ORIGINAL

Niger J Paed 2014; 41 (1): 7 - 14

Eseigbe EE

The outcome of growth and

development assessment of

under-fives using a new tool, the

SMAT Score

DOI:http://dx.doi.org/10.4314/njp.v41i1,2

Accepted: 30th May 2013

Abstract Background: The death

of growth and development

screening tools in developing

countries has grave implications

for child health outcomes. The

aim of the study was to determine

with age range of 0.5 to 4.9 years

(mean 2.3 ± 1.3 years) studied. Out

of these 34 (16.2%) were screened

as NOT SMAT. All the 90

(51.1%) randomly selected SMAT

subjects as against 1 (2.9%) of the

NOT SMAT subjects were clini-

cally evaluated as normal. Inter

rater and test – retest agreement

rate in SMAT Score administrators

was 100%. SMAT Score sensitiv-

ity and negative predictive value

was 100% respectively in all age

groups. The specificity was 98.9%

overall and 96.3% among infants.

Higher SMAT Score positive pre-

dictive value (97.1%) was ob-

served with the entire study popu-

lation as against 87.5% among

infants.

Eseigbe EE (

)

Department of Paediatrics,

Ahmadu Bello University Teaching

Hospital, Shika-Zaria,

Nigeria.

Email: eeeseigbe@yahoo.com

the effectiveness of

a novel

screening tool in a rural Nigerian

community.

Method: Speech and language,

Motor, Appearance and Tempera-

ment (SMAT) parameters of un-

der-fives were queried using a

novel tool, the SMAT Score. The

effectiveness of the tool was as-

sessed in three phases. In the first

two phases the tool was adminis-

tered to 210 under- fives

(

Subjects) independently. Those

screened as having anomalies are

classified as NOT SMAT while

those screened otherwise as

SMAT. In the third phase all NOT

SMAT subjects and a number of

randomly selected SMAT subjects

were clinically evaluated. Out-

comes of SMAT Score admini-

stration and clinical evaluation

were subjected to psychometric

assessments.

Conclusion: SMAT Score effec-

tively identified subjects with

growth and developmental disor-

ders. Its use has potential for im-

proving health systems and conse-

quently child health outcomes in

developing countries.

Keywords: Growth, Development,

Assessment, Tool, Under-fives

Results: There were 210 subjects

8

–10

Even where these tools are available

Introduction

counterparts.

their use is limited by cost of accessing the tools, social-

cultural diversity that affect validity, and poor

knowledge of tool administration. The measures taken in

the past to obviate these limitations, such as tools valida-

tion for local use and creation of culturally sensitive

developmen₈_–t₁a₃ssessment tools, have met with functional

limitations.

Growth and developmental disorders are significant con-

tributors to childhood, particularly unde_–r₃-five, morbidity

1

and mortality in developing countries. Early identifi-

cation of childhood disorders_,₅has been reported to im-

4

prove child health outcomes. The regular assessment

or monitoring of childhood growth and development,

particularly of those at risk such as the under-fives,

would facilitate improvement in the outcome of growth

and developmental disorders.

The SMAT Score is a screening tool, designed by the

author, which assesses multiple growth and develop-

ment domains using conventional methods. The aim of

the study was to determine the effectiveness of this tool

in identifying under-fives with growth and developmen-

tal disorders in a rural Nigerian community.

While there is a plethora of growth and de₆v_,₇elopmental

screening tools in the developed countries,

dearth of such tools in their under developed

there is a

8

IV.

SUB TOTAL SCORE……………..

Method

Study area

*

D. TEMPERAMENT AT ACTIVITY MOST TIMES

HIGH ODERATE LOW

The study was conducted in the Katari North District of

Kachia Local Government Area (L.G.A.) and the 44

Nigeria Army Reference Hospital in Kaduna South

L.G.A. both in Kaduna State, Northwestern Nigeria.

