Ontario and the enhanced 18-month well-baby visit: Trying new approaches

In Ontario, the 18-month well-baby visit is the last scheduled primary care visit before school entry. Recognizing the importance of this visit and the role that primary care plays in developmental surveillance, an Ontario expert panel recommended enhancing the 18-month visit. Their recommendations are based on evidence from multiple disciplines, which underscore the reality that the quality of the early years experience establishes trajectories of health and well-being for children. An underlying premise of the recommendations is that when there are collaborations among parents, primary care, community health and child development services, the outcomes for children will be improved. The present article focuses on two Ontario pilot projects that were funded to discover how, in real life primary care settings, the recommendations could be implemented and outcomes measured. Findings and insights were significant, and future directions are clear, as the strategy for an enhanced 18-month well-baby visit is implemented in the future for Ontario.     

The value of early intervention for children with autism

Autism is a heterogeneous neurodevelopmental condition characterised by difficulties in social communication and social interaction, along with a range of impairing sensory interests or aversions, and repetitive and stereotyped behaviour. Prevalence estimates vary from approximately 1 to 2 in 100. Diagnosis may be as early as 2 years of age, but this is influenced by a range of factors such as the symptom severity, family circumstances and professional factors. Interventions for young children with autism spectrum disorder primarily aim to promote social communication and basic core skills through a number of different behavioural approaches. These may be administered by professionals but also often involve parents as co-therapists. Behavioural interventions primarily incorporate either a developmental approach, based on an understanding of the way that language and communication emerge in typical development, or approaches based on applied behavioural analysis. The evidence base for the effectiveness of interventions for children with autism is limited but a number of randomised control trials have shown benefits across a number of outcome measures, including early social communication in children and parental communication style within parent-child dyads. Emerging findings suggest that earlier and more intensive treatment may result in more favourable outcomes.     

General paediatric practice in autism spectrum disorder screening in Ontario,Canada: Opportunities for improvement

BackgroundScreening is important for early identification of children with autism spectrum disorder (ASD), potentially leading to earlier intervention. Research has identified some barriers to early identification of ASD, however, information about ASD screening in Canadian general paediatric practice is lacking.ObjectivesThe aim of the study is to better understand ASD screening practice patterns by examining the use of ASD and general developmental screening tools by general paediatricians.MethodsThe research team conducted a cross-sectional survey of general paediatricians.ResultsTwo-hundred and sixty-seven paediatricians responded and 132 were eligible for the study. Ninety-three per cent of the responders used a developmental screening tool. Eighty-five per cent of the responders used an ASD screening tool when there were concerns for ASD, and 15% never used one. The most commonly used ASD screening tool was the M-CHAT. Children suspected of having ASD were referred to specialists not only to confirm the diagnosis but also to facilitate access to resources. General paediatricians were keen to incorporate formal ASD screening tools in their practice but identified the need for clearer guidelines.ConclusionPrevious studies have shown that children at risk of ASD continue to be missed through developmental surveillance and targeted screening. Paediatricians are interested in implementing an ASD screening tool and cite brevity and forms that can be completed by parents as factors that would support the use of a screening tool. Clearer guidelines and tools to support ASD screening and access to resources are needed.     

The effectiveness of early parental coaching in the autism spectrum disorder

ObjectiveAnalysis of the effectiveness of early Parental Coaching in the Autism Spectrum Disorder.MethodRandomized, controlled and blinded clinical trial to analyze parent-child interaction videos.ResultsThe sample consisted of 18 children being followed up at the Autism Outpatient Clinic of a Neuropediatric Center in southern Brazil diagnosed with Autism Spectrum Disorder, between 29 and 42 months of age, randomly allocated to two groups: the Study Group (SG; n = 9), which received Parental Coaching performed by a professional certified by the Early Start Denver Model; and the Control Group (CG; n = 9), which was in a routine follow-up, without treatment and training of parents by a trained professional. The parents of the SG were willing to attend weekly meetings and to apply the instructional techniques at home with their children. It took 12 weeks and an average of 2 h per meeting.ConclusionsThe learning rate for comprehensive development skills in the Early Start Denver Model checklist, such as receptive communication, expressive communication, social capacity, imitation, cognition, games, fine motor skills, gross motor skills, behavior, and personal independence was significantly higher in the SG, as well as the strategies and the quality of interaction between parents and children. Thus, Parental Coaching presents as a possibility of early intervention in children with Autism Spectrum Disorder.     

