Predictors of diagnosis in Huntington disease

Douglas R. Langbehn, Jane S. Paulsen, Phillipa Hedges, Elizabeth McCusker, Samantha Pearce, Ronald Trent, David Abwender, Peter Como, Irenita Gardiner, Charlyne Hickey, Elise Kayson, Karl Kieburtz, Frederick Marshall, Nancy Pearson, Ira Shoulson, Carol Zimmerman, Elan Louis, Karen Marder, Carol Moskowitz, Carmen Polanco & 101 others Stuart Taylor, Naomi Zubin, Catherine Brown, Jill Burke-Holder, Mark Guttman, Sandra Russell, Dwight Stewart, Jackie Thomson, Daniel S. Sax, Marie Saint-Hilaire, Jackie Gray, Cindy Hunter, Nanette Mercado, Eric Siemers, Joanne Wojcieszek, Ted M Dawson, Elizabeth Leritz, Adam Rosenblatt, Meeia Sherr, Candace Young, Tetsuo Ashizawa, Jenny Beach, Joseph Jankovic, Jeana Jaglin, Kathleen Shannon, Anders Lundin, Kathleen Francis, Kim Lane, Alexander Auchus, J. Timothy Greenamyre, Steven Hersch, Randi Jones, David Olson, Jang Ho John Cha, Merit Cudkowicz, Walter Koroshetz, Greg Rudolf, Paula Sexton, Anne B. Young, Roger Albin, Kristine Wernette, Donald S. Higgins, Carson Reider, Vicki Hunt, Francis Walker, Robert Hauser, Juan Sanchez-Ramos, Audrey Walker, Martha Nance, Susan Cleary, Gina Rohs, Oksana Suchowersky, Kerry Duncan, Lauren Seeberger, Jody Corey-Bloom, Michael Swenson, Neal Swerdlow, Henry Paulson, Robert Rodnitzky, Lynn Vining, Wayne Martin, Marguerite Wieler, Alicia Facca, Gustavo Rey, William Weiner, Charles Adler, John Caviness, Cindy Lied, Stephanie Newman, Andrew Feigin, Jennifer Mazurkiewicz, Karen Caplan, Janet Cellar, Kenneth Marek, Michael Hayden, Lynn Raymond, Leon S. Dure, Jane Lane, Diane Brown, Stewart Factor, Eric Molho, Madeline Harrison, Carol Manning, Elke Rost-Ruffner, Jonelle Adams, Ruth Cummings, Vicki Wheelock, Richard Dubinsky, Carolyn Gray, Ann Catherine Bachoud-Levi, Hartmut Meierkord, Joseph Friedman, Margaret Lannon, Joan Lawrence, Allen Rubin, Rose Schwarz, Alicia Brocht, Kathy Claude, Joshua Goldstein, Michael McDermott, David Oakes

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: Subtle signs and symptoms of Huntington disease (HD) are often present before impairments reach a point where the neurologic disease is manifest and a diagnosis must be considered. The objective is to examine the prognostic significance of these early clinical signs and symptoms regarding time until unequivocal clinical HD diagnosis. METHODS: We analyzed longitudinal data from 218 at-risk but healthy participants in the Huntington Study Group database who had either normal motor examination results or minimal soft motor signs at first observation. This group was followed periodically in HD clinics for up to 4.5 years. We used survival analysis to examine predictors of time until HD diagnosis. RESULTS: Diagnostic prediction was significantly improved using specific, nonredundant items from the Unified Huntington's Disease Rating Scale. When a movement disorder specialist initially had a global impression of "soft signs" present, cumulative relative risk of diagnosis was 4.68 times greater at 1.5 years of follow-up and 3.58 at 3 years. A neuropsychological test pattern with psychomotor speed 1 SD worse than a semantic knowledge measure increased cumulative risk by 1.99 times at 1.5 years and 1.81 at 3 years. Finally, reports of various subjective HD symptoms increased 3-year relative risk by 2.6 to 3.4. CONCLUSIONS: Findings demonstrate that neuropsychological performance and both the clinician rating and the patient subjective perception of motor difficulties contribute nonredundantly to a prediction of Huntington disease diagnosis. These findings may have implications for prognostic assessment of persons at risk and eventually assist with early interventions.