Kachia L.G.A. was selected through a simple random

selection from the 23 LGAs that make up Kaduna State,

one of the 36 states and the Federal Capital Territory

that constitute Nigeria. The Katari North district was

also selected through a simple random selection from

the 24 districts in Kachia Local Government Area. It has

an estimated population of 3,500 persons₁₄who are

mainly subsistence farmers and petty traders. Admin-

istratively the district is headed by a District Head who

is assisted by the Village Heads of the 20 villages that

make up the district. Health care delivery is made avail-

able through a Primary Health Care Centre, a private

hospital owned by a faith based organization and a gov-

ernment owned General Hospital 30km away. Main

languages spoken are Hausa, Adara and Pidgin English.

The 44 Nigerian Army Reference Hospital Kaduna (44

NARHK) is a tertiary health institution located in the

state capital and approximately 100 kilometers from

Katari. It renders specialist health services to military

personnel and the civilian population in Kaduna and its

environs. The hospital is an accredited centre for post

graduate medical training by the National Postgraduate

Medical College of Nigeria and the West African Post-

graduate Medical College. The department of Paediat-

rics offers both out and in patient clinical services. It has

a total of 16 beds and its medical staff comprises of two

Consultant Paediatricians, one medical officer and,

I. Level of motor involvement in activity

II. Mood level during activity

III. Energy level during activity

IV. Level of change in activity needed

for response

V. Adaptability to new activity

VI. Role completion in activity

VII. Role completion despite interference

VIII. Response to new activity

IX. Regularity at activity

1

0

1

0

1

X.

SUB TOTAL SCORE……………….

1

1. TOTAL SCORE= A.IV + B.IV + C.IV + D.X

*

ACTIVITY (FEEDING for those≤ one year of age or PLAY for

those˃ one year of age)

2. ASSESSMENT OUTCOME: ……………………...….. (SMAT if

1

total score=18 and NOT SMAT if total score ˂18)

1

3. Assessed by ……………………. 14. Date ………………………

The SMAT Score, conceived and developed by the au-

thor, assesses three developmental domains and physical

growth. The assessed parameters, from which the acro-

nym SMAT is derived from, are Speech and language,

Motor, Appearance (representing physical growth) and

Temperament. Administration of the tool involves both

caregiver’s and tool administrator’s assessment of a

child’s growth and development.

SMAT Score parameters:

a. Speech and language

This parameter is assessed through queries in three

sections. These include:

i. The first query, directed at the caregiver, asks about

the presence or absence of speech and/or language.

The expected response is ‘Yes’ or ‘No’.

ii. The second query, also directed at the caregiver,

asks whether the development of speech and/or lan-

guage has been normal. The expected response is

also a ‘Yes’ or ‘No’.

iii. The third query, directed at the tool administrator,

determines the relationship between the child’s state

of speech and language development and that of its

peers. To achieve this, the child state of develop-

ment is compared w₁i₅th that of its peers using a con-

ventional standard. the expectations in this stan-

dard is similar to that expected of Nigerian chil-

residents and interns rendering service and undergoing

various stages of training. SMAT Score (Table 1)

Table 1. SMAT Score

1

2

4

5

8

. Identification Number……..…………………………….

. Name………………….…..3. Informant................................

. Address…...………………………………………………….

. Age (Years)……… 6.Sex…… 7. Height/length (H/L)….cm

. Weight (W)……..…… kg 9.Occipito–Frontal–

Circumference (OFC)………….........cm

0. PARAMETER RESPONSE (CIRCLE)

A. SPEECH – LANGUAGE

1

YES

NO

I.

II.

III.

Is it present

Is it normal

Is current status appropriate for age

1

0

1

6

IV.

B.

SUB TOTAL SCORE……………..

MOTOR

dren. The expected response to the query, after

assessment, is a ‘Yes’ or ‘No’.

b. Motor (Motor function development)

I.

II.

III.

Is it present

Is it normal

Is current status appropriate for age

1

0

The queries are similar to those in the speech and lan-

guage parameter and they include:

IV.

SUB TOTAL SCORE……………..

i. Query about the presence of motor function in the

child and directed at the caregiver with an expected

response of ‘Yes’ or ‘No’.

ii. Query about the presence of any observed abnor-

mality in motor function of the child directed at the

caregiver with an expected response of

C.

