Jill Houb é, MD, MPhil, FAAP, FRCP(C)

1. Healthy BeginningsInternational Evidence-Based Strategies toImprove Developmental Health Services for Children Jill Houbé, MD, MPhil, FAAP, FRCP(C) Assistant Professor, Division of Developmental Paediatrics, UBC Department of Paediatrics Faculty Researcher, Centre for Healthcare Innovation and Improvement (CHII), BC Research Institute for Children’s and Women’s Health (BCRICWH)

2. Healthy Beginnings • Rationale • Definitions • Methodology • Results • Conclusions • BC context • Applications to policy and public health legislation • Implications for future research

3. Why Do We Care? • Children are appealing • Children have rights • Children are vulnerable • Children cost money • Child care • Education • Family supports • Health care • Children benefit society

4. How Do Children Benefit Society? • Children improve our quality of life • Children become adults • Wage earners = tax payers • Citizens • Health care users

5. Income and Social Status Social Support Networks Education and Literacy Employment/Working Conditions Social Environments Physical Environments Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture Personal Health Practices/ Coping Skills

6. Population Health: I Am Canadian! • Lalonde Report (1974) “A New Perspective on the Health of Canadians” • The Ottawa Charter for Health Promotion (1986) and Epp (1986) “Achieving Health for All: A Framework for Health Promotion” • Canadian Institute for Advanced Research (CIAR) (1989) introduction of “population health concept” • Strategies for Population Health : Investing in the Health of Canadians” (1994)

7. (1994)

8. Pathways to Health • Latent effects • Early life affects adult health independent of intervening experience • e.g. Low Birth Weight • Pathway effects • Early life environment sets individuals on life trajectories • e.g. Early Intervention • Cumulative effects • Dose-response relationship of experiences • e.g. Socioeconomic conditions Hertzman, 2001

9. Biological risks Metabolic and genetic Low birth weight and prematurity Physical environment Sleep safety Car seat Accidents Housing Social environment Socioeconomic status Neighbourhoods Schools Public policy Family environment Parenting Child care Maternal mental health What Affects Healthy Child Development?

10. Healthy Child Development: Where are we at? • 12-16% of children under the age of 17 years have a developmental or behavioral disorder (Boyle 1994; Hakim 2001) • 10-20% incidence of maternal depression in women with children age 4 months to 5 years (Garrison 1986) • 48% of single mothers with depressive symptoms (Invest in Kids 1999) • Canadian national survey of parents (Invest in Kids 1999) • 25% parents are not confident about their knowledge of social, emotional and intellectual development • 61% of parents count on their child’s doctor for information and support

11. Developmental Disabilities:Incidences

12. Healthy Child Development:How are physicians doing? • Motor delays are referred sooner than global or speech delays • Older children referred more often than younger • Severe delays referred more often • Referrals occur later when parents are less educated • 15-20% of US paediatricians use screening tools despite evidence of their benefit in early identification of development disorders

13. Healthy Beginnings • Rationale • Definitions • Methodology • Results • Conclusions • BC context • Applications to policy and public health legislation • Implications for future research

14. What are Developmental Health Services? • Services that target parenting, mental health and child development • Anticipatory guidance • Appropriate assessments • Identification of problems • Appropriate interventions and referral • Settings • Primary care clinics • Community health centres • Providers • Nurses • Primary care physicians • “Developmental specialists”

15. Why Does Early Identification Matter? • Access to early intervention • Lower rates of morbidities • Less severe morbidities • Prevention of secondary disabilities • Maladaptive behavior • School failure • Low self-esteem • Family dysfunction Guralnick 1987

16. What are good “Strategies”? 1. Interventions that address an important problem 2. Associated risks for the problem have been identified 3. There is evidence of treatments that improve outcomes 4. There is evidence of efficacy vs. effectiveness Efficacy: works in a targeted sample Effective: works when generalized 5. There is evidence of cultural relevance and availability 6. Requirements for dissemination are known

17. What is “Evidence-Based”: Public Health Reviews • Develop a conceptual framework • Organize and group select interventions • Choose outcomes • Systematically search for and retrieve evidence • Assess the quality and summarize the strength of the body of evidence of effectiveness • Summarize information about other evidence • Applicability • Economic • Other effects • Barriers • Identify and summarize research gaps Anderson 2003; The Community Guide 2000

