basic cognitive and socio-emotional skills. ECDI scores are positively associated with caregiver–child joint activities such as reading and playing which simply highlights the integral role that a positive relationship between the child and caregiver has on the child’s social and cognitive development [8]. It is incumbent upon all parents to know what they should expect their child to be able to do by a certain age and what they can do to help. They must also be well informed about when and who they should inform in case of delay. Parents noticing red flags at the right time and allowing for early intervention can be the turning point in deciding the prognosis of children and supporting them in becoming independent members of society and preventing disability [9]. This study aims to assess the baseline knowledge of parents about the red flags in developmental milestones in childhood and to learn about parents’ developmental knowledge-seeking attitudes and healthcare usage regarding developmental care [10].

A total of 390 participants responded to a survey with a 100% completion rate. The median age of study participants was 33 (IQR = 29 – 37) years whereas the age range was 20–59 years. One male was 59 years old and reported that his youngest child was four years old. Education levels of participants were variable throughout the sample including illiterate (4.6%), primary education (9.7%), secondary education (29.5%), graduation (38.5%), and post-graduates (17.7%). Most of the responses were received from mothers (55.4%) and urban areas (92.6%). Participants of multiple ethnicities responded to the survey including Urdu speaking (61.8%), Punjabi (19.7%), Sindhi (8.2%), Pashto (5.9%), Memon (2.1%), Balochi (1.5%), Hindko (0.5) and Kashmiri (0.3). Most of them were Muslims (96.7) whereas few were Hindu (2.6%), Christians (0.5), and Parsi (0.3%). One-third (33.6%) of the participants were first-time parents, and 84.1% of our participants reported that they did not have a consanguineous marriage and were living in a nuclear family system (69%). The median number of children per respondent was 2(IQR = 1–3) and the median age of children was also 2 (IQR = 1–3).The primary caretaker of children was the mother (83.3%), grandmother (6.9%), babysitter or daycare (6.7%), father (1.3%), aunt (1%), elder sibling (0.5%) and grandfather (0.3%).

Our study was designed to assess the knowledge, attitude, and practices of parents regarding the red flags of developmental milestones.

Out of the four domains of children’s development, parents were most knowledgeable about language milestones with over 25 percent of respondents showing adequate knowledge. These findings suggest that in our population, perhaps parents monitor their children’s linguistic development more vigilantly than other domains of development. A similar study done in the USA also showed that knowledge about language development was stronger than other domains although they only assessed the knowledge of mothers, and while our study depicts the knowledge of both parents, the results, however, are similar [15]. The fact that linguistic development especially concerns parents is reiterated by results obtained by inquiring about parental practices. 91 percent of parents admitted that they spent time with their children with an explicit intent of improving and aiding their children’s language and social development. This encouraging statistic highlights an opportunity for healthcare professionals to avail; with such an overwhelming majority (91 percent) of parents actively demonstrating vigilance and great concern about their children’s development, adequate measures, if taken, to educate parents on red flag signs will profoundly help facilitate early diagnosis. However, an alarmingly high number of respondents did not have correct knowledge regarding the age at which a child responds to his/her own name and this we assume may be because in our set-up, parents may be on the look-out for the first words but would probably not notice the age at which a child starts responding to his/her own name and thus, would not overlook this important milestone even though a delay in this milestone may also be a red flag for the autism spectrum.

Parents generally tend to place more emphasis on certain motor milestones as compared to other milestones. For instance, in the parent's view, being able to walk is an immensely important milestone in the child's development and thus this milestone rarely goes unnoticed. This had led to the authors expecting adequate parental knowledge regarding the age at which a child walks independently but unfortunately, only 37 percent of respondents were correctly able to answer the pertinent question. Similarly, the authors had expected fair to adequate parental knowledge regarding other well-known motor milestones, e.g., sitting without support., but surprisingly, an overwhelming 81 percent of respondents answered the pertinent question incorrectly. Knowledge regarding motor milestones was overall inadequate with gross motor being lower than fine motor. Parents seemed more confident about knowing when a child should be able to reach for an object, which is a component of fine motor than knowing at what age the child should be able to walk in a straight line, a component of gross motor which was answered incorrectly by 88.2 percent of the parents. Even though a study done in Saudi Arabia showed that parents in that region focused more on the motor milestone than the other domain and their results showed that 50% of the parents had adequate knowledge about motor milestones [2]. The reason for this difference could stem from the fact that the education level of parents in Pakistan varies from the education levels of parents in Saudi Arabia due to differences in literacy rates. It is possible that what parents in the Middle East region of the world consider a developmental delay, parents in Pakistan assume it to be within the range of normal development and hence do not shed light on it. We assume that they may use reasons such as genetics, diet, physical activity, and the environment to be the cause of the late achievement of a milestone and may not get their child treated on time for his/her delay. Hence the parents must be aware of the average age of reaching a developmental milestone to avoid permanent damage to their child’s motor skills which could affect their quality of life as they grow up [16].

Knowledge regarding motor and language milestones did give better results than social which shows that primary concerns of parents are based on their movements and speech rather than their ability to socialize [7]. A similar study done in Saudi Arabia proves that although overall knowledge regarding developmental milestones was poor, knowledge specifically regarding motor milestones was indeed better than the other domains, shedding light on the fact that delays in language and motor are easily noticed by the parents while social and cognitive go unnoticed [2].

