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Primary Care Services Promoting Optimal Child Development From Birth to Age 3 Years
Review of the Literature
Michael Regalado, MD;
Neal Halfon, MD, MPH
Arch Pediatr Adolesc Med. 2001;155:1311-1322.
ABSTRACT
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Objective To examine the evidence base for primary health care services promoting
the optimal development of typically developing children aged birth to 3 years.
Data Sources Peer-reviewed publications addressing clinical evaluations of primary
care services from the MEDLINE and PsychINFO databases.
Study Selection Criteria for selection were as follows: (1) publication between 1979
and 1999; (2) evaluation of efficacy or effectiveness of education, intervention,
and care coordination services or validation of assessment approaches; (3)
services applicable to an office practice setting; (4) target population including
children aged birth to 3 years; and (5) publication in English.
Data Extraction A total of 312 publications were abstracted and reviewed by both of
us; 47 were selected for inclusion.
Data Synthesis Assessments of parental concerns and psychosocial risk factors using
validated approaches seem to be more accurate in identifying developmental
problems than clinicians' appraisals. In general, study results support the
efficacy of (1) primary care educational efforts toward promoting optimal
parent-child interaction, parents' understanding of child temperament, book-sharing
activities, and approaches to healthy sleep habits and (2) office interventions
such as counseling for the management of excessive infant crying and sleep
problems.
Conclusions The literature suggests that many primary care activities promoting
the optimal development of children are efficacious. Evaluations of developmental
assessment and services in primary care should be expanded in depth and breadth.
The implications for clinical practice, training, and health care policy are
discussed.
INTRODUCTION
THE FIRST 3 YEARS of a child's life are increasingly recognized as an
important time for brain growth and a window of opportunity to optimize children's
development in many ways. Because of heightened professional, parental, and
policymaker attention on this developmentally sensitive period, the provision
of appropriate developmental services to young children has been the focus
of several recent state and national policy initiatives aimed at improving
pediatric care.1, 2 Although the
importance of providing appropriate developmental services during this sensitive
period is widely recognized, there are significant barriers in realizing the
intent of these efforts in the current pediatric practice environment.
The evolution of managed care has imposed new criteria for authorizing
and reimbursing services, including evidence of effectiveness, and in many
cases, cost-effectiveness, to justify medical necessity.3
In addition to the growing need for a strong evidence base, there are also
questions about what constitutes routine developmental services and how they
should be provided. Services such as developmental assessment and anticipatory
guidance about developmental concerns have historically been bundled together
with, and are indistinguishable from, other primary pediatric and preventive
services. This makes it impossible to target them specifically for quality
improvement or augmented service provision strategies apart from other aspects
of health supervision. Moreover, some authors4, 5
have argued that the current recommendations of the American Academy of Pediatrics
and the Maternal and Child Health Bureau are neither feasible nor consistent
with new evidence emerging about targeting developmental surveillance and
monitoring approaches. Additional potential barriers include the inability
to separate bills for developmental services, low reimbursement rates, time
constraints, lack of training to conduct these services, and insufficient
community-based resources to accommodate the needs of children with problems.6
Therefore, defining and examining the evidence base for developmental
services is important to guide clinical practice and health care policy decisions.
This review addresses pediatric services that promote the optimal development
of typically developing children from birth to 3 years of age in studies published
during the past 2 decades. Our approach uses a typology for categorizing developmental
services that includes assessment, education, intervention, and care coordination
in an attempt to distinguish or "unbundle" recommended developmental services
separate from other health supervision activities. The intent of this review
was to provide a framework for conceptualizing pediatric service provision
in terms of specific developmental health care outcomes and to explore whether
the current evidence base supports this kind of approach for evaluating health
services intended to promote optimal development or prevent developmental
morbidity. Although it is our belief that improving the provision of effective
developmental services can improve child developmental outcomes, the studies
reviewed herein focus on the efficacy and effectiveness of specific services
to identify signs and symptoms, educate parents, change behaviors, and connect
children with appropriate ongoing care. Furthermore, we believe that these
services should lead to better health and developmental outcomes for children;
however, we make no attempt to offer this kind of assessment in this review.