18. Healthy Beginnings • Definitions • Developmental health services • Evidence-based strategies • Methodology • Analytic method • Selection of studies • Results • Conclusions • BC context • Applications to policy and public health legislation • Implications for future research

19. Analytic Method • Databases • Medline, PsychInfo, ERIC • Article review • Websites from professional and advocacy organizations • Expert opinion • Abstraction criteria • Primary care setting • Target families with children • Target primary care provider behaviour • Evaluation studies completed • Changes in physician practices • Changes in rates of referrals from primary care physicians • Changes in child or family outcomes • Child behaviour • Parenting behaviour

20. Healthy Beginnings • Background • Methodology • Results • Conclusions • BC context • Applications to policy and public health legislation • Implications for future research

21. Programmes Identified ChildServ Assuring Better Child Health and Development (ABCD)

22. ABCDAssuring Better Child Health and Development • In collaboration with North Carolina Medicaid • Started in 3 clinics serving 9000 low-income children in one county • Now expanded to 17 practices in 3 counties • Integration of Ages and Stages Questionnaire (ASQ) into practice • Parent completed questionnaire at up to 19 intervals between 4 and 60 months • Motor, communication, problem-solving, personal/social skills • Helps involve parents in a conversation about their child’s development • Developmental specialist provided follow-up, referrals, home visits, assist in parent education

23. ABCD • Child outcomes (2002) • Increase in number of children receiving developmental screens by healthcare providers (5% to 63%) • Increased referrals for services from 2.9% to 7% in one year • Parents satisfied with increased time on developmental issues • Providers find ASQ useful and would recommend it to others

24. “Contemporary behavioural family intervention (BFI)” • Goals: • To promote “positive, caring relationships between parents and their children • To help parents to develop effective management strategies for common childhood developmental and behavioural issues • Increase parents’ sense of competence about their parenting abilities • Improve couples communication about parenting • Reduce parenting stress • Tiered continuum of increasing intensity • Different parents will need different levels of support • 5 levels of intervention • Well organized implementation and training

25. Level 1 Universal parent information strategy • Level 2 • Brief sessions with primary health care provider • Early anticipatory guidance • Parents with children with mild behaviour difficulties • Level 3 • Up to 80 minutes with primary health care provider • Parents with children with mild to moderate behaviour difficulties • Active skills training for parents • Level 4 • Intensive 10 session individual or 8 session group parent training programs for children with more severe behavioural problems • Level 5 • 5-11 sessions BFI program for families with other sources of family distress as well as parenting difficulties

26. Extensive evaluations of parent outcomes at Levels 1, 4 and 5 of program • Improved parenting style • Decreased child disruptive behaviour • Improved parent relationships • Applicable across different settings • One evaluation at Levels 2 and 3 General practitioners • 32 GPs trained in two waves 2 months apart • Repeated measures design between intervention and wait-list comparison groups • Outcome measures: consultation skills and practice audit

27. Results • Improved parent consultation skills • More time spent discussing non-health problems • More likely to rehearse strategies with parents • More likely to provide written information and show a video • Less likely to prescribe medication • Improved management plans • Significantly greater satisfaction with their management plans

28. The Healthy Steps For Young Children Program “A Practice-Based Intervention to Enhance Quality of care in the First 3 Years of Life” Minkowvitz CS, Hughart N, Strobino D et al JAMA, December 17, 2003—Vol 290 No23 p3081-3138

29. Intervention • “Healthy Steps Specialists” join practices to focus on developmental, behavioral and psychosocial issues • Nurses • Nurse practitioners • ECE’s • Social workers with training and experience in child development

30. Intervention 7 services provided • “Enhanced well child care” • “Teachable moments” focus on parents’ concerns re: child development and behavior • Promotion of positive parent-child interventions • Concern re: maternal [mental] health • “Reach Out and Read program” literacy promotion • 6 home visits in the first 3 years • Telephone line • Developmental assessments • Written materials on prevention and health promotion • Parent groups • Targeted community service referrals

