- Strategies to enhance the effectiveness of child health services deserve consideration to promote children's optimal growth and development.
- Anticipatory guidance and developmental monitoring are key elements of child health supervision services.
- New models of pediatric care demand critical, prospective study.
- Broad-based approaches, exceeding the traditional boundaries of child health care, are necessary to address contemporary needs of children and their families.
As defined by the American Academy of Pediatrics (AAP),the goal of child health services is to promote children's optimal growth and development.1 Child health services are of potentially critical importance in enhancing children's developmental outcomes. However, an important caveat must be considered when examining the impact of such services on children's development. Expectations for child health services must be tempered by reality, for the most urgent risk factors influencing children's development result from complex sociopolitical and behavioral factors.2 Examples include, but are not limited to intentional and unintentional injuries, substance abuse, suicide, HIV, violence, and learning and behavioral problems. Furthermore, the broad-based approaches necessary to address children's needs clearly exceed the boundaries of health. Such approaches, like the inspirational Harlem Children's Zone, promote collaboration among child health, social services, education, and families, while encouraging advocacy in support of community-based programs.
Recently, much attention has been focused on the potential of child health services to promote children's optimal development. Bright Futures, a collaborative project originally involving the AAP, Maternal and Child Health Bureau (MCHB), and Medicaid, has developed national guidelines for child health supervision.3 The US Preventive Services Task Force has reconsidered its recommendations for child health supervision in its Guide to Clinical Preventive Services. The Committee on Children with Disabilities of the AAP is currently revising its policy statement on the early detection of children at risk for developmental delays.4
In addition to professionals' interest and activity, parents have also expressed the desire to strengthen the developmental content of child health services. A survey of parents conducted by the Commonwealth Fund in 1998 found that parents sought expert guidance and information on a wide range of topics, including how to encourage learning, discipline, toilet training, sleep patterns, crying, and newborn care.5
The goal of this Introduction is to consider efforts to enhance developmental outcomes in the context of contemporary child health services. The traditional content of such services will be briefly reviewed, with a specific focus on those elements most relevant to children's development. Strategies to improve effectiveness will be considered, with implications derived to inform the design, implementation, and evaluation of promising innovations.
TRADITIONAL CONTENT OF CHILD HEALTH SEVICES
As outlined by the AAP Committee on Practice and Ambulatory Medicine, the traditional content of child heath supervision services includes a patient history, physical examination, measurements, sensory screening, developmental and behavioral assessment, immunizations and procedures, and anticipatory guidance.6 While all content is relevant to health promotion, those items most specifically focused on children's developmental outcomes include anticipatory guidance and developmental and behavioral assessment (i.e., developmental monitoring).
Anticipatory guidance is the provision of information to parents and/or children with the expected outcome being a change in parent and/or patient attitude, knowledge, or behavior. Telzrow views anticipatory guidance as focusing on "…ideas and opinions about normal parental responses to development," while Brazelton describes anticipatory guidance as "…the mechanism for strengthening a child's developmental potential."7,8
Studies in the pediatric and health education literature have examined the effectiveness of anticipatory guidance, both with respect to such specific issues as injury prevention, breast feeding, and HIV prevention, and more general issues such as developmental promotion. In general, the impact of such counseling on targeted outcomes has been shown to be modest. Implications from such research suggest that despite its relatively limited effectiveness, anticipatory guidance will continue to be emphasized as a means to promote children's development. However, findings suggest the need to individualize the content of such counseling, and to discuss matters at the level of parents' cognitive, cultural, and psychological readiness. In fact, open-ended, parent-led agenda may be preferable to discussions of age-specific, recommended topics.9
An important goal of child health supervision is the early detection of children with developmental disabilities and those at high risk for adverse developmental and behavioral outcomes. Research on early brain development during the 1990s, the so-called "decade of the brain," has emphasized the critical importance of early detection to ensure the provision of appropriate intervention services and support. While early detection is facilitated by the access of child health providers to young children and their families, how to best perform such identification is uncertain. At present, recommendations are informed by limited research findings, empiricism, and good intentions.
The AAP Committee on Children with Disabilities has recommended that the related processes of developmental screening and surveillance be employed by child health providers to promote the early detection of children at risk for adverse outcomes.4 The Committee is currently revising its policy statement and reconsidering the role of longitudinal monitoring and the periodic application of such screening tools as parent-completed questionnaires and professionally-administered tests.
While detection is necessary to address the needs of children at developmental risk, it is of value only to the extent that children and their families are linked to appropriate and effective programs and services. Perrin has questioned the ethics of detection without such intervention, expressing concern that early detection without the provision of services and support may only serve to raise parental anxiety and worry.10 Strengthening the effectiveness of developmental monitoring demands the identification of relevant programs and services and the successful linkage of at-risk children and their families.