The ActionAid disability programmes: Experiences in early identification and early intervention

The World Health Organisation (WHO) estimates that about 10% of the world’s population has some form of disability, while statistics from different sources show that about 3.8% of India's population has locomotor, visual or communication disabilities or mental retardation. The Disability Division of ActionAid-India supports 38 non-governmental organisations involved in disability programmes in India. This paper touches upon the experiences of some of its project partners in the areas of early identification and early intervention.     

喂养干预对特应性高风险婴儿湿疹、食物过敏影响的跟踪研究

目的对具有特应性遗传背景的高风险婴儿随机进行不同方式的喂养干预,观察湿疹和食物过敏的发生情况,探讨喂养干预对婴儿湿疹和食物过敏发生的影响。方法从特应性夫妇中筛选出46例脐血IgE〉0．35kU／L的婴儿,随机分为干预组和非干预组。干预组23例,母乳喂养〉4个月,4个月龄内不添加任何固体辅食,随后低抗原性配方奶粉喂养,6个月内不添加鱼类、虾类食物,12个月内不添加蛋类、花生和坚果类食物;非干预组23例,母乳喂养〈4个月,或普通配方奶粉混合喂养或人工喂养,4个月添加蛋类辅食,其他辅食添加内容和顺序无任何建议或暗示,随访至18个月。临床观察婴儿湿疹的发生情况,食物点刺试验或Fx5E或sIgE检测食物过敏的发生情况。结果6个月时,喂养干预组婴儿湿疹累计发生率4．3％（1／23）,非干预组婴儿湿疹累计发生率26．1％（6／23）;12个月时．喂养干预组婴儿湿疹累计发生率8．7％（2／23）,非干预组婴儿湿疹累计发生率34．8％（8／23）;18个月时,喂养干预组时婴儿湿疹累计发生率17．4％（4／23）,非干预组婴儿湿疹累计发生率39．1％（9／23）,两组湿疹的发生率在各个阶段差异均有统计学意义。干预组食物过敏发生率为13．0％（3／23）;非干预组食物过敏发生率为34．8％（9／23）,差异有统计学意义,过敏食物以鸡蛋最为常见。结论母乳喂养、低抗原性配方奶、延迟添加辅食、高风险食物回避等综合喂养干预方式可以降低高风险婴儿特应性湿疹和食物过敏的发生率,是对具有特应性遗传背景的婴儿有效的初级干预措施。     

Getting it right at 18 months: In support of an enhanced well-baby visit

Evolving neuroscience reveals an ever-strong relationship between children’s earliest development/environment and later life experience, including physical and mental health, school performance and behaviour. Paediatricians, family physicians and other primary care providers need to make the most of well-baby visits—here a focus on an enhanced 18-month visit—to address a widening ‘opportunity gap’ in Canada. An enhanced visit entails promoting healthier choices and positive parenting to families, using anticipatory guidance and physician-prompt tools, and connecting children and families with local community resources. This statement demonstrates the need for measuring/monitoring key indicators of early childhood health and well-being. It offers specific recommendations to physicians, governments and organizations for a universally established and supported assessment of every Canadian child’s developmental health at 18 months.     