I.

II.

III. Is current physical status (H/L, W, OFC)

appropriate for age

APPEARANCE

No absence in form

No abnormality in form

1

0

1

0

9

‘

Yes’ or ‘No’.

hood activities namely feeding, play and sleep were con-

sidered for assessment in the temperament parameter of

SMAT Score. In the course of the pre test it was ob-

served that in children between the ages of six months

and one year of age caregivers provided comparatively

more information, relevant to the temperament parame-

ter, about feeding than during play or sleep. Also, for

children between the ages of one and five years more

relevant information was available concerning play than

feeding or sleep. Consequently feeding and play were

the assessed activities for children aged less than one

year and those between one and five years respectively.

iii. The third query is directed at the tool administrator

and questions the relationship between the child’s

state of motor function development and that of its

peers. The child’s state of development is compared

with that of its peers using a summary of the World

Health Organization motor milestones development

standards₁₇a_,₁n₈d a more comprehensive conventional

standard.

The WHO standard is universal but

limited to six major milestones and children less

than two years of age. The milestones in the con-

ventional standard are more encompassing and

1

6,18

similar to those expected of Nigerian children.

The expected response to the query, after assess-

ment, is a ‘Yes’ or ‘No’.

SMAT Score scoring

For the parameters of Speech and language, Motor func-

tion and Appearance a ‘Yes’ response scores one point

while a ‘No’ response scores zero. Consequently for

each of these parameters the maximum score is three

points and the minimum is zero. For the parameter of

Temperament, every ‘High’ grade scores one point ex-

cept in the characteristic ‘Level of change in activity

needed for response’ which scores zero. Thus the maxi-

mum score in the ‘High’ grade is eight. The ‘Moderate’

grade scores one point for all characteristics giving a

maximum score of nine. The ‘Low’ grade scores zero

for all characteristics except for the characteristics of

‘Regularity at activity’ and ‘Level of change in activity

need for response’ making two points the maximum

recordable score for this grade. In total Temperament

has maximum and minimum recordable scores of nine

and two respectively. Overall a normal SMAT Score is

the outcome when a child scores maximum scores in all

four parameters assessed. A child that scores the maxi-

mum score of 18 is referred to as SMAT Score positive

or SMAT. Conversely any child who scores less than 18

is referred to as SMAT Score negative or NOT SMAT.

A child who is SMAT Score negative or NOT SMAT

would require a further clinical evaluation.

c. Appearance (Physical growth)

In this parameter growth is assessed through queries

about the physical attributes of the child.

i. The first query, directed at the caregiver, questions

the presence of any deficit in the physical attributes

specifically the absence or lack of formation of any

physical structure of the body. The expected re-

sponse is ‘Yes’ or ‘No’.

ii. The second query, also directed at the caregiver,

questions the presence of any abnormality in the

form of the child’s physical structure specifically

the presence of dysmorphic features in the child.

The expected response is ‘Yes’ or ‘No’.

iii. The third query, directed at the tool administrator,

questions the current state of development of the

child’s physical attributes by comparing the child’s

current anthropometric measurements of Height,

Weight and Occipito-Frontal-Circumference with

that of its peers. The comparative conventional stan-

dard is the 2₁₉0_,₂0₀6 World Health Organization growth

standards.

All measurements less than -2 z

scores or greater than 2 z scores for age and sex are

regarded as abnormal. The expected response after

assessment is a ‘Yes’ or ‘No’.

SMAT Score administration

d. Temperament

To administer SMAT Score in the study, two English

and Hausa Languages speaking Community Health Ex-

tension Workers (CHEWS) were recruited and trained

by the author on the content and how to administer

SMAT Score as a screening tool. Prior to commence-

ment of the study a pretest was conducted in a commu-

nity with characteristics similar to Katari. The commu-

nity, the Rido community, is located approximately

85km from Katari. Also a translation and back transla-

tion of SMAT Score from English to Hausa Language,

the commonly spoken language in the pretest and study

communities, was carried out during the pretest. It takes

15 to 20 minutes to administer SMAT Score.