31. Prospective Sept 1996 to November 1998 Controlled Multi-site in 14 states 6 randomized: 200 to each group 9 “quasi-experimental” sites that refused to be randomized were matched with comparable clinics N=5565: Birth to age 3 years English or Spanish-speaking Enrolled consecutive newborns up to 4 weeks of age Excluded neonates with severe illness preventing routine visit in first month of life Excluded transient families (intention to move <6months)

32. Implementation • 3 annual training sessions • Manuals • Biweekly teleconferences • Monitoring of implementation of protocols by central office

33. Outcome measures • Parenting: • Response to misbehavior: use of severe discipline • Practices to promote child development and safety • Quality of care: • Effectiveness: receipt of services • Patient-centeredness: satisfaction • Timeliness: children receiving standard of care well-child visits • Efficiency: ED and hospitalizations

34. Analysis • No reassignment of families • Randomized and QE sites first analyzed separately, then combined • X2 for bivariate analyses • t stats for continuous variables • Telephone interviews at 2-4 mos and 30-33 mos • Chart extractions

35. Response Rates • 67.2% for telephone interview at 30-33 months in study • More highly educated • More non-Hispanics • Higher income • Non-Medicaid • Mainly differences at QE sites • No selective attrition

36. Regression Model • Model included dummy variables for sites • Accounted for repeated-measures data • Baseline variables to account for missing data • Control variables: • Site • Age at interview • Maternal demographics: age, race, education, employment • Paternal employment • Family demographics • Infant characteristics

37. Results • Effectiveness • Higher in intervention groups in both types of sites • Larger effect for anticipatory guidance and assistance • Patient-centeredness • Less dissatisfaction: small effect • Timeliness • Intervention groups more timely preventive care: small effect • Efficiency • Fewer injury-related ED visits: significant only in QE sites

38. Results • Parenting • Fewer face slap/spank with object: significant overall and QE sites • Child behavior Checklist • Intervention mothers report more aggressive behavior and sleep problems in their children • Promotion of safety • More discussion of mother’s mental health

39. ChildServ • Training of primary health providers in effective developmental surveillance • Inventory of community-based programs supporting families and children’s development • Case coordination system to link prenatal, postpartum, and early childhood services and support • Data collection and analyses of developmental status Dworkin 2001

40. ChildServ • 155 children referred during first year of operation; 305 referrals over 24 months • 80% preschool age or younger • Majority of referrals (63%) for single need • parenting assistance/support • developmental assessment • speech/language assessment/services • 67% of referrals to services at no cost to either family or health plan

41. ChildServ • Child Outcomes • 41% of referred children receiving services at follow-up • 15% chose not to pursue recommended services • 30% not available for follow-up despite aggressive outreach • 84% of child health providers familiar with ChildServ • 70% made at least 1 referral • 67% satisfied, 29% somewhat satisfied with program activities • No published evaluations

42. Healthy Beginnings • Definitions • Developmental health services • Evidence-based strategies • Methodology • Analytic model • Selection of studies • Results • Conclusions • BC context • Applications to policy and public health legislation • Implications for future research

43. Conclusions • There is good evidence from very few studies • Interventions can be effective • Improved rates of referrals • Improved provider confidence and behaviour • Improved parent satisfaction • May affect parent health-seeking behaviour • May affect parenting behaviour • Interventions may be applicable across different populations • No economic studies • Some barriers to implementation • Physician time • Ancillary staff • Cost and inadequate reimbursement • Requirement for extra training

44. Conclusions • There is currently no standard of practice in BC for providing developmental health services. • It is unknown the extent to which these services are provided in primary care settings in BC. • There are no legislative mandates in Canada or BC for disabilities identification or treatment. • There is limited professional incentive to invest in professional training and maintenance of competence, or in additional practice supports. • There is no professional accountability for providing this care. • There is potential for improving population health through improvements in healthy child development.

45. Professional Development AAP Guidelines for Health Supervision Rourke Baby Records - Revised Medicaid EPDST

46. Implications: “To Do List” • Identify current organization and delivery of developmental services in BC • Identify why these processes have evolved • Barriers and promoters to service delivery • Identify ways to implement best practices in all BC primary care setting • Identify mechanisms to support implementation • Incentives • Repercussions • Develop population level outcome measures

47. Healthy Beginnings