Speech and language support: How physicians can identify and treat speech and language delays in the office setting

Failure to recognize and intervene early in speech and language delays can lead to multifaceted and potentially severe consequences for early child development and later literacy skills. While routine evaluations of speech and language during well-child visits are recommended, there is no standardized (office) approach to facilitate this. Furthermore, extensive wait times for speech and language pathology consultation represent valuable lost time for the child and family. Using speech and language expertise, and paediatric collaboration, key content for an office-based tool was developed.The tool aimed to help physicians achieve three main goals: early and accurate identification of speech and language delays as well as children at risk for literacy challenges; appropriate referral to speech and language services when required; and teaching and, thus, empowering parents to create rich and responsive language environments at home. Using this tool, in combination with the Canadian Paediatric Society’s Read, Speak, Sing and Grow Literacy Initiative, physicians will be better positioned to offer practical strategies to caregivers to enhance children’s speech and language capabilities.The tool represents a strategy to evaluate speech and language delays. It depicts age-specific linguistic/phonetic milestones and suggests interventions. The tool represents a practical interim treatment while the family is waiting for formal speech and language therapy consultation.     

The role of the Child Health Services in promoting mental health: an introduction

This paper gives an introduction to the psychosocial work in the Swedish Child Health Services (CHS). There are substantial problems in defining and evaluating the preventive mental health work of the CHS. The issues raised include: why early preventive intervention is important; the promotion of parental mental health as an aim of the CHS; how the CHS can increase parenting knowledge and skills; what evidence there is about intervention among target groups; and finally, how recent research knowledge can be applied in the CHS.     

From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice

Previous research has highlighted the importance of addressing the social determinants of health to improve child health outcomes. However, significant barriers exist that limit the paediatrician’s ability to properly address these issues. Barriers include a lack of clinical time, resources, training and education with regard to the social determinants of health; awareness of community resources; and case-management capacity. General practice recommendations to help the health care provider link patients to the community are insufficient. The objective of the current article was to present options for improving the link between the office and the community, using screening questions incorporating physician-based tools that link community resources. Simple interventions, such as routine referral to early-year centres and selected referral to public health home-visiting programs, may help to address populations with the greatest needs.     

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目的观察早期干预对脑性瘫痪(脑瘫)患儿进食困难的治疗效果。方法温州市第二人民医院于2002-03—2004-10,对收治的34例脑瘫患儿(观察组)进行摄食及口咽运动康复训练6个月至1年后进行进食功能评价;对同期康复门诊42例脑瘫患儿(对照组)在常规康复初期即进行进食功能评价,将两组评价结果进行比较。结果观察组较对照组各种进食功能障碍,吸吮困难、吞咽困难、食物送入手或口困难、用杯喝水困难,咀嚼半固体或固体食物困难的发生率明显降低,两组差异具显著性,P<0.05。结论对可能有发育障碍的脑瘫患儿及早开始进行进食能力及口咽运动训练能改善其进食功能。     

Preschool autism services: A tale of two Canadian provinces and the implications for policy

For children with autism spectrum disorder (ASD), a lifelong neurodevelopmental condition, assessment and treatment services vary widely across Canada—potentially creating inequities. To highlight this, the Preschool Autism Treatment Impact study compared children’s services and outcomes in New Brunswick (NB) and Nova Scotia (NS). Diagnostic practices, service delivery models, wait times, and treatment approaches differed, as did children’s 1-year outcomes and costs for families and the public sector. Considering NB and NS strengths, we suggest that an optimal system would include: rapid access to high-quality diagnostic and intervention services; adherence to research-informed practice guidelines; interventions to enhance parents’ skills and self-efficacy; and measures to minimize financial burdens for families. Our results also suggest that provinces/territories must do more to ensure equitable access to effective services, including sharing and reporting on national comparative data. Canadian children with ASD deserve access to effective and consistent services, no matter where they live.     