METHODS
DEVELOPMENTAL SERVICES TYPOLOGY
A list of developmental services for children during the first 3 years
of life was created based on a review of recommendations detailed in health
supervision guidelines of the American Academy of Pediatrics7
and the Bright Futures Project.1 Additional
service enhancements derived from innovative primary care demonstration programs,
such as the Healthy Steps for Young Children Program8
and Zero to Three's Developmental Specialist in Pediatric Practice Project,9 were added to this list. The various services were
grouped into 4 major categories—assessment, education, intervention,
and care coordination. Within these major categories, 8 subcategories were
defined. Assessment activities include evaluation of information from parents,
developmental monitoring (including screening for developmental problems),
psychosocial assessment, parent-child observation, and assessments of child
behavior. Education services include anticipatory guidance that addresses
the parent-infant relationship, child behavior, and various developmental
challenges (eg, promoting healthy sleep habits and discipline practices) and
parenting education in different formats. Intervention activities include
various types of problem-focused counseling in the office setting, as a telephone
service, or through home visitation. Care coordination refers to the management
of service needs, eg, referrals for diagnostic assessments or other specialists
for care, and was not further subdivided.
LITERATURE SEARCH
A list of key words and subject headings was created for each service
category. A computerized search of the literature using the MEDLINE and PsychINFO
databases between 1979 and 1999 yielded a list of 312 publications, including
original research, commentaries, and committee guidelines statements, which
were reviewed for additional relevant references. These publications were
abstracted and compiled into tabular form under the subject headings of service
category, author and year published, description and purpose of the publication,
quality of the evidence (ie, use of a randomized control design), methods,
and results. A final list of publications was created based on the following
criteria: (1) evaluation of efficacy (tested experimentally under tightly
controlled conditions), effectiveness (evaluated in the real-world setting),
and cost-effectiveness or validation of assessment approaches; (2) performance
in a pediatric office setting, in conjunction with a pediatric practice, or
applicable to office practice; (3) the target population included children
aged birth to 3 years; and (4) publication in English.
Given that the primary purpose of the review was to examine general
health supervision addressing child development, the method used was different
from other approaches taken toward the systematic review of clinical trials.
This broad topic area encompasses many different clinical activities, each
requiring a search unto itself. In many instances, there were few or no studies
to examine. On the other hand, some service categories required boundaries
to limit the work to a manageable volume. Three decisions were made to limit
the scope of the review. First, the concept of developmental surveillance10 was used to organize the developmental services typology
and to narrow the scope of activities to those most relevant to current practice.
The process of developmental surveillance emphasizes eliciting and evaluating
parents' concerns, monitoring developmental progress, and performing skilled
observations.9 The routine use of developmental
screening tests is considered to be impractical, and, therefore, this clinical
activity was excluded from the review. Instead, other aspects of assessment
from the typology were targeted. Second, although we intended to examine the
effectiveness of office-based, developmentally focused interventions, this
service category resulted in a diverse array of clinical interventions. Therefore,
2 common clinical issues, interventions for excessive infant crying and sleep
problems, were selected as prototypes for a larger grouping of developmentally
focused interventions. Finally, to limit the scope of the review to well-child
care, studies addressing biologically high-risk infants and those examining
the clinical application of techniques and tools requiring specialized training,
eg, newborn neurobehavioral assessment,11 were
excluded.
RESULTS
Forty-seven articles examining the clinical efficacy or effectiveness
of child development services, or examining the validity of assessment approaches
in any form relevant to this typology, were selected from the larger list
of abstracted articles according to the inclusion and exclusion criteria.
Of these, 30 were controlled clinical trials, including 20 that used a randomized
control design. The remainder included cross-validation studies of assessment
approaches and one cost-benefit analysis. Except for intervention studies,
data were not of the type that permits quantitative analysis. For most categories
of the typology, except intervention studies, the literature search yielded
few studies that were directly comparable. When a validated measure of methodological
quality was applied to the intervention studies,12
only 5 (2 of infant crying and 3 of sleep problems) were of sufficient quality
to consider quantitative analysis. Therefore, only a descriptive analysis
is presented, by service category.
