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Improving Early Childhood Development
What Are These Services?
Dr. Carole Lannon, Co-Director of the Children's Primary Care Research Group, University of North Carolina, Chapel Hill, NC.
Dr. Marian Earls, Medical Director of Guilford Child Health, Greensboro, NC.
Dr. Michael Regalado, University of California, Los Angeles (UCLA) School of Medicine, Los Angeles, CA.
Dr. Margot Kaplan-Sanoff, Associate Professor of Pediatrics, Boston University School of Medicine, Boston, MA.
Dr. Peter Margolis, Managing Director of the National Initiative, Children's Healthcare Quality (NICHQ), and Co-Director, Children's Primary Care Research Group, University of North Carolina, Chapel Hill, NC.
Dr. Mary Hansell, Director of the Prenatal to Three Initiative, San Mateo County, CA.
Developmental services for young children can be grouped in four major categories:
- Assessment and screening.
- Anticipatory guidance and education.
- Developmentally focused interventions.
- Care coordination.
These services can be provided within the pediatric setting to promote optimal early development and improve developmental outcomes.
Assessment and screening facilitate the early detection of risk factors for adverse developmental outcomes and development delays. According to Dr. Lannon, multiple screening instruments are available to conduct developmental surveillance, screening, and assessment, but there is no single universally accepted tool.
Despite this lack of consensus, providers are encouraged to conduct developmental assessments, either through population-based surveillance or formal screening, and to use the assessment process to provide information about development to parents and to address their concerns.
For example, the North Carolina Assuring Better Child Health and Development (ABCD) Project has implemented the parent-administered Ages and Stages Questionnaire (ASQ) as the first step in identifying developmental risk factors for infants and young children and providing information to parents.
According to Dr. Earls of Guilford Child Health, the ASQ has been integrated into Early Periodic Screening, Diagnostic, and Testing (EPSDT) well-child visits in certain pediatric and family practice offices in the State.
Anticipatory guidance includes preventive counseling to promote optimal growth and development, information about parenting and developmental advice, and motivation to adopt healthy practices within the family.
According to Dr. Regalado, effective anticipatory guidance in the first 3 years of life promotes cognitively and emotionally stimulating interaction between parent and child. Pediatric providers should address parent-child interaction, discipline, sleep habits, temperament, and learning in their interactions with parents of young children.
Dr. Kaplan-Sanoff of the Boston University School of Medicine emphasized that relationships—between parent and child and family and practice—are key to successful delivery of developmental services, providing a foundation of trust so that other issues affecting child development such as parents' risk factors and behaviors and environmental factors can also be addressed as part of the pediatric visit.
Dr. Margolis noted that, although a gap exists between what parents and physicians want and what is practiced, system improvements at the practice, health system, and community levels can translate the evidence of early child development into good preventive practice.
Developmentally focused interventions are the supports and services that parents and their young children need to improve developmental outcomes and address potential risk factors. These services can include parent counseling and education activities, home visiting, and diagnostic and treatment services such as speech and hearing.
For example, the Prenatal to Three Initiative in San Mateo County, California, provides home visits by a multidisciplinary team of public health nurses, social workers, nutritionists, and community workers to families identified through an assessment process as being at risk.
According to Dr. Mary Hansell, Director of the Prenatal to Three Initiative, the home visit provides an opportunity for the team to conduct assessments with the ASQ and other formal assessment tools and to provide therapy, support, information, and referrals on:
- Mental health issues.
- Infant care.
- Early literacy.
In the ABCD project in North Carolina, once the completed ASQ has been reviewed by the pediatric provider, the practice provides parent education and referrals to early intervention services, reading programs, nutrition services, and family support services, as appropriate.
Care coordination is the final element of developmental services, providing the monitoring and management of services for the child and family. In both examples noted above, designated individuals in the care delivery system are responsible for following the family once a potential risk has been identified and for referring them to appropriate services. In the North Carolina model, the Early Intervention Specialist (EIS) serves as case manager, meeting with families, making referrals, and working with a consortium of providers of early intervention services and resources to ensure that the family's needs are met.
The EIS is housed in the pediatric practice and supported by the administrative infrastructure of the practice network. The case management function in the Prenatal to Three initiative is supported by a combination of Medicaid funding as a targeted case management service and other administrative funds.