Journal of Tropical Pediatrics, 2016, 62, 83–85 doi: 10.1093/tropej/fmw018 Editorial
EDITORIAL
Improving Neurodevelopmental Care for Young Children in Primary Care Services Globally, the ‘burden’ of speech and language difficulties, learning disabilities, emotional difficulties and behavioural disorders is between 10% and 20% in children 90% of the care for families globally during the first 5 years of life [12]. These health professionals are not seen as traditional providers of early neurodevelopmental care and many staff lack confidence and skills in managing young children. Few primary care providers also receive appropriate education, training and tools for implementation of basic neurodevelopmental care for young children. A child health assessment may only result in recommendation for review or referral to a specialist service that visits infrequently and has a long waiting list. A primary care provider can play an active role in improving child neurodevelopment, as opposed to simply screening and referring to other services. Child health surveillance and screening (often called child health checks) is a core component of primary care in many high-income countries. It includes assessment of weight, oral health, hearing, vision and developmental milestones [13]. However, this type of child health surveillance has limited ability to address ‘high burden’ speech, language and behavioural issues in young children [2]. Many skills lie on a continuum of ability rather than reflecting a specific deficit or defect, and it can be difficult to define what does or does not constitute a problem while using current tools [2, 13]. There is emerging evidence that anticipatory guidance and brief interventions implemented by primary
C The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected] V
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Editorial
care providers can improve social and emotional wellbeing and long-term neurodevelopmental outcomes in socially disadvantaged children [9, 14, 15]. ‘Anticipatory guidance’ includes practical information about ‘what to expect’ in behavioural and neurodevelopmental milestones in the immediate and longer term. Anticipatory guidance aims to equip caregivers with knowledge and skills to provide positive experiences and environments for their child [16, 17]. ‘Brief interventions’ have been defined as time-limited interventions implemented by primary care providers that focus on changing caregiver behaviour. They are usually motivational in nature and use counselling skills to change behaviour [3, 18, 19]. Many countries and jurisdictions include anticipatory guidance in their child health surveillance schedules, but this can be implemented poorly if primary care providers have not been specially trained [8]. Models that include both anticipatory guidance and brief intervention training for ‘mainstream’ primary care providers are emerging [9, 14, 15]. In the UK, many staff who work with preschool children have neurodevelopmental training [2, 20]. Preschool services staff observe children in education centres over days or weeks, rather than just in a single short encounter as in traditional surveillance procedures. Early years staff advise parents, discuss worries, developmental needs and language, speech and behavioural problems. A family services plan is agreed jointly by the family and health professional, and completed by the child’s first birthday. A more targeted approach follows with fewer routine health professional contacts, which releases staff to offer intensive educational and social support for those who need it [2, 20]. This has been called progressive universalism ‘support for all but more support for those who need it most’ [21–23]. ‘Care for Development’ is a training program developed by the World Health Organization (WHO) and the United Nations Children’s Fund to support health professionals in using anticipatory guidance, brief interventions and counselling parents in play and communication techniques to stimulate their child’s development [14]. The package consists of simple recommendations health workers can make to families, training materials for health workers and advocacy materials. Effectiveness studies have
identified substantial effects on child development in low- to middle-income countries including Pakistan, China and Bangladesh [9, 14, 19, 24]. In Australia, a number of jurisdictions have moved towards progressive universalism [25]. Brief interventions based on the WHO care for development models have also been developed. A primary care provider training program includes guidance on how to teach families about age-appropriate play and communication activities. It includes demonstration, teachable moments, observation, checking understanding and counselling families in early child development. Implementation guides are being developed and tested. They include ‘scripts’ for ‘one on one’ sessions between a family and primary care provider that can be conducted over 15–30 min at the time of child health check. Specialist services such as social workers, psychologists and child development service staff provide ‘train the trainer’ sessions and ongoing ‘on the job’ support [26]. Recognition of the importance of continuous quality improvement (CQI) initiatives for child neurodevelopment is also increasing [27–29]. Recent CQI systematic