ASSESSMENT ACTIVITIES IN PRIMARY CARE
Articles addressing the efficacy of physicians' ability to elicit and
address parents' concerns about child development, identify children's risk
of developmental disability, evaluate the psychosocial context of development,
and characterize children's behavioral characteristics were reviewed.
Evaluating Parents' Concerns About Child Development
Eliciting and evaluating parents' concerns about development and behavior
are a central focus in developmental surveillance and can be reliable and
accurate indicators of true developmental problems.13
Five studies examined the use of a checklist or questionnaire to elicit and
evaluate parents' concerns about child development and behavior (Table 1). In one study,14
parents' concerns about child development and behavior were discussed more
often (53% vs 30%) when a checklist was used. The use of the checklist also
highlighted differences in the topics parents were most concerned about compared
with what pediatricians were most likely to discuss (concerns about child
behavior and other parenting issues vs general development and appetite, respectively).
The remaining studies in this category suggest that parents' concerns about
development and behavior may serve as an effective surveillance strategy.
The works by Glascoe and colleagues suggest that the number and nature of
parents' concerns are correlated with a probability of failing a developmental
screening test15 and having significant behavior
problems16 or true speech and language problems.17 Parents of children with global developmental delay
had concerns about behavior, speech and language, and emotional status more
often than concerns about global development.18
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Table 1. Studies Evaluating Assessments in Primary Care
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In summary, literature examining the elicitation and evaluation of parents'
concerns about their child's development provides important validation for
developmental surveillance as a clinical strategy. Results of these studies
suggest that structured and systematic approaches to eliciting parents' concerns
improve communication at the health visit and seem to be reliable and fairly
accurate in the detection of developmental problems. Given the potential efficiency
of this approach (the questionnaires and checklists require <5 minutes
to complete), it deserves serious attention as a key strategy for organizing
the activities of the health visit.
Assessment for Risk of Developmental Disability
Four studies were reviewed that examined the effectiveness and cost-benefits
of efforts to identify children at risk for developmental problems (Table 1). Two studies19, 20
addressed physicians' effectiveness at identifying developmental problems,
both suggesting that relatively few are identified before school entry and
that only severe, clinically apparent disabilities are most likely to be identified
early by physicians. Two other studies examined issues relevant to the process
of developmental screening. In a study21 of
a large program in Scotland, developmental screening was most accurate when
done at ages 9 months and 2 years, with tests of adaptive and neurological
function being best for identifying later school and behavior problems. A
study22 comparing costs and benefits for screening
strategies that elicit parental concerns vs those that use a standardized
screening test or a combination of both suggested that all are equivalent
with respect to long-term costs and benefits of early detection and intervention.
However, short-term costs of screening favor the more efficient strategy of
evaluating parental concerns.
In summary, these 4 studies suggest that current community efforts to
identify children with developmental problems are not effective. It is unclear
from the literature reviewed how much of this deficit is explained by the
lack of an efficiently organized service provision effort in the pediatric
sector. There have been few validated and recommended assessment options for
pediatric providers beyond the use of lengthy developmental screening tests,
and little direction has been given about how recommended assessments could
be accomplished, particularly in busy, high-volume settings. Taken together,
these studies are important in suggesting potential alternative approaches
to increase the accuracy of early detection of developmental problems. These
approaches range in intensity, cost, and time efficiency, permitting their
adaptation to different clinical populations or to time constraints of different
practice settings.
Assessment of the Psychosocial Environment
Eight studies that examined the identification of psychosocial risk
factors for poor parenting, quality of the home environment for supporting
child development, and office assessment of the parent-child relationship
were reviewed (Table 1). Studies
that addressed the identification of psychosocial risk factors (parental alcohol
and substance abuse, maternal depression, lack of social support, domestic
violence, housing instability, and parents' own childhood history of abuse)
compared the accuracy of questionnaires that were shorter versions of longer
research-oriented instruments with clinical judgment. These studies demonstrate
that questionnaires identified more problems than did clinical judgment.