Original languageEnglish (US)
Pages (from-to)1710-1717
Number of pages8
JournalNeurology
Volume68
Issue number20
DOIs
StatePublished - May 2007

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Huntington Disease
Signs and Symptoms
Neuropsychological Tests
Movement Disorders
Survival Analysis
Nervous System Diseases
Semantics
Healthy Volunteers
Observation
Databases

ASJC Scopus subject areas

  • Neuroscience(all)

Cite this

Langbehn, D. R., Paulsen, J. S., Hedges, P., McCusker, E., Pearce, S., Trent, R., ... Oakes, D. (2007). Predictors of diagnosis in Huntington disease. Neurology, 68(20), 1710-1717. https://doi.org/10.1212/01.wnl.0000261918.90053.96

Predictors of diagnosis in Huntington disease. / Langbehn, Douglas R.; Paulsen, Jane S.; Hedges, Phillipa; McCusker, Elizabeth; Pearce, Samantha; Trent, Ronald; Abwender, David; Como, Peter; Gardiner, Irenita; Hickey, Charlyne; Kayson, Elise; Kieburtz, Karl; Marshall, Frederick; Pearson, Nancy; Shoulson, Ira; Zimmerman, Carol; Louis, Elan; Marder, Karen; Moskowitz, Carol; Polanco, Carmen; Taylor, Stuart; Zubin, Naomi; Brown, Catherine; Burke-Holder, Jill; Guttman, Mark; Russell, Sandra; Stewart, Dwight; Thomson, Jackie; Sax, Daniel S.; Saint-Hilaire, Marie; Gray, Jackie; Hunter, Cindy; Mercado, Nanette; Siemers, Eric; Wojcieszek, Joanne; Dawson, Ted M; Leritz, Elizabeth; Rosenblatt, Adam; Sherr, Meeia; Young, Candace; Ashizawa, Tetsuo; Beach, Jenny; Jankovic, Joseph; Jaglin, Jeana; Shannon, Kathleen; Lundin, Anders; Francis, Kathleen; Lane, Kim; Auchus, Alexander; Greenamyre, J. Timothy; Hersch, Steven; Jones, Randi; Olson, David; Cha, Jang Ho John; Cudkowicz, Merit; Koroshetz, Walter; Rudolf, Greg; Sexton, Paula; Young, Anne B.; Albin, Roger; Wernette, Kristine; Higgins, Donald S.; Reider, Carson; Hunt, Vicki; Walker, Francis; Hauser, Robert; Sanchez-Ramos, Juan; Walker, Audrey; Nance, Martha; Cleary, Susan; Rohs, Gina; Suchowersky, Oksana; Duncan, Kerry; Seeberger, Lauren; Corey-Bloom, Jody; Swenson, Michael; Swerdlow, Neal; Paulson, Henry; Rodnitzky, Robert; Vining, Lynn; Martin, Wayne; Wieler, Marguerite; Facca, Alicia; Rey, Gustavo; Weiner, William; Adler, Charles; Caviness, John; Lied, Cindy; Newman, Stephanie; Feigin, Andrew; Mazurkiewicz, Jennifer; Caplan, Karen; Cellar, Janet; Marek, Kenneth; Hayden, Michael; Raymond, Lynn; Dure, Leon S.; Lane, Jane; Brown, Diane; Factor, Stewart; Molho, Eric; Harrison, Madeline; Manning, Carol; Rost-Ruffner, Elke; Adams, Jonelle; Cummings, Ruth; Wheelock, Vicki; Dubinsky, Richard; Gray, Carolyn; Catherine Bachoud-Levi, Ann; Meierkord, Hartmut; Friedman, Joseph; Lannon, Margaret; Lawrence, Joan; Rubin, Allen; Schwarz, Rose; Brocht, Alicia; Claude, Kathy; Goldstein, Joshua; McDermott, Michael; Oakes, David.

In: Neurology, Vol. 68, No. 20, 05.2007, p. 1710-1717.

