Healthy Beginnings for Children: Developmental Health Promotion and The Frontline Worker

1
Healthy Beginnings for Children Developmental
Health Promotion and The Frontline Worker

• Jill Houbé, MD, MPhil, FAAP, FRCP(C)
• Division of Developmental Paediatrics
• UBC Department of Paediatrics
• Centre for Healthcare Innovation and Improvement
• British Columbia Research Institute For
  Childrens and Womens Health

2
Healthy Beginnings

• Rationale
• Definitions
• Services
• ECE professionals
• Other providers

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
(1994)
7
What Affects Healthy Child Development?

• 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

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
Effects of Psychosocial Risk Factors on
Intelligence
Percentiles 84th 75th
50th
IQ
25th
16th
Risk Factors Poor health status, gt 3 children,
stressful events, single parent, parental
mental health problems, less responsive
parenting, poverty, minority status, limited
social support
Glascoe, 1997
10
Developmental DisabilitiesIncidences
11
Why Does Early Identification Matter?

• Access to early intervention
• Less-differentiated brain of younger child
  amenable to intervention
• EI results in lower rates of morbidities
• EI results in less severe morbidities
• Prevention of secondary disabilities
• Maladaptive behavior
• School failure
• Low self-esteem
• Family dysfunction
• Legal Mandate
• Canadian Charter of Rights and Freedoms (1985)
• Section 7 Legal rights
• Section 15 Equality Rights
• BC Human Rights Code (1996)
• BC School Act (revised 1989)

12
VALUE OF EARLY INTERVENTION
Improve mother-child relationship
Provide information to parents on management of
problems and development
Enhance cognitive, language and social competence
Provide social support
EI
Provide developmentally enriching setting
Mediate external risk factors
Provide continuous positive redirection and focus
skill building
Improve parenting
Improve families abilities to meet special needs
of their children
Prieto, 2004 PED 96, 95, 97, 2001. PED REV 2000
2001
13
Parents often need advice about behavior
NORMAL DEVELOPMENT minimal psychosocial risk
factors
Parents often need training, and social services.
Children need enrichment tutoring, mentoring,
mental health, etc.
BELOW AVERAGE DEVELOPMENT frequent
psychosocial risk factors
Children need special education, speech therapy,
etc.
DISABLED some psychosocial risk
factors and/or biomedical problem
Glascoe, 1997
14
Components of Healthy Child Development System

• Primary and specialty medical care
• Early childhood education
• Developmental disabilities services
• assessment
• intervention
• Mental health
• Family and social support (home-, center-based)
• Child advocacy/legal services

15
Front Line Professionals How you make a
difference

• Your observations occur in natural settings
• Home
• Daycare
• School
• You see the child in relationship to her family,
  caregivers, and peers
• You have familiarity with social and familial
  factors
• Identification of children at environmental risk
• Your assessment is longitudinal
• You observe how the child learns, as opposed to
  what she knows
• You have professional training about child
  development

16
Healthy Beginnings

• Rationale
• Definitions
• Services
• ECE professionals
• Other providers

17
Domains of Development

• Fine Motor
• Motor
• Gross Motor
• Speech and Language
• Cognitive
• Adaptive/Personal-social

18
Developmental Differences

• Delay, Dissociation, Deviance
• DELAY
• Performance significantly below average (DQ lt70)
  in a given area of skill.
• May occur in a single stream or several streams.
• DEVIANCY\
• Atypical development within a single stream, such
  as developmental milestones occurring out
  of sequence.
• Does not necessarily imply abnormality, but
  should alert one to the possibility that
  problems may exist.
• EXAMPLE An infant who crawls before sitting, or
  an infant with early development of
  hand preference.
• DISSOCIATION
• Substantial difference in the rate of development
  between two streams.
• EXAMPLE Cognitive-motor difference in some
  children with mental retardation
  or cerebral palsy.

19
Developmental Trajectories
Normal
Illness
M I LESTONES
Delay
HIV
TIME
20
High Risk Children

• Established Risk
• Chromosomal abnormalities, e.g. Down Syndrome
• Environmental Risk
• Poverty
• Maternal mental health issues
• Biological Risk
• Prenatal exposure to drugs and alcohol
• Low birth weight and/or prematurity

21
Healthy Beginnings

• Rationale
• Definitions
• Services
• ECE professionals
• Other providers

22
Components of Healthy Child Development System

• Primary and specialty medical care
• Early childhood education professionals
• Developmental disabilities services
• assessment
• intervention
• Mental health
• Family and social support (home-, center-based)
• Child advocacy/legal services

23
Developmental Surveillance

• a flexible, continuous process in which
  knowledgeable professionals perform skilled
  observations of children...
• Components
• eliciting/attending to parents concerns
• obtaining a relevant developmental history
• skillfully observing childrens development
• sharing opinions with other professionals