reviews concluded that CQI has enhanced efficacy if it includes on the job support and clinical governance. It can be delivered through a combination of strategies including local priority setting, development of targeted tools, on the job education and training, targeted electronic primary care systems, review and reflection, feedback and problem solving [28]. Given the substantial potential gains from investment in early childhood neurodevelopmental programs globally, there is an urgent need for robust health service evaluation methodologies of these and other innovative approaches. More cluster randomized and stepped wedge trials are needed. Studies such as inference modelling and instrumental variable methodology should also be embedded within routine programs in health services that manage infants at high risk of neurodevelopmental delay. All studies should include both short- and long-term health, social and neurodevelopmental outcomes. Karen Edmond School of Paediatrics and Child Health, University of Western Australia, [email protected]
Editorial
REFERENCES 1. Walker SP, Wachs TD, Grantham-McGregor S, et al Inequality in early childhood: risk and protective factors for early child development. Lancet 2011;378:1325–38. 2. Blair M, Hall D. From health surveillance to health promotion: the changing focus in preventive children’s services. Arch Dis Child 2006;91:730–5. 3. Engle PL, Fernald LC, Alderman H, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet 2011;378:1339–53. 4. Brinkman SA, Gialamas A, Rahman A, et al. Jurisdictional, socioeconomic and gender inequalities in child health and development: analysis of a national census of 5-year-olds in Australia. BMJ Open 2012;2:1–14. 5. Lake A. Early childhood development-global action is overdue. Lancet 2011;378:1277–8. 6. Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. J Am Med Assoc 2009;301:2252–9. 7. Engle PL, Black MM, Behrman JR, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet 2007;369:229–42. 8. Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet 2007;369:60–70. 9. Yousafzai AK, Rasheed MA, Rizvi A, et al. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014;384:1282–93. 10. Maulik PK, Darmstadt GL. Community-based interventions to optimize early childhood development in low resource settings. J Perinatol 2009;29:531–42. 11. Daelmans B, Black MM, Lombardi J, et al. Effective interventions and strategies for improving early child development. BMJ 2015;351:h4029. 12. Bryce J, Arnold F, Blanc A., et al. Measuring coverage in MNCH: new findings, new strategies, and recommendations for action. PLoS Med 2013;10:e1001423. 13. Oberklaid F, Baird G, Blair M, et al. Children’s health and development: approaches to early identification and intervention. Arch Dis Child 2013;98:1008–11. 14. Unicef. Care for Child Development Package. November 2015. (22 February 2016, date last accessed) www.unicef. org/earlychildhood/index_68195.html. 15. Regalado M, Halfon N. Primary care services promoting optimal child development from birth to age 3 years. Arch Pediatr Adolesc Med 2001;155:1311–22.
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16. Bryanton J, Beck CT. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev 2010;1:121. 17. Barkin SL, Scheindlin B, Brown C, et al. Anticipatory guidance topics: are more better? Ambul Pediatr 2005;5:372–6. 18. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev 2011;CD005191. 19. Ertem IO, Atay G, Bingoler BE, et al. Promoting child development at sick-child visits: a controlled trial. Pediatrics 2006;118:e124–31. 20. Shribman S, Billingham K. Healthy Child Programme: Pregnancy and the first five years. In: Department of Health (ed.). Update of Standard One (incorporating Standard Two) of the National Service Framework for Children, Young People and Maternity Services (2004) edn. London, 2009. 21. Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? The. Lancet 2011;377:2160–1. 22. Marmot M, Allen J, Goldblatt P, et al. Fair society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010. London: The Marmot Review, 2010. 23. Australian Health Ministers’ Advisory Council. National Framework for Universal Child and Family Health Services: Vision, Objectives and Principles for Universal Child and Family Health Services for all Australian Children Aged Zero to Eight Years. Australian Government Department of Health and Ageing, 2011. 24. Jin X, Sun Y, Jiang F, et al. “Care for Development” intervention in rural China: a prospective follow-up study. J Dev Behav Pediatr 2007;28:213–8. 25. Oberklaid F. Prevention and early detection in young children: challenges for policy and practice. Med J Aust 2014;201:369–70. 26. Edmond KM, McAuley K. Quality of social and emotional wellbeing services for young Indigenous children attending primary care centres; a cross sectional analysis. Per Commun 2016. 27. Gardner KL, Dowden M, Togni S, Bailie R. Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multisite case study of the Audit and Best Practice for Chronic Disease project. Implement Sci 2010;5:21. 28. Phillips C, Pearce C, Hall S, et al. Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence. Med J Aust 2010;193:602–7. 29. Bailie RS, Si D, O’Donoghue L, Dowden M. Indigenous health: effective and sustainable health services through continuous quality improvement. Med J Aus 2007;186: 525–7.