From all questions regarding social milestones, the correct responses only came from 9.7% of the parents showing a huge gap in the knowledge of social milestones. The question that received the most incorrect responses was the age at which a child should be able to participate in group play. Only, 14 percent of our respondents answered correctly. In one of the studies done in Aseer, Saudi Arabia shows that only 12.5%, slightly higher than our population [17]. This shows that overall knowledge regarding social milestones is poor regardless of the region of the world. Poor parental knowledge regarding social development should be of great concern to healthcare workers and the Pakistani community. In the case of a child being autistic, parents with inadequate knowledge will most likely overlook his/her abstention from social engagement which will invariably lead to a delay in diagnosis and intervention [18].

Assessing the socio-demographic characteristics of our respondents led to a rather surprising revelation: Parents living in joint families were less knowledgeable about language milestones than those living in nuclear families. This was statistically significant. Ideally the scenario should have been that people belonging to joint family system should be more knowledgeable regarding developmental signs because of more kids around them but in this study we did not found it to be true. We speculate that this is because parents in nuclear families, being the only available caregivers for their children, take a keener interest in acquiring knowledge, develop a more cautious attitude and exercise more vigilance than parents in joint families. Moreover, there may be more children in joint family systems leading to overlooking of certain milestones of individuals. Parents have a tendency of evaluating their child’s development by comparing their activities and behavioral patterns with those of other children of similar age [10]. Some parents who participated in a similar study conducted in Iran were of the opinion that delays in speech and language milestones are not necessarily a cause for concern, as this is a “hereditary aspect” and children will reach these milestones eventually [19]. The authors had anticipated new parents to be less knowledgeable than parents who had had children previously, but contrary to this expectation, the results showed that number of children does not significantly impact parental knowledge (OR = 0.87, 95% CI 0.63–1.18, p = 0.359).

The correct attitude and practices of parents may be protective factors in a child’s development. The findings of our study showed a significant association between the female gender and positive attitude. This is perhaps because even in our study, the primary caretakers were mothers. Therefore, mothers also spent the maximum amount of time spent with children and thus there are increased chances of them looking up developmental milestones. A study reported that mothers’ knowledge mainly came from their own mother’s experiences or family sources, therefore it can be assumed that women are more likely to learn from observing children around them, contacting others for information, and are more likely to have a better understanding of a child’s growth compared to fathers [1]. 88 percent of parents reported taking their children to the pediatrician at least once a year; this is a trend that should be looked upon favorably and attempts should be made to incorporate parental education in these visits e.g. distribution of printed brochures containing information about developmental milestones. We anticipate such measures to positively impact parental knowledge.

Our results also show a significant association between the female gender and education when it comes to practices and attitude. Educated parents are more likely to use resources available to them for maximum benefit for themselves and for their children. It is possible that parents with lesser education or lesser resources available may compare their child’s growth with other children and use that as a means of assessment of their child’s growth [19]. Educated parents are more likely to be empowered with an understanding of when and how to interact with children to improve their cognitive, social, and language development. They are also more likely to do their own research to know whom to approach in case help is required. Our findings are consistent with other studies which report the association of better maternal education with better caregiving practices [20]. Furthermore, a recent study involving LMICs demonstrated that both early child economic well-being, as well as the education status of the primary caregiver, predict receptive vocabularies at the age of 5 years [21]. Educated mothers were found to have a positive attitude towards development which means they did believe in getting a clinical assessment done if their child showed any unusual signs or how they think that their pediatrician provides them with sufficient information regarding milestones. We believe that this is a very important factor that helps in the early diagnosis of a developmental delay compared to a mother with a lower level of education who realizes the unusual signs in her child's development but does not know that this is a delay that requires intervention and has the negative attitude that the pediatrician has not provided her sufficient information. Mothers, being mostly the primary caregivers are more observant about milestones and invest more time and energy with the intent of bettering their child’s development [22]. Mothers' knowledge usually comes from previous experience with children or learning about development from children around them however, our study shows that it is not just the fathers who need improvement in learning about a child’s developmental milestones but mothers also need to improve their knowledge to fulfill the criteria of having adequate knowledge. An important factor that this study highlights is that parental education did not play a significant role in having adequate knowledge about developmental milestones. Previous studies done in north India state a similar fact about mothers’ education [10]. Many studies conducted in the past mainly focused on mother’s knowledge and attitude regarding a child’s development [23] hence we included fathers in this study as well and found that there is no significant difference between adequate and inadequate knowledge of both mothers and fathers indicating that both genders need equal awareness regarding development. The difference in the relation between education and knowledge versus the association of education with attitude and practices may be that while the parents may be educated, they may not necessarily have the correct knowledge regarding developmental milestones [24].

Perhaps the reason behind this is that when we asked parents about their sources of information, many answered that they either learn from the internet or the child’s grandparents. A few parents also mentioned that pediatricians have been a great help in helping them learn about their children’s developing milestones. Regardless, the overall knowledge remains inadequate in all domains hence we must have educational programs for parents where they learn the signs of developmental delay and act as early as possible in case of a developmental delay, as a study done previously in the USA has shown a positive response in parent’s awareness regarding milestone, we hope for a similar response from our population [25, 26].

Although knowledge was overall inadequate in all four domains, our study indicated relatively better knowledge of gross and fine motor milestones as compared to language and social milestones. With regards to attitude and practices, the female gender had a positive association, which highlights that although knowledge levels do not differ between genders, mothers have the right approach in dealing with indicators of developmental delay. Our study highlights the need to devise ways to educate parents on this subject to enable them to vigilantly monitor their child’s developmental status and any associated abnormalities and ultimately facilitate the right course of action.