24
Attending to Parents Concerns

• Strong relationship between parents concerns and
  childs developmental status (Glascoe, Peds In
  Rev 2000. Chis, Peds Rev 2000)
• Parents have high levels of sensitivity for
  problems regarding fine motor, language,
  cognitive and school skills (Glacoe, Peds 95, 97
  Glascoe, Ped 91. Diamond , J Div Early Childhood
  87)
• Parental concerns about gross motor, hearing and
  medical status are highly related to
  developmental problems (Glascoe, Clin Pediatr 91,
  94)

Dworkin, 2001
25
Attending to Parents Concerns

• In 87 of children with ADHD, parents have
  concerns related to impulsiveness, inattention or
  overactivity (Mulhern et al, Am J Dis Child. 93)
• Absence of parental concerns or concerns in other
  areas (self-help or socialization) correlates
  with children without developmental disorders
  (Glascoe FP, Am J Dis Child 89)

26
Developmental Surveillance Pitfalls

• Gross Motor Skills
• Gross motor milestones DO NOT predict
  intelligence!
• 35 of profoundly mentally retarded infants walk
  by 15 months
• 80 of mildly mentally retarded infants have
  normal motor milestones
• REMEMBER a child with delayed motor milestones
  is not necessarily mentally deficient
• e.g. cerebral palsy

27
Developmental Surveillance Pitfalls

• Language
• Development of language doesnt start with
  talking!
• Attention needs to be paid to the childs
  acquisition of
• pre-linguistic milestones
• Social smile
• Gestures
• Pointing
• Appropriate facial expressions
• Absence or delay in speech development cannot be
  attributed to otitis media!

28
Developmental Surveillance Pitfalls

• Appearance
• Attractive children with mental retardation are
  identified later than unusual looking children
• e.g. Autistic children usually look normal

29
Developmental Surveillance Pitfalls

• When does a child have abnormal attention?
• Attention is a developmental concept
• There are increasing expectations of the
  development
• of attention and other executive functions with
  age
• Symptoms of inattentiveness need to be seen in
  the
• context of
• Family
• School
• Mental health
• Developmental and biological factors

30
Developmental Surveillance Pitfalls

• At what age can/should you consider a diagnosis
  of ADHD?
• Preschoolers have a wide range of attentional
  capabilities so assessment at age 3-5 years is
  difficult
• Severe symptoms at an earlier age seen in certain
  situations
• Prenatal cocaine
• Prenatal alcohol exposure

31
Developmental Surveillance Pitfalls

• Are there other things besides ADHD which present
  with abnormal attention? YES!
• Children have a limited range of ways they can
  express themselves
• Behaviours that can look like ADHD
• Disruptive
• Acting out
• Withdrawn

32
Developmental Surveillance Pitfalls

• Possible Causes of Attention Problems
• Sensory Deficit
• Receptive Language Problem
• Other Specific Learning Disabilities
• Coexists in 12-60 of children with attention
  deficit
• Seizures
• Mood Disorders (e.g. depression)
• Coexists in 18 of children with ADHD

33
Developmental Surveillance Pitfalls

• Possible Causes of Attention Problems
• Anxiety Disorders
• Coexists in 25
• Oppositional Defiant Disorder, Conduct Disorder
• Coexists in 35 of children with ADHD
• Parent Child Interaction Problems
• Mental Retardation
• Sexual and/or Physical Abuse
• Neglect

34
Developmental Surveillance Pitfalls

• What Else Should You Be Thinking About?
• Environment
• Neglect
• Deprivation
• Abuse
• Maternal mental health issues

35
ADD vs. Fetal Alcohol Syndrome

• ADD
• Trouble focusing/sustaining focus
• Impulsive
• Insight and problem solving

• FAS
• Poor encoding
• Difficulty shifting focus
• Impulsive
• Poor insight and problem solving

36
Screening Tests?
Detection rates without screening tests in
paediatric practices ? 70 of children with
developmental disabilities not
identified (Palfrey et al. J PEDS.
1994111651-655) ? 80 of children with
mental health problems not
identified (Lavigne et al. Pediatr. 199391649 -
655)
Glascoe, 1997
37
Screening Tests?

• Detection rates with screening tests in
  paediatric practices
• ? 70 to 80 of children with
  developmental disabilities correctly
  identified (Squires et al, JDBP. 199617420
  427)
• ? 80 to 90 of children with mental
  health problems correctly identified (Sturner,
  JDBP . 1991 12 51-64)
• ? Most over-referrals on standardized
  screens are children with below average
  development and psychosocial risk factors
  (Glascoe, APAM. 2001 15554-59)

38
Developmental Screening Tools

Child Development Inventories
Brigance Screens
39
Behavioral/Emotional Screening

• Pediatric Symptom Checklist (PSC)
• Eyberg Child Behavior Inventory
• Family Psychosocial Screening

40
Tools

• Purpose
• To provide guidelines and standards for observing
  and interpreting young children's growth and
  behavior
• To provide information that parents and
  caregivers can use in everyday interactions with
  their children
• Components
• Observation Record
• Family Album
• Developmental Profile

Invest in Kids 2004
41
When Should You Ask for Further Evaluation?