Research output: Contribution to journalArticle

Langbehn, DR, Paulsen, JS, Hedges, P, McCusker, E, Pearce, S, Trent, R, Abwender, D, Como, P, Gardiner, I, Hickey, C, Kayson, E, Kieburtz, K, Marshall, F, Pearson, N, Shoulson, I, Zimmerman, C, Louis, E, Marder, K, Moskowitz, C, Polanco, C, Taylor, S, Zubin, N, Brown, C, Burke-Holder, J, Guttman, M, Russell, S, Stewart, D, Thomson, J, Sax, DS, Saint-Hilaire, M, Gray, J, Hunter, C, Mercado, N, Siemers, E, Wojcieszek, J, Dawson, TM, Leritz, E, Rosenblatt, A, Sherr, M, Young, C, Ashizawa, T, Beach, J, Jankovic, J, Jaglin, J, Shannon, K, Lundin, A, Francis, K, Lane, K, Auchus, A, Greenamyre, JT, Hersch, S, Jones, R, Olson, D, Cha, JHJ, Cudkowicz, M, Koroshetz, W, Rudolf, G, Sexton, P, Young, AB, Albin, R, Wernette, K, Higgins, DS, Reider, C, Hunt, V, Walker, F, Hauser, R, Sanchez-Ramos, J, Walker, A, Nance, M, Cleary, S, Rohs, G, Suchowersky, O, Duncan, K, Seeberger, L, Corey-Bloom, J, Swenson, M, Swerdlow, N, Paulson, H, Rodnitzky, R, Vining, L, Martin, W, Wieler, M, Facca, A, Rey, G, Weiner, W, Adler, C, Caviness, J, Lied, C, Newman, S, Feigin, A, Mazurkiewicz, J, Caplan, K, Cellar, J, Marek, K, Hayden, M, Raymond, L, Dure, LS, Lane, J, Brown, D, Factor, S, Molho, E, Harrison, M, Manning, C, Rost-Ruffner, E, Adams, J, Cummings, R, Wheelock, V, Dubinsky, R, Gray, C, Catherine Bachoud-Levi, A, Meierkord, H, Friedman, J, Lannon, M, Lawrence, J, Rubin, A, Schwarz, R, Brocht, A, Claude, K, Goldstein, J, McDermott, M & Oakes, D 2007, 'Predictors of diagnosis in Huntington disease', Neurology, vol. 68, no. 20, pp. 1710-1717. https://doi.org/10.1212/01.wnl.0000261918.90053.96
Langbehn DR, Paulsen JS, Hedges P, McCusker E, Pearce S, Trent R et al. Predictors of diagnosis in Huntington disease. Neurology. 2007 May;68(20):1710-1717. https://doi.org/10.1212/01.wnl.0000261918.90053.96
Langbehn, Douglas R. ; Paulsen, Jane S. ; Hedges, Phillipa ; McCusker, Elizabeth ; Pearce, Samantha ; Trent, Ronald ; Abwender, David ; Como, Peter ; Gardiner, Irenita ; Hickey, Charlyne ; Kayson, Elise ; Kieburtz, Karl ; Marshall, Frederick ; Pearson, Nancy ; Shoulson, Ira ; Zimmerman, Carol ; Louis, Elan ; Marder, Karen ; Moskowitz, Carol ; Polanco, Carmen ; Taylor, Stuart ; Zubin, Naomi ; Brown, Catherine ; Burke-Holder, Jill ; Guttman, Mark ; Russell, Sandra ; Stewart, Dwight ; Thomson, Jackie ; Sax, Daniel S. ; Saint-Hilaire, Marie ; Gray, Jackie ; Hunter, Cindy ; Mercado, Nanette ; Siemers, Eric ; Wojcieszek, Joanne ; Dawson, Ted M ; Leritz, Elizabeth ; Rosenblatt, Adam ; Sherr, Meeia ; Young, Candace ; Ashizawa, Tetsuo ; Beach, Jenny ; Jankovic, Joseph ; Jaglin, Jeana ; Shannon, Kathleen ; Lundin, Anders ; Francis, Kathleen ; Lane, Kim ; Auchus, Alexander ; Greenamyre, J. Timothy ; Hersch, Steven ; Jones, Randi ; Olson, David ; Cha, Jang Ho John ; Cudkowicz, Merit ; Koroshetz, Walter ; Rudolf, Greg ; Sexton, Paula ; Young, Anne B. ; Albin, Roger ; Wernette, Kristine ; Higgins, Donald S. ; Reider, Carson ; Hunt, Vicki ; Walker, Francis ; Hauser, Robert ; Sanchez-Ramos, Juan ; Walker, Audrey ; Nance, Martha ; Cleary, Susan ; Rohs, Gina ; Suchowersky, Oksana ; Duncan, Kerry ; Seeberger, Lauren ; Corey-Bloom, Jody ; Swenson, Michael ; Swerdlow, Neal ; Paulson, Henry ; Rodnitzky, Robert ; Vining, Lynn ; Martin, Wayne ; Wieler, Marguerite ; Facca, Alicia ; Rey, Gustavo ; Weiner, William ; Adler, Charles ; Caviness, John ; Lied, Cindy ; Newman, Stephanie ; Feigin, Andrew ; Mazurkiewicz, Jennifer ; Caplan, Karen ; Cellar, Janet ; Marek, Kenneth ; Hayden, Michael ; Raymond, Lynn ; Dure, Leon S. ; Lane, Jane ; Brown, Diane ; Factor, Stewart ; Molho, Eric ; Harrison, Madeline ; Manning, Carol ; Rost-Ruffner, Elke ; Adams, Jonelle ; Cummings, Ruth ; Wheelock, Vicki ; Dubinsky, Richard ; Gray, Carolyn ; Catherine Bachoud-Levi, Ann ; Meierkord, Hartmut ; Friedman, Joseph ; Lannon, Margaret ; Lawrence, Joan ; Rubin, Allen ; Schwarz, Rose ; Brocht, Alicia ; Claude, Kathy ; Goldstein, Joshua ; McDermott, Michael ; Oakes, David. / Predictors of diagnosis in Huntington disease. In: Neurology. 2007 ; Vol. 68, No. 20. pp. 1710-1717.