Physicians underestimated substantially the
prevalence of intrafamilial violence, maternal psychosocial distress,
and associated behavior problems in children compared with use of a
questionnaire for this purpose.23 The use of a clinic
questionnaire identified significantly more mothers with potential risk
factors for poor parenting compared with review of medical
records.24 Shorter versions of this questionnaire for
evaluating parental depressive disorders,25 substance
abuse,26 and parental history of physical abuse as a
child27 compared favorably to the original measures in
terms of accuracy.
Two studies used a modification of the HOME Inventory (Home Observation
for Measurement of the Environment)28 for pediatric
office use to assess the quality of the home environment. The Home Screening
Questionnaire for children aged birth to 3 years was highly correlated with
the HOME Inventory and was accurate compared with the original inventory.29 The Pediatric Review of Children's Environmental
Support and Stimulation, which combines an adaptation of the HOME Inventory
with observations of parent-infant interaction, showed significant correlations
with measures of parent-child interaction, safety, and family income.30
Only one systematic approach to parent-child observation in office settings
has been reported. Pediatric assessments of mother-child interaction correlated
significantly with the HOME Inventory, laboratory ratings of mother-child
interaction, and measures of development, intelligence, language, and behavior
problems.31
In summary, the literature on the effectiveness of psychosocial assessment
in office settings indicates that the accuracy of identifying psychosocial
risk factors can be improved by using questionnaires and that there is also
some evidence supporting the validity of home environment and parent-child
assessments. Although these studies are essentially examinations of efficacy,
they should provide a strong incentive for further investigations of this
aspect of pediatric care. Better psychosocial assessment tools and procedures
could facilitate the pediatric provider's ability to monitor and refer common
and debilitating psychosocial problems, from maternal depression to family
violence. Pediatric health care supervision could be a more effective entry
point for "2-generation" family interventions, eg, referrals to an Early Head
Start program or to family literacy programs.
Assessment of Child Behavior
We found no assessment approaches to behavioral problems specific for
the first 3 years of life in the published literature, reflecting the absence
of a universally accepted diagnostic classification scheme for behavioral
problems in this age group.32 Behavior problem
checklists standardized for children beginning in the third year of life33, 34 have not been examined in terms of
their effectiveness in pediatric practice. Instead, approaches to temperament
assessment have been used to address behavioral concerns in infants and younger
children.35, 36 Both American Academy
of Pediatrics and Bright Futures health supervision guidelines recommend the
discussion of infant temperament as part of routine well-child care. We believe
that the context for the use of temperament assessment is better suited to
anticipatory guidance in helping parents understand their child's individuality.
EFFECTIVENESS OF ANTICIPATORY GUIDANCE
Until recently, few studies have examined the effectiveness of anticipatory
guidance in terms of child developmental outcomes, perhaps because of the
bundling of developmental services with all other health promotion services.
Twenty studies were found that address the provision of anticipatory guidance
relevant to promoting optimal child development (Table 2).
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Table 2. Studies Evaluating the Effectiveness of Anticipatory Guidance
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In an important study with first-time mothers, Chamberlin et al37 reported that the strongest predictor of child development
outcome was the mother's reported use of positive contact with her child and
that physicians' teaching efforts toward increasing parents' positive contact
contributed a small amount to this prediction. Teaching efforts affected mothers'
knowledge of child development and feelings of being supported; however, neither
was related to children's developmental status. In a 1-year follow-up of this
study,38 physicians' teaching efforts were
no longer related to mothers' use of positive contact with their children,
although the latter was still the strongest predictor of child development
outcome. Physicians' efforts to encourage these kinds of behavior were minimal
compared with discussions about stage-related behavior, individual differences,
and common behavior problems. A similar conclusion was reached in another
study39 in which discussions about developmental
stages relevant to anticipatory guidance topics were not effective in terms
of measures of mother-infant interaction, perceptions and attitudes, and satisfaction
with pediatric care.
Parent Education to Enhance Parent-Child Interaction
Given the importance of these findings, it is surprising that only 3
studies were found in the literature that examine interventions to enhance
mother-infant interaction (Table 2).
Only one of these was conducted in an office-based setting; however, the other
2 approaches are accessible to the average pediatric practice in terms of
their feasibility. In all 3 studies, effective interventions were demonstrated.