EDITORIAL
Improving Neurodevelopmental Care for Young Children in Primary Care Services Globally, the ‘burden’ of speech and language difficulties, learning disabilities, emotional difficulties and behavioural disorders is between 10% and 20% in children 90% of the care for families globally during the first 5 years of life [12]. These health professionals are not seen as traditional providers of early neurodevelopmental care and many staff lack confidence and skills in managing young children. Few primary care providers also receive appropriate education, training and tools for implementation of basic neurodevelopmental care for young children. A child health assessment may only result in recommendation for review or referral to a specialist service that visits infrequently and has a long waiting list. A primary care provider can play an active role in improving child neurodevelopment, as opposed to simply screening and referring to other services. Child health surveillance and screening (often called child health checks) is a core component of primary care in many high-income countries. It includes assessment of weight, oral health, hearing, vision and developmental milestones [13]. However, this type of child health surveillance has limited ability to address ‘high burden’ speech, language and behavioural issues in young children [2]. Many skills lie on a continuum of ability rather than reflecting a specific deficit or defect, and it can be difficult to define what does or does not constitute a problem while using current tools [2, 13]. There is emerging evidence that anticipatory guidance and brief interventions implemented by primary
C The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected] V
83
84
Editorial
care providers can improve social and emotional wellbeing and long-term neurodevelopmental outcomes in socially disadvantaged children [9, 14, 15]. ‘Anticipatory guidance’ includes practical information about ‘what to expect’ in behavioural and neurodevelopmental milestones in the immediate and longer term. Anticipatory guidance aims to equip caregivers with knowledge and skills to provide positive experiences and environments for their child [16, 17]. ‘Brief interventions’ have been defined as time-limited interventions implemented by primary care providers that focus on changing caregiver behaviour. They are usually motivational in nature and use counselling skills to change behaviour [3, 18, 19]. Many countries and jurisdictions include anticipatory guidance in their child health surveillance schedules, but this can be implemented poorly if primary care providers have not been specially trained [8]. Models that include both anticipatory guidance and brief intervention training for ‘mainstream’ primary care providers are emerging [9, 14, 15]. In the UK, many staff who work with preschool children have neurodevelopmental training [2, 20]. Preschool services staff observe children in education centres over days or weeks, rather than just in a single short encounter as in traditional surveillance procedures. Early years staff advise parents, discuss worries, developmental needs and language, speech and behavioural problems. A family services plan is agreed jointly by the family and health professional, and completed by the child’s first birthday. A more targeted approach follows with fewer routine health professional contacts, which releases staff to offer intensive educational and social support for those who need it [2, 20]. This has been called progressive universalism ‘support for all but more support for those who need it most’ [21–23]. ‘Care for Development’ is a training program developed by the World Health Organization (WHO) and the United Nations Children’s Fund to support health professionals in using anticipatory guidance, brief interventions and counselling parents in play and communication techniques to stimulate their child’s development [14]. The package consists of simple recommendations health workers can make to families, training materials for health workers and advocacy materials. Effectiveness studies have
identified substantial effects on child development in low- to middle-income countries including Pakistan, China and Bangladesh [9, 14, 19, 24]. In Australia, a number of jurisdictions have moved towards progressive universalism [25]. Brief interventions based on the WHO care for development models have also been developed. A primary care provider training program includes guidance on how to teach families about age-appropriate play and communication activities. It includes demonstration, teachable moments, observation, checking understanding and counselling families in early child development. Implementation guides are being developed and tested. They include ‘scripts’ for ‘one on one’ sessions between a family and primary care provider that can be conducted over 15–30 min at the time of child health check. Specialist services such as social workers, psychologists and child development service staff provide ‘train the trainer’ sessions and ongoing ‘on the job’ support [26]. Recognition of the importance of continuous quality improvement (CQI) initiatives for child neurodevelopment is also increasing [27–29]. Recent CQI systematic reviews concluded that CQI has enhanced efficacy if it includes on the job