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abstract = "OBJECTIVE: Subtle signs and symptoms of Huntington disease (HD) are often present before impairments reach a point where the neurologic disease is manifest and a diagnosis must be considered. The objective is to examine the prognostic significance of these early clinical signs and symptoms regarding time until unequivocal clinical HD diagnosis. METHODS: We analyzed longitudinal data from 218 at-risk but healthy participants in the Huntington Study Group database who had either normal motor examination results or minimal soft motor signs at first observation. This group was followed periodically in HD clinics for up to 4.5 years. We used survival analysis to examine predictors of time until HD diagnosis. RESULTS: Diagnostic prediction was significantly improved using specific, nonredundant items from the Unified Huntington's Disease Rating Scale. When a movement disorder specialist initially had a global impression of {"}soft signs{"} present, cumulative relative risk of diagnosis was 4.68 times greater at 1.5 years of follow-up and 3.58 at 3 years. A neuropsychological test pattern with psychomotor speed 1 SD worse than a semantic knowledge measure increased cumulative risk by 1.99 times at 1.5 years and 1.81 at 3 years. Finally, reports of various subjective HD symptoms increased 3-year relative risk by 2.6 to 3.4. CONCLUSIONS: Findings demonstrate that neuropsychological performance and both the clinician rating and the patient subjective perception of motor difficulties contribute nonredundantly to a prediction of Huntington disease diagnosis. These findings may have implications for prognostic assessment of persons at risk and eventually assist with early interventions.",
author = "Langbehn, {Douglas R.} and Paulsen, {Jane S.} and Phillipa Hedges and Elizabeth McCusker and Samantha Pearce and Ronald Trent and David Abwender and Peter Como and Irenita Gardiner and Charlyne Hickey and Elise Kayson and Karl Kieburtz and Frederick Marshall and Nancy Pearson and Ira Shoulson and Carol Zimmerman and Elan Louis and Karen Marder and Carol Moskowitz and Carmen Polanco and Stuart Taylor and Naomi Zubin and Catherine Brown and Jill Burke-Holder and Mark Guttman and Sandra Russell and Dwight Stewart and Jackie Thomson and Sax, {Daniel S.} and Marie Saint-Hilaire and Jackie Gray and Cindy Hunter and Nanette Mercado and Eric Siemers and Joanne Wojcieszek and Dawson, {Ted M} and Elizabeth Leritz and Adam Rosenblatt and Meeia Sherr and Candace Young and Tetsuo Ashizawa and Jenny Beach and Joseph Jankovic and Jeana Jaglin and Kathleen Shannon and Anders Lundin and Kathleen Francis and Kim Lane and Alexander Auchus and Greenamyre, {J. Timothy} and Steven Hersch and Randi Jones and David Olson and Cha, {Jang Ho John} and Merit Cudkowicz and Walter Koroshetz and Greg Rudolf and Paula Sexton and Young, {Anne B.} and Roger Albin and Kristine Wernette and Higgins, {Donald S.} and Carson Reider and Vicki Hunt and Francis Walker and Robert Hauser and Juan Sanchez-Ramos and Audrey Walker and Martha Nance and Susan Cleary and Gina Rohs and Oksana Suchowersky and Kerry Duncan and Lauren Seeberger and Jody Corey-Bloom and Michael Swenson and Neal Swerdlow and Henry Paulson and Robert Rodnitzky and Lynn Vining and Wayne Martin and Marguerite Wieler and Alicia Facca and Gustavo Rey and William Weiner and Charles Adler and John Caviness and Cindy Lied and Stephanie Newman and Andrew Feigin and Jennifer Mazurkiewicz and Karen Caplan and Janet Cellar and Kenneth Marek and Michael Hayden and Lynn Raymond and Dure, {Leon S.} and Jane Lane and Diane Brown and Stewart Factor and Eric Molho and Madeline Harrison and Carol Manning and Elke Rost-Ruffner and Jonelle Adams and Ruth Cummings and Vicki Wheelock and Richard Dubinsky and Carolyn Gray and {Catherine Bachoud-Levi}, Ann and Hartmut Meierkord and Joseph Friedman and Margaret Lannon and Joan Lawrence and Allen Rubin and Rose Schwarz and Alicia Brocht and Kathy Claude and Joshua Goldstein and Michael McDermott and David Oakes",
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T1 - Predictors of diagnosis in Huntington disease