STRATEGIES TO IMPROVE EFFECTIVENESS
A variety of innovative strategies have been proposed and examined to improve the effectiveness of child health supervision services in promoting children's optimal growth and development. Examples of strategies with some research evidence of effectiveness include home visiting, group well-child care, office-based literacy programs, parent-held child health records, and new models of pediatric care delivery. Other suggested approaches include health promotion and planning methods (e.g., the PRECEDE-PROCEED model and a focus on the specific needs of the child and family), a family-focused, systems orientation, the incorporation of cultural beliefs, and linkage to community-based programs, such as legal aid and advocacy services and early childhood education.11
Office-Based Literacy Programs
Promoting school readiness has been a national concern for decades. Reach Out and Read (ROR) is an innovative, successful, nationally-disseminated, office-based program that incorporates waiting room readers, anticipatory guidance on literacy development, and gifts of books at well-child visits. Studies have demonstrated such positive outcomes as parents more likely to report looking at books and to report reading as a favorite activity of their child, as well as such advances in child development as improved vocabulary scores.12 Literacy programs are likely of special importance to disadvantaged children growing up in under-stimulating environments.
New Models of Pediatric Care
Healthy Steps for Young Children, a national initiative supported by The Commonwealth Fund, has redesigned child health supervision services and the pediatric office to more optimally support families in promoting children's development. Goals include the strengthening of parents' knowledge, attitudes, and behaviors; promotion of children's health and development; and improvement of such child outcomes as language development, the use of well child care, and the prevalence of problem behaviors, hospitalization, and injuries. Child development specialists are incorporated as a new professional within the practice setting. The developmental content of child health services is enhanced through office and home visits, assessment of developmental progress, referrals to community resources, early reading activities, and a telephone advice line.13 Evaluation has suggested the benefits of such interventions on children's outcomes.
The optimal promotion of children's healthy development may require a redesign of child health supervision services. Schor has suggested that such a redesign include basing the periodicity of visits on child development; naming each visit for a developmental issue; eliminating unnecessary procedures (e.g., physical examination); using time before and after the visit to address developmental issues; reminding parents and providers of key issues; developing a single resource as a standard for quality care; and enlisting the aid of other service providers in the community.14
A variety of strategies deserve consideration to enhance development through child health services. Research findings and empirical observations suggest the potential benefits of individualizing the content of anticipatory guidance, effective developmental monitoring and linking children and their families to programs and services, targeted home visiting, group well-child care, office-based literacy programs (e.g., ROR), parent-held child health records, and new models of care such as Healthy Steps. The importance of such approaches is supported by findings from research on early brain development.
Formidable obstacles must be overcome to implement such strategies, including enhanced funding for preventive services and training to ensure the requisite knowledge and skills of care providers. Furthermore, broad-based approaches exceeding the traditional boundaries of preventive heath care are needed to confront contemporary needs, as is child advocacy. Finally, the value of promising innovations and new models must be examined through well-designed, prospective studies. Despite the challenges, efforts to enhance the effectiveness of child health services must be prioritized to enable child health providers to fulfill their goal of promoting children's optimal growth and development.
1. American Academy of Pediatrics, Committee on Standards of Child Health Care. In: Standards of Child Health Care
. 2nd ed. Evanston, IL: American Academy of Pediatrics; 1972.
2. Murray-Garcia J. African-American youth: essential prevention strategies for every pediatrician. Pediatrics
3. Green M. Bright Futures. Guidelines for Health Supervision of Infants, Children, and Adolescents
. Arlington, VA: National Center for Education in Maternal and Child Health; 1994.
4. American Academy of Pediatrics, Committee on Children with Disabilities. Developmental surveillance and screening of infants and young children. Pediatrics
5. Young KY, Davis K, Schoen C, et al. Listening to parents: a national survey of parents with young children. Arch Pediatr Adolesc Med
6. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for pediatric preventive care. Pediatrics
7. Telzrow R. Anticipatory guidance in pediatric practice. Journal of Continuing Education in Pediatrics
8. Brazelton TB. Anticipatory guidance. Pediatr Clin North Am
9. Dworkin PH, Allen D, Geertsma A, et al. Does developmental content influence the effectiveness of anticipatory guidance? Pediatrics
10. Perrin EC. Ethical questions about screening. J Dev Behav Pediatr
11. Dworkin PH. Preventive health care and anticipatory guidance. In: Shonkoff JP, Meisels S. Handbook of Early Childhood Intervention.
Ch 15. 2nd
ed. Cambridge, UK; Cambridge University Press; 2000: 327-228.
12. Weitzman CC, Roy L, Walls, et al. More evidence for reach out and read: a home-based study. Pediatrics
13. Zuckerman B, Kaplan-Sanoff M, Parker S, et al. The healthy steps for young children program. Zero to Three
. June/July 1997: 20-25.
14. Schor EL. Rethinking well-child care. Pediatrics