This parameter assesses the behavioral responses of a

child to a common childhood activity. The two child-

hood activities queried in SMAT Score are Feeding and

Play. The behavioral queries were developed, by the

author, along the₈_,₂t₁emperamental characteristics of Tho-

1

mas and Chess.

The queries are directed at the care-

giver and concern the child’s behavioral responses most

of the times and during feeding or play to the character-

istics of activity level, adaptability, approach and with-

drawal, attention span and persistence, distractibility,

intensity of reaction, quality of mood, rhythmicity and

threshold of responsiveness. The responses are graded as

High, Moderate or Low reflecting both the intensity and/

or frequency of the behavioral characteristics most of

the times with emphasis on ‘most of the times’ presenta-

tion.

Sample size determination

The estimated prev₂alence of the under-five population in

2

Nigeria is 16.8%. This prevalence was used in calcu-

lating the under-five population size for this study. Con-

sequently with a prevalence of 17%, a confidence level

During the SMAT Score pre test, three common child-

1

0

of 95% and allowing for a 5% margin of error a sample

population sample size of 211 was calculated. However

considering that the study population is less than 10,000

persons, the sample population was readjusted to 210

under-fives.

nearest 0.1cm. Each growth parameter was measured

twice by the tool administrator, at the beginning and end

of the tool application, and the average measurement

recorded as the measurement for that parameter.

SMAT Score was re administered, three weeks later, by

the same administrators to the same caregivers and Sub-

jects in the second phase of the study. The third phase

was conducted at 44 NARHK. In this phase all NOT

SMAT Subjects and at least half of the SMAT Subjects,

randomly selected, were evaluated clinically in the pae-

diatric outpatient clinic of 44 NARHK by a consultant

paediatrician. All those diagnosed as having a medical

disorder were treated and managed accordingly in the

department of paediatrics.

Inclusion criteria

Included in the study were all under-fives, referred to as

Subjects, residing in Katari Community and who have a

verifiable birth date made available through birth re-

cords or corroborative oral evidence.

Exclusion criteria

Excluded were Subjects who did not fulfill the inclusion

criteria and those who had a current illness requiring

immediate medical attention. The need for intervention

in such cases could influence participation and outcome

of the study.

Data analysis

SMAT Score was analyzed for inter rater, test retest and

validity outcomes. Chi-square test, with Yates’ correc-

tion were appropriate, was used for assessing the signifi-

cance of validity differences in the age groups. A p

value less than 0.05 was regarded as significant.

Conduct of study

The study was conducted between September and De-

cember 2012. Ethical approval was obtained from the

Research Ethics Committee of 44 NARHK and consent

obtained from the district head, respective village heads

and heads of every participating household before com-

mencement of the study.

Results

A total of 210 Subjects were assessed using SMAT

Score. They had an age range of 0.5 to 4.9 years (mean

2

.3±1.3years) and a male preponderance 123(58.6%).

The study was conducted in three phases. The first and

second phases were conducted in Katari Community.

The 20 villages were enumerated and a village selected

for study through a simple random selection. From the

house of the village head an axis is randomly selected

and all eligible Subjects in households along a selected

axis are studied. If the households along a selected axis

are exhausted and the sample size not met, there is a

return to the house of the village head and a new axis to

be studied along randomly selected. If a village is stud-

ied and the study sample size is yet to be attained an-

other village is randomly selected and the study process

repeated until the sample size was attained.

Out of the total number assessed, 34(16.2%) were iden-

tified as NOT SMAT. Their age range was 0.5 to 4.3

years (mean 2.1±1.3years) and had a male preponder-

ance (18, 52.9%) as well. Table 2 shows the age and sex

distribution of the 210 Subjects and the 34 NOT SMAT

Subjects.