AU - Langbehn, Douglas R.

AU - Paulsen, Jane S.

AU - Hedges, Phillipa

AU - McCusker, Elizabeth

AU - Pearce, Samantha

AU - Trent, Ronald

AU - Abwender, David

AU - Como, Peter

AU - Gardiner, Irenita

AU - Hickey, Charlyne

AU - Kayson, Elise

AU - Kieburtz, Karl

AU - Marshall, Frederick

AU - Pearson, Nancy

AU - Shoulson, Ira

AU - Zimmerman, Carol

AU - Louis, Elan

AU - Marder, Karen

AU - Moskowitz, Carol

AU - Polanco, Carmen

AU - Taylor, Stuart

AU - Zubin, Naomi

AU - Brown, Catherine

AU - Burke-Holder, Jill

AU - Guttman, Mark

AU - Russell, Sandra

AU - Stewart, Dwight

AU - Thomson, Jackie

AU - Sax, Daniel S.

AU - Saint-Hilaire, Marie

AU - Gray, Jackie

AU - Hunter, Cindy

AU - Mercado, Nanette

AU - Siemers, Eric

AU - Wojcieszek, Joanne

AU - Dawson, Ted M

AU - Leritz, Elizabeth

AU - Rosenblatt, Adam

AU - Sherr, Meeia

AU - Young, Candace

AU - Ashizawa, Tetsuo

AU - Beach, Jenny

AU - Jankovic, Joseph

AU - Jaglin, Jeana

AU - Shannon, Kathleen

AU - Lundin, Anders

AU - Francis, Kathleen

AU - Lane, Kim

AU - Auchus, Alexander

AU - Greenamyre, J. Timothy

AU - Hersch, Steven

AU - Jones, Randi

AU - Olson, David

AU - Cha, Jang Ho John

AU - Cudkowicz, Merit

AU - Koroshetz, Walter

AU - Rudolf, Greg

AU - Sexton, Paula

AU - Young, Anne B.

AU - Albin, Roger

AU - Wernette, Kristine

AU - Higgins, Donald S.

AU - Reider, Carson

AU - Hunt, Vicki

AU - Walker, Francis

AU - Hauser, Robert

AU - Sanchez-Ramos, Juan

AU - Walker, Audrey

AU - Nance, Martha

AU - Cleary, Susan

AU - Rohs, Gina

AU - Suchowersky, Oksana

AU - Duncan, Kerry

AU - Seeberger, Lauren

AU - Corey-Bloom, Jody

AU - Swenson, Michael

AU - Swerdlow, Neal

AU - Paulson, Henry

AU - Rodnitzky, Robert

AU - Vining, Lynn

AU - Martin, Wayne

AU - Wieler, Marguerite

AU - Facca, Alicia

AU - Rey, Gustavo

AU - Weiner, William

AU - Adler, Charles

AU - Caviness, John

AU - Lied, Cindy

AU - Newman, Stephanie

AU - Feigin, Andrew

AU - Mazurkiewicz, Jennifer

AU - Caplan, Karen

AU - Cellar, Janet

AU - Marek, Kenneth

AU - Hayden, Michael

AU - Raymond, Lynn

AU - Dure, Leon S.