Continuing education in the child health handbook: an educational software for primary care1

ObjectiveTo present, the process of development and evaluation of an educational software on the Child Health Handbook proposed for the continuing education of primary care nurses and physicians.MethodsQuantitative study of methodological development. For software development, the following steps were followed: definition of objectives; determination of the target audience; choice of pedagogical and theoretical reference for content; content selection and structuring; software development and evaluation by experts (five nurses and four physicians). All responded to an instrument that included four domains: pedagogical; content; functionality; system presentation and usability. The evaluation criteria were arranged on a Likert-type scale. The percentage of agreement and Content Validity Index were used for the quantitative analysis of the degree of agreement, considering a Content Validity Index cutoff point equal to 0.80.ResultsThe overall agreement index, calculated by the arithmetic mean of the Contents Validity Index of the evaluated domains, was 0.96, with scores ranging from 0.90 to 1.00. The average percentage of agreement of the experts per domain was 92.86%, with lower agreement in the content (80.95%), presentation, and usability (90.48%) domains. 100% of percentage of agreement was observed in the pedagogical and functionality domains among the evaluated specialists.ConclusionThe percentage of agreement, Content Validity Index and overall agreement index of the Child Health Handbook educational software in the context of primary care disclosed the software adequacy as an educational resource for continuing education of primary care nurses and physicians. Considering the assessed dimensions, it can also be used by other health professionals and undergraduate students.     

Early communication in preterm infants following intervention in the NICU

Background

Despite ongoing improvements in clinical care, preterm infants experience a variety of stressors in the first weeks of life, including necessary medical procedures, which may affect development. Some stress-reduction programmes based in the Neonatal Intensive Care Unit (NICU) have reported a positive impact on development. In particular, trials of the Mother–Infant Transaction Program (MITP) have shown positive short and longer term effects, and are based on training parents to recognise and minimise stress responses in preterm infants.

Aims

To evaluate the impact on early developmental milestones of an enhanced MITP (PremieStart) delivered over an extended period in the NICU.

Study design

This was a parallel 2-group randomised controlled trial involving 109 women with 123 infants born at < 30 weeks gestation assessed initially at term-equivalent age and then at 6 months' corrected-age.

Results

Intervention mothers were more sensitive in providing infant care, stressed their infants less, showed greater awareness of, and responded more appropriately to, negative infant cues (p < 0.05 in each case). Intervention infants displayed significantly lower stress when being bathed by mothers at term-equivalent age (p < 0.05). At 6 months corrected-age, intervention infants showed higher mean scores on the Communication and Symbolic Behavior Scales Developmental Profile Infant–Toddler Checklist. The strongest effects appeared in Symbolic behaviour (p = 0.05) and this was reflected in the Total score (p < 0.05).

Conclusions

As significant cognitive and language deficits are reported in longitudinal studies of preterm children, an intervention that improves early infant communication abilities is promising, especially since previous research suggests that the strongest benefits may emerge at later ages.     

A perfect 10: Why Sweden comes out on top in early child development programming

Sweden ranked first in the United Nations Children's Fund 2008 league table of early childhood education and care. In a book published 74 years previously, Crisis in the Population Question, Alva and Gunnar Myrdal outlined many of the features that were later assessed by the United Nations Children's Fund. Three aspects may have affected the implementation of Myrdal's ideas. First, the Social Democratic Party has been in power for 85% of the time since 1932. They often had to form coalitions with other parties that supported a nonpartisan stance. Second, according to evidence from the World Values Survey, Swedes are more individualistic than people in any of the other 64 societies included in that study. The State is expected to create social conditions on equal terms for individuals to realize their own goals. Finally, schools and other social services are managed by 290 semi-independent municipalities. Thus, reforms can be tested in a few municipalities before others follow suit.     

Policies to support obesity prevention for children: a focus on of early childhood policies

Policies at many levels may help to shape environments that promote healthy weight and prevent obesity. We present policies to support obesity prevention for young children. We highlight policy Sand environmental systems change examples in the areas of promoting breastfeeding and providing healthy affordable food and information about food in community and child care settings and promoting physical activity in child care and the community. We address the role of the health care system and health care professionals to shape and advocate for policy and environmental systems change and provide resources for pediatric health care professionals to engage in community-based advocacy.