Table 2: Age and sex distribution of the 210 assessed and 34

NOT SMAT Subjects

Age

(years)

All assessed Subjects (%)

Sex

NOT SMAT Subjects (%)

Sex

%of

Total

M

F

Total

M

F

Total

≤

1

21

17.1)

35

13 (14.9) 34(16.2)

26 (29.9) 61(29)

19 (21.8) 50(23.8)

4(22.2) 4(25)

8(23.5)

13.1

38.1

28.6

20.2

(

1.1–2

2.1–3

3.1–4

7(38.9) 6(37.5) 13(38.2)

1(5.5) 3(18.8) 4(11.8)

(28.4)

In the first phase SMAT Score was administered by the

trained administrators, to the same caregivers and their

respective Subjects, independently and simultaneously.

The administrators took all anthropometric measure-

ments and assessed all comparative responses with the

derived conventional standards. Height was measured

using a stadiometer for those who could stand erect and

to the nearest 0.1cm while recumbent length, using an

adjustable calibrated flat board, was measured in those

who could not stand or were yet to achieve the mile-

stone. Weight was measured to the nearest 0.1kg and

using a standing weighing scale for those who could

stand and a bassinet weighing scale for those who could

not or had not achieved the milestone. The OFC was

measured using a non stretchable but flexible tape meas-

ure. The tape measure is applied across the frontal bone

anteriorly and the occipital bone posteriorly along the

widest possible diameter and measurement taken to the

31

(25.2)

14

(11.4)

17 (19.5) 31(14.8)

12(13.8) 34(16.2)

3(16.7) 1(6.2) 4(11.8)

3(16.7) 2(12.5) 5(14.7)

4.1–5

2

(17.9)

Total

123

87

210

18

16

34

100

Inter rater reliability

There was no difference in the outcome of the assess-

ment by the two SMAT Score assessors in the first

phase of the study. Both identified the same Subjects

and number that were NOT SMAT.

Test retest reliability

The repeat assessment of the study population in the

second phase of the study by the same assessors yielded

1

the same outcomes. The same Subjects and number

34, 16.2%) were identified as NOT SMAT.

contemporary growth and development screening tools.

Even though SMAT Score specificity was lower in in-

fants, all psychometric outcomes met requirements for

(

7

Validity

standard screening test accuracy. The tool also demon-

strated remarkable ability to screen out children with

mild to severe disorders of growth and development.

All the 90 randomly selected SMAT Subjects were as-

sessed as normal after clinical evaluation in the depart-

ment of paediatrics, 44 NARHK. Out of the 34 NOT

SMAT Subjects, only 1(2.9%) was clinically evaluated

as normal. The Subject that was evaluated as clinically

normal is a seven month old male whose SMAT Score

was 16. The SMAT Score abnormality was observed in

the Temperament parameter in which LOW MOST

TIMES (score of 0) response to the queries about re-

sponse and adaptation to a new activity (feeding) was

indicated respectively. This singular finding among the

infants compared to none in the older children was not

Modalities for assessing or monitoring growth and

development in developing countries are variable. They

include us₂e₃ of assessment tools from the developed

countries, locally developed tools, the Road To Health

2

4–26

and routine clinical evaluation dur-

Card (RTHC),

ing hospital visits. Generally there is a dearth of assess-

ment tools, particularly those concerning development,

in developing countries. While high cost of procure-

ment, lack of knowledge about the existence and appli-

cation of these tools contribute to the scarcity of tools

from the developed countries, paucity of research into

2

significant (ᵪ =0.40, df=1, p=0.526). Table 3 shows the

validity estimates of SMAT Score.

9

child development as reported by Ertem and colleagues

is a constraint to tool development in the in developing

countries.

Table 3: Estimates of SMAT Score validity in clinically

evaluated 90 SMAT and 34 NOT SMAT Subjects

Variable

All

Subjects

≤ 1 year

Subjects

˃1 year

Where tools from the developed countries are available,

socio cultural differences between the two worlds and

very robust construct cont₂e₃nt throw up validity issues.

Gladstone and colleagues observed several items on

social development in assessment tools from developed

countries performing poorly in a typical developing

country setting. The content of the construct of some

assessment tools are so extensive such that the benefit of

shortening them have been explored even in the devel-

oped countries. The Very Short Form of the Children’s

Behavior Questionnaire (CBQ-VSF) was recently psy-

chometrically evaluated and limited validity was found

Sensitivity(a/a+c x 100)

Specificity(d/b+d x100)

Positive Predictive Value

100

98.9

97.1

100

96.3

87.5

100

(

a/a+b x100)

Negative Predictive Value 100

d/c+d x100)

100

(

a=true positives b=false

positives c=false negatives

d=true negatives

2

7

for the extracted factors and the external constructs.