AU - Lane, Jane

AU - Brown, Diane

AU - Factor, Stewart

AU - Molho, Eric

AU - Harrison, Madeline

AU - Manning, Carol

AU - Rost-Ruffner, Elke

AU - Adams, Jonelle

AU - Cummings, Ruth

AU - Wheelock, Vicki

AU - Dubinsky, Richard

AU - Gray, Carolyn

AU - Catherine Bachoud-Levi, Ann

AU - Meierkord, Hartmut

AU - Friedman, Joseph

AU - Lannon, Margaret

AU - Lawrence, Joan

AU - Rubin, Allen

AU - Schwarz, Rose

AU - Brocht, Alicia

AU - Claude, Kathy

AU - Goldstein, Joshua

AU - McDermott, Michael

AU - Oakes, David

PY - 2007/5

Y1 - 2007/5

N2 - OBJECTIVE: Subtle signs and symptoms of Huntington disease (HD) are often present before impairments reach a point where the neurologic disease is manifest and a diagnosis must be considered. The objective is to examine the prognostic significance of these early clinical signs and symptoms regarding time until unequivocal clinical HD diagnosis. METHODS: We analyzed longitudinal data from 218 at-risk but healthy participants in the Huntington Study Group database who had either normal motor examination results or minimal soft motor signs at first observation. This group was followed periodically in HD clinics for up to 4.5 years. We used survival analysis to examine predictors of time until HD diagnosis. RESULTS: Diagnostic prediction was significantly improved using specific, nonredundant items from the Unified Huntington's Disease Rating Scale. When a movement disorder specialist initially had a global impression of "soft signs" present, cumulative relative risk of diagnosis was 4.68 times greater at 1.5 years of follow-up and 3.58 at 3 years. A neuropsychological test pattern with psychomotor speed 1 SD worse than a semantic knowledge measure increased cumulative risk by 1.99 times at 1.5 years and 1.81 at 3 years. Finally, reports of various subjective HD symptoms increased 3-year relative risk by 2.6 to 3.4. CONCLUSIONS: Findings demonstrate that neuropsychological performance and both the clinician rating and the patient subjective perception of motor difficulties contribute nonredundantly to a prediction of Huntington disease diagnosis. These findings may have implications for prognostic assessment of persons at risk and eventually assist with early interventions.

AB - OBJECTIVE: Subtle signs and symptoms of Huntington disease (HD) are often present before impairments reach a point where the neurologic disease is manifest and a diagnosis must be considered. The objective is to examine the prognostic significance of these early clinical signs and symptoms regarding time until unequivocal clinical HD diagnosis. METHODS: We analyzed longitudinal data from 218 at-risk but healthy participants in the Huntington Study Group database who had either normal motor examination results or minimal soft motor signs at first observation. This group was followed periodically in HD clinics for up to 4.5 years. We used survival analysis to examine predictors of time until HD diagnosis. RESULTS: Diagnostic prediction was significantly improved using specific, nonredundant items from the Unified Huntington's Disease Rating Scale. When a movement disorder specialist initially had a global impression of "soft signs" present, cumulative relative risk of diagnosis was 4.68 times greater at 1.5 years of follow-up and 3.58 at 3 years. A neuropsychological test pattern with psychomotor speed 1 SD worse than a semantic knowledge measure increased cumulative risk by 1.99 times at 1.5 years and 1.81 at 3 years. Finally, reports of various subjective HD symptoms increased 3-year relative risk by 2.6 to 3.4. CONCLUSIONS: Findings demonstrate that neuropsychological performance and both the clinician rating and the patient subjective perception of motor difficulties contribute nonredundantly to a prediction of Huntington disease diagnosis. These findings may have implications for prognostic assessment of persons at risk and eventually assist with early interventions.

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