Mothers receiving discussions during well-child care visits about infant social
development to encourage sensitive and responsive interactions with their
infants and to increase their own sense of effectiveness demonstrated more
favorable interactive behavior with their infants, who later were more advanced
on measures of vocal behavior.40 In a second
study,41 mothers receiving a skill-training
program designed to teach the competencies of newborns demonstrated higher
quality behavioral interaction. In a third study,42
a 15-minute videotape intervention was effective in enhancing mealtime communication
and attitudes in black adolescent mothers.
Temperament-Based Anticipatory Guidance
An understanding of the child's behavioral individuality is important
in encouraging positive contact between parents and their children. In this
regard, physicians are encouraged to discuss the child's temperament as a
way of imparting an understanding of this individuality to the parent and
promoting an optimal " fit" between them. Despite an expansive literature
addressing child temperament, only 2 studies have examined the clinical use
of temperament assessments in pediatric primary care (Table 2). Both studies43, 44
report that most parents find temperament information helpful and influential
in their approach to parenting. In the first year, temperament-based anticipatory
guidance materials for parents were most helpful for parents with challenging
("high-energy") infants.44 One study44 recruited participants from a large health maintenance
organization, suggesting the feasibility of routine temperament-based anticipatory
guidance in the child's first year. This has strategic importance in light
of the relationship between infant temperament and later behavior problems.45
Other Office-Based Educational Activities
During the past decade, studies have examined more focused educational
activities addressing specific developmental topics that fall within the larger
domain of anticipatory guidance. These services include efforts to promote
healthy sleep habits, effective discipline, and children's cognitive development
by encouraging book-sharing activities (Table 2). Preventive counseling sessions and written instructions
were effective in promoting better infant sleep patterns46
and in reducing stress and increasing parents' confidence47
during the first 2 months of life. Written anticipatory guidance about sleep
practices was effective in reducing night waking during infancy,48
as was written information promoting the use of "time-out" for parents who
had never tried it.49 A pediatric book distribution
program for promoting early literacy was effective in increasing book-sharing
activities with children, particularly in poor ethnic minority families,50, 51 and was associated with higher receptive
language development.52
Although not a specific educational activity per se, group well-child
care was as effective as traditional care53
and seemed to promote more discussions of personal issues,54
parenting, and child behavioral concerns.55
However, such benefits do not seem to extend completely to higher risk populations.56, 57
In summary, anticipatory guidance seems to be effective during the first
3 years of life, when teaching efforts are directed toward increasing positive
contact between parent and child. Efficacy was demonstrated for efforts to
enhance the quality of mother-child interaction using methods accessible to
most pediatricians. Temperament-based counseling seems particularly helpful
to parents with challenging infants, but its potential role in preventive
mental health remains to be addressed. The literature also suggests that anticipatory
guidance can be effective when it is targeted to specific issues such as sleep
habits, discipline, and promoting children's learning. On the other hand,
this literature suggests that efforts to increase parents' knowledge of child
development may do so without necessarily having any impact on child development
outcomes. Finally, several studies suggested that group well-child care is
at least as good as traditional well-child care in providing basic services
in certain settings and seems to encourage the process and content of health
visits in favor of nonmedical issues.
PROBLEM-FOCUSED DEVELOPMENTAL INTERVENTION
Excessive Infant Crying
Of the many approaches to the management of colic or excessive crying
during infancy, the view that excessive crying represents a temperament-environment
mismatch has had the most consistent support in the pediatric literature.58 The treatment of excessive crying or infant colic
has been the subject of other reviews.59, 60
We do not intend to replicate these reviews or to address the dispute surrounding
the role of cow's milk protein allergy in this phenomenon. Instead, we focus
more narrowly on the evidence relevant to developmental services, in this
case the efficacy of behavioral or counseling interventions. Five controlled
studies examined the effectiveness of counseling approaches to helping parents
manage the "colicky" or "fussy" infant (Table 3). Four of the studies61, 62, 63, 64
supported the temperament-environment mismatch hypothesis, demonstrating the
efficacy of counseling parents to use specific strategies to help calm fussy
infants. In one study,65 counseling regarding
specific management techniques was no more effective than reassurance from
a pediatrician or use of a vibratory stimulus.
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Table 3. Studies Evaluating Interventions for