support and clinical governance. It can be delivered through a combination of strategies including local priority setting, development of targeted tools, on the job education and training, targeted electronic primary care systems, review and reflection, feedback and problem solving [28]. Given the substantial potential gains from investment in early childhood neurodevelopmental programs globally, there is an urgent need for robust health service evaluation methodologies of these and other innovative approaches. More cluster randomized and stepped wedge trials are needed. Studies such as inference modelling and instrumental variable methodology should also be embedded within routine programs in health services that manage infants at high risk of neurodevelopmental delay. All studies should include both short- and long-term health, social and neurodevelopmental outcomes. Karen Edmond School of Paediatrics and Child Health, University of Western Australia, [email protected]
Editorial
REFERENCES 1. Walker SP, Wachs TD, Grantham-McGregor S, et al Inequality in early childhood: risk and protective factors for early child development. Lancet 2011;378:1325–38. 2. Blair M, Hall D. From health surveillance to health promotion: the changing focus in preventive children’s services. Arch Dis Child 2006;91:730–5. 3. Engle PL, Fernald LC, Alderman H, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet 2011;378:1339–53. 4. Brinkman SA, Gialamas A, Rahman A, et al. Jurisdictional, socioeconomic and gender inequalities in child health and development: analysis of a national census of 5-year-olds in Australia. BMJ Open 2012;2:1–14. 5. Lake A. Early childhood development-global action is overdue. Lancet 2011;378:1277–8. 6. Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. J Am Med Assoc 2009;301:2252–9. 7. Engle PL, Black MM, Behrman JR, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet 2007;369:229–42. 8. Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet 2007;369:60–70. 9. Yousafzai AK, Rasheed MA, Rizvi A, et al. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet 2014;384:1282–93. 10. Maulik PK, Darmstadt GL. Community-based interventions to optimize early childhood development in low resource settings. J Perinatol 2009;29:531–42. 11. Daelmans B, Black MM, Lombardi J, et al. Effective interventions and strategies for improving early child development. BMJ 2015;351:h4029. 12. Bryce J, Arnold F, Blanc A., et al. Measuring coverage in MNCH: new findings, new strategies, and recommendations for action. PLoS Med 2013;10:e1001423. 13. Oberklaid F, Baird G, Blair M, et al. Children’s health and development: approaches to early identification and intervention. Arch Dis Child 2013;98:1008–11. 14. Unicef. Care for Child Development Package. November 2015. (22 February 2016, date last accessed) www.unicef. org/earlychildhood/index_68195.html. 15. Regalado M, Halfon N. Primary care services promoting optimal child development from birth to age 3 years. Arch Pediatr Adolesc Med 2001;155:1311–22.
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16. Bryanton J, Beck CT. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev 2010;1:121. 17. Barkin SL, Scheindlin B, Brown C, et al. Anticipatory guidance topics: are more better? Ambul Pediatr 2005;5:372–6. 18. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev 2011;CD005191. 19. Ertem IO, Atay G, Bingoler BE, et al. Promoting child development at sick-child visits: a controlled trial. Pediatrics 2006;118:e124–31. 20. Shribman S, Billingham K. Healthy Child Programme: Pregnancy and the first five years. In: Department of Health (ed.). Update of Standard One (incorporating Standard Two) of the National Service Framework for Children, Young People and Maternity Services (2004) edn. London, 2009. 21. Gwatkin DR, Ergo A. Universal health coverage: friend or foe of health equity? The. Lancet 2011;377:2160–1. 22. Marmot M, Allen J, Goldblatt P, et al. Fair society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010. London: The Marmot Review, 2010. 23. Australian Health Ministers’ Advisory Council. National Framework for Universal Child and Family Health Services: Vision, Objectives and Principles for Universal Child and Family Health Services for all Australian Children Aged Zero to Eight Years. Australian Government Department of Health and Ageing, 2011. 24. Jin X, Sun Y, Jiang F, et al. “Care for Development” intervention in rural China: a prospective follow-up study. J Dev Behav Pediatr 2007;28:213–8. 25. Oberklaid F. Prevention and early detection in young children: challenges for policy and practice. Med J Aust 2014;201:369–70. 26. Edmond KM, McAuley K. Quality of social and emotional wellbeing services for young Indigenous children attending primary care centres; a cross sectional analysis. Per Commun 2016. 27. Gardner KL, Dowden M, Togni S, Bailie R. Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multisite case study of the Audit and Best Practice for Chronic Disease project. Implement Sci 2010;5:21. 28. Phillips C, Pearce C, Hall S, et al. Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence. Med J Aust 2010;193:602–7. 29. Bailie RS, Si D, O’Donoghue L, Dowden M. Indigenous health: effective and sustainable health services through continuous quality improvement. Med J Aus 2007;186: 525–7.