Validity could have been more limited in an under de-

veloped setting. Consequently limited validation is ob-

served with most of these tools. Limited validation and

application of the tools make it difficult to appreciate the

impact of these tools on child development in develop-

ing countries.

Under nutrition seen in 13(39.4%) of the 33 Subjects

with a clinical diagnosis was the commonest childhood

disorder (Table 4). The least common disorder was

physiologic stereotypy diagnosed in a 10 month old

male who presented with a two month history of re-

peated head nodding without any other co-morbidity.

Assessment tools such as the Guide for Monitoring

Table 4: Outcome of the clinical evaluation of 33 NOT SMAT

Subjects

9

Child Development (GMCD₁)₀, the Malawi Development

Assessment Tool (MDAT), the Ten Questions Ques-

1

1,12

Childhood disorder

No of Subjects Percent of

Total

tionnaire (TQQ₁)₃,

and the Disability Screening

Schedule (DSS) are some recent tools that have been

designed in developing countries. However there are

reported limitations of these tools which restrict their

application or impact. The validity of the GMCD though

remarkable was obtained in a clinical research setting

questioning the possibility of similar outcomes in popu-

Under nutrition

Rickets

Sickle Cell Anemia

Cerebral palsy

Stuttering

13

6

4

3

39.4

18.2

12.1

9.1

Expressive Language Disorder

Physiologic Stereotypy

Total

2

1

33

6.1

3

100

9

lation based samples, the MDAT was developed using a

select group of Ma₀lawian children as standard with lim-

1

ited applicability, the TQQ and DSS have been re-

ported to having a tendency of identifying only children

with severe disabilities and not having a frame₁₁w_-₁o₃rk for

monitoring the development of young children.

Discussion

The R₂₄T_,₂H₅ C is widely available in developing coun-

SMAT Score recorded absolute inter rater and test-retest

agreement outcomes in this study. Its high sensitivity

and specificity outcomes are comparable to that of

tries.

It documents information about a child’s socio-

demographic characteristics, immunization history,

1

2

feeding practices as well as growth and developmental

advances in charts. The focus, in this card, being on

documentation rather than assessment can be implied

from the RTHC’s under utilizati₅on as a growth and

deficits. It also provides another platform of exploring

behavioral responses to common childhood activities.

SMAT Score has shown remarkable reliability and

validity in a population based sample. Its potential in

developing caregiver perception and participation in

screening assessments in addition to developing the

assessment capacity of the health worker strengthens the

health care system. Application of SMAT Score

required administrators with basic qualification in health

care delivery, simple administrative materials and was

easily administered in a rural population. These attrib-

utes suggests a minimal cost and a cost effective benefit

to the health care system. The characteristics exhibited

by SMAT Score in this study underscore its relevance

and that of tools like it in child health care delivery par-

ticularly in developing countries.

2

development assessment tool. This short coming is

likely enhanced by the restricted number of growth and

developmental domains indicated for assessment in

these cards. The restriction limits caregiver participation

in assessment and obscures the training needs of the

health worker filling these cards. These increase the risk

of not identifying early a significant population of chil-

dren with growth and developmental anomalies. The use

of clinical evaluation as a screening tool, in developing

countries, is impracticable cons₂id₈ ering the scarcity of

human and health care resources.

SMAT Score recorded high sensitivity and specificity

outcomes for a growth and development assessment

tool. The outcomes were as remarkable as findings from

A limitation in the use of SMAT Score was highlighted

in the discrepancy between clinical evaluation and tem-

peramental assessment in the respective infant. Care-

giver understanding or expectation rather than the actual

temperamental status could be the response to queries in

a parameter. This can be reduced by providing adequate

caregiver enlightenment and emphasizing the need to

giving appropriate responses to queries. Also there are

complexities associated with growth and development in

very young children which could limit the outcome of

SMAT Score. These complexities include the challenge

associated with quantifying all inherent variations, in

growth indices and motor functions of very young chil-

dren, in a normal population and being able to account

for all of them in an established standard. This was high-

lighted by Gorter and colleagues in a study concerning

classification of mot₀or function in very young children

7

other environmentally sensitive assessment tools, such

as the₉_,G₁₀MCD and MDAT, proposed for use in

LMICs.

