Health Systems represent the most common entry point for developmental assessment and services for children. They reach more children under the age of three than any other family-facing system. Traditionally, health systems focused on the developmental consequences of growth and nutrition, and reducing the mortality and morbidity associated with infectious diseases through vaccination. Now, besides reducing developmental risk and addressing established developmental disabilities, they focus on optimising healthy child development before developmental problems arise.
Healthcare has evolved beyond clinical process improvement and is taking advantage of opportunities to build bridges with other sectors, namely education, social work, and other services in the community, to deliver community coordinated services, like early childhood intervention (ECI). Several factors have contributed to the growing role of health systems in identifying and managing child development. The improvement of antenatal, perinatal and neonatal care, in particular the advent of neonatal intensive care, has improved the odds of survival and the developmental course of some new-borns — those born prematurely — that would certainly not have survived, and has saved many more at high developmental risk. Genetic counselling has reduced chromosomal anomalies and other genetic conditions associated with developmental problems that are now avoided through prenatal diagnosis.
The risk of adversity in early childhood
Health professionals are increasingly aware of the ways that adversity is linked to childhood developmental hazards. There is growing evidence that early psychosocial adversity (poverty, low education, and racial and ethnic discrimination) becomes biologically ingrained in physiology and health behaviour. In the same way, severe stress, and emotional trauma due to childhood abuse, neglect, household violence, mental illness, or substance abuse, are threats not only to children’s physical health, but also brain development. Primary care providers (PCPs) play an indispensable role in detecting, tracking, and managing children's mental health, behavioural, and developmental issues thanks to frequent contact, as no other early childhood programme or agency can track the development of young children with the same scale and continuity as PCPs, and a unique trusting relationship with families through which providers can effectively discuss parental concerns.
Most health systems in developed countries have established preventive health care programmes for children that provide free, universal access to quality guideline based healthcare at key-ages. Typically, in the first three years, these programmes propose between 10 and 12 visits, and more, if unexpected problems arise. They include:
- Assessment of general health, growth, nutrition, vaccines, oral health, screening of vision and hearing.
- Age-appropriate preventive and anticipatory guidance.
- Developmental screening and monitoring.
Early detection of developmental problems
Early detection of developmental problems relies on frequent screening with validated and accurate tools. Informal milestone checklists and untested questions to parents will miss most children with developmental problems as they are neither efficient nor effective. Most developmental problems are not fully detectable in young children (such as language problems, behaviour problems including attention-deficit/ hyperactivity disorder, learning disorders — especially reading disabilities, academic deficits due to psychosocial risks etc.). They are typically diagnosed at school age. It is recommended to have screening tools completed before the start of the visit. Screening can be incorporated into office workflows efficiently when tools are completed in waiting rooms, or even at home and brought in before the visit, so that screening tools can be scored promptly and interpreted at the beginning of the visit.
Referral to the local ECI team
When screening and evaluation detect developmental problems or delays, a referral to the local ECI team is very important. Typically, this kind of referral does not need a diagnosis and services can be provided based on concerns raised by parents or clinicians. In some more complex situations, referrals for specialised evaluation and assessment are needed when additional evaluation is important.
Developmental paediatricians, child neurologists, geneticists, cardiologists, ophthalmologists, otorhinolaryngologists, orthopaedists and a few other subspecialties not found in primary care, can be useful in some situations. In these cases, services are provided in secondary or tertiary health care, often in paediatric hospitals. In any case, referral to the ECI programme should be immediate after the problem is detected and should never wait for the specialised diagnostic workup.
Important considerations for developmental surveillance in routine preventive healthcare for children:
- Practitioners should elicit parents’ concerns related to behaviour or developmental progression
- Screen to measure children’s skills, with validated tools. This should include: behavioural and developmental screening; autism screening (18 and 24 months)
- Identify psychosocial risk factors as well as resilience factors
- Clarify family/ child medical history and identify biological risk factors
- Observe parent-child interactions
- Conduct physical and developmental examinations
Whenever appropriate, practitioners should interpret results and discuss the findings; coordinate referrals and plan follow-up; communicate findings to childcare, ECI program, secondary or tertiary healthcare levels according to the parent’s wishes.
Dr. José Boavida is a neurodevelopmental paediatrician with a 42-year career in Coimbra Children’s Hospital, encompassing clinical work, research, teaching, as well as public policy. He was part of the team that started the Coimbra Project, that formed the basis of the original Portuguese ECI legislation. He is a member of the coordinating team of the National System of Early Childhood Intervention (SNIPI), as a representative of the Ministry of Health and Eurlyaid consultant and trainer. His interests include early intervention, family centred services, cross-sectoral service delivery, attention deficit hyperactivity disorder (ADHD), and neurodevelopmental clinical practice.