• Global Developmental Delay
• Persistent significant delay in all domains that
  cannot be attributed to other known factors
• Delays in a sphere of development that adversely
  impact the childs functioning
• At home
• Daycare
• School
• Significant Emotional Concerns

42
When Should You Ask for Further Evaluation?

• Sudden Unexpected Change In Developmental
  Trajectory
• Unexplained regression
• Sudden change in personality
• Change in mood or emotional well-being
• May be due to disease or illness
• May reflect important events occurring at home

43
Healthy Beginnings

• Policy Rationale
• Definitions
• Services
• ECE professionals
• Other providers

44
What Do You Ask For?

• Community health unit and GP
• Hearing screen
• Vision screen
• Speech and language evaluation
• Paediatrician referral
• Sunny Hill Developmental Paediatric School
  Outreach Program
• Infant Development Program good to have GP
  referral
• Child Development Centre good to have GP referral

45
Sunny Hill Health Centre Outpatient Clinics

• School Consults
• SERT Team (Substance Exposure Resource Team)
• Brain Injury
• Craniofacial Clinic
• Downtown Eastside Clinic
• Visually Impaired Program
• Preschool Clinic
• Developmental-Genetics Clinic
• Hearing Loss Team
• Neuromotor/Spasticity/Feeding
• Provincial Autism Program

http//www.sunny-hill.bc.ca/sunnyhill/shhcc/defaul
t.asp
46
Alan Cashmore Centre

• Child-Family Therapy Centre [phone]
• Under umbrella of services provided by Vancouver
  Coastal Health
• Parent Infant Program home based therapy for
  mother/family/infant having difficulties in the
  initial stage of their relationship (birth to 30
  months of age)
• Parent Child Therapy Program therapy services
  for families finding it challenging to care for
  their young child (21/2 to 7 years of age)
• Parent Child Day Program intensive services for
  families experiencing a significant social,
  emotional and/or behavioral difficulties in
  parenting their young child (2 ½ to 6 years)
• Childcare Centre Outreach program consultation
  and support to childcare staff in their own
  centres in managing children with social,
  emotional and/or behavioral challenges.

47
Mental Health Services

• Alan Cashmore Centre Child-Family Therapy Centre
  [phone]
• BC Psychological Association - www.psychologists.b
  c.ca
• UBC Psychology Clinic - http//www.psych.ubc.ca/cl
  inic/
• SFU Psychology Clinic 604-291-4720
• New Westminster Counselling
• Tel [phone]
• Treatment is free and patients can self-refer

48
Psychiatry Clinics At BC Children's Hospital

• Psychiatry
• Mood Disorders Clinic
• Neuropsychiatry Clinic
• Attention Deficit Hyperactivity Disorder Clinic
• Infant Psychiatry
• Urgent Assessment

49
Other Sources of Information

• MCFD website - http//www.mcf.gov.bc.ca/
• Redbook - http//www2.vpl.vancouver.bc.ca/dbs/redb
  ook/htmlpgs/home.html
• Community Brain Injury Program coordinated by
  Center for Abilities

50
Sunny Hill Developmental Paediatric School
Outreach Program

• Aim To provide timely developmental pediatric
  consultation in the community
• For children unable or unlikely to obtain
  tertiary developmental assessment at Sunny Hill
  Health Centre for Children
• Poverty
• Psychosocial dysfunction
• Language barrier

51
Sunny Hill Developmental Paediatric School
Outreach Program

• Process
• Daycare/preschool/school-based team appoint a
  case manager
• Case manager makes a referral to Sunny Hill
  administrative assistant Marisa Ferrara at 604
  453-8306
• Pediatrician reviews referral for
  appropriateness
• Request must conform to mandate of the program to
  service children who wouldnt access service
  otherwise

52
Sunny Hill Developmental Paediatric School
Outreach Program

• Assessment
• Pediatrician comes to daycare/school to meets
  with staff, family child.
• Full history
• Neurodevelopmental assessment
• Physical exam
• Observation
• Summary of findings and recommendations are
  communicated to family and staff at the visit.
• A written evaluation integrates the context of
  the childs development
• Prenatal exposures
• Postnatal environment
• Genetic influences
• A written evaluation is sent to all involved in
  the childs care (with parents permission).

53
Healthy Beginnings