Consequently SMAT Score has immense

prospect as a tool for effective identification of those

who have or are at risk of having growth and develop-

ment anomalies in early childhood. This could have a

significant impact on child health services in the country

and other LMICs that do not have a model fo₉r promo-

2

tion and monitoring of child development. SMAT

Score equally recorded a high concurrent validity out-

come. This attribute of SMAT Score and its ease of ap-

plication underscore its potential in augmenting child

health services particularly in settings where skilled

manpower and equipment for identifying growth and

development anomalies are either scarce or not avail-

able. SMAT Score also displayed the capacity of detect-

ing growth and developmental anomalies in a wide

range of disorders with varying prevalence, severity and

etiology. It was able to identify these anomalies in a

potentially serious condition like under nutrition, a se-

vere condition like cerebral palsy and a genetic disorder

like sickle cell anemia. The capacity for facilitating early

detection of these conditions and other potentially grave

childhood disorders signify great potential for SMAT

Score in strengthening child health services particularly

with its incorporation into well child health visits and

school health services. Furthermore, the age range for

which SMAT Score is applicable makes it a valuable

tool for the m₂₉onitoring of early childhood growth and

development.

3

with cerebral palsy. Also complex is the extrication of

the impact of a variable in a developmental domain from

the assessment of another related variable. For instance

observation of a low most times response to a new activ-

ity (feeding) in this study could be the product of a nor-

mal positive psychological influence such as attachment

on development.

SMAT Score, the limitations notwithstanding, has

shown relevance and standard psychometric properties

in a population based sample of under-fives. Its incorpo-

ration into health care delivery through affiliation with

maternal and newborn health initiatives, school health

programs and community based health initiatives would

broaden the scope of health services coverage. The train-

ing of all health workers and health allied workers, such

as school health teachers, on the SMAT Score and its

application would help develop service delivery capacity

in the health sector. Also establishment of a SMAT

Score data bank, in the health monitoring units at all

levels of health care delivery, to document and commu-

nicate the outcomes of periodic evaluation of children

would facilitate dissemination of health information

within health systems. Consequently SMAT Score has

the potential of strengthening health care systems and as

a result would improve child health outcomes in devel-

oping countries. However, further insight into the effec-

tiveness of this tool would be served by more studies in

The characteristics of an effective growth and develop-

ment screening tool, in developing countries, were aptly

9

described by Ertem and colleagues. They highlighted

that such a tool must be based on and supported by stan-

dard theories of child development, be reliable and

valid, have capacity for supporting and managing devel-

opmental frame works, should be easily applicable and

9

at a minimal cost. The SMAT Score is based on stan-

dard theories and universal standards. This reduces the

need to standardize and validate across countries. More-

over the tool adds to contemporary growth assessment

by appraising the presence or otherwise of physical

1

3

larger and more diverse under- five populations.

Acknowledgement

Authors’ contribution

I wish to thank the following for their participation in

data collection: Dr Patricia Eseigbe of the Department of

Family Medicine, Ahmadu Bello University Teaching

Hospital, Shika-Zaria; the CHEWs, Eunice Ambi and

Esther Daniel; Dr Bala Usman of the department of

African Languages, Kaduna State University; Bilikisu

Iliya of the Special Education and Needs Centre

The study was conceived and designed by the author.

The author also supervised data collection, analyzed and

interpreted the data, and wrote the final draft of the

manuscript.

Conflict of interests: None

Funding: None

Kaduna; Dr Sam Adama, and the members of staff of

the department of Paediatrics 44NARHK; the District

Head of Katari North Community, Danmadami Adara,

and the entire members of the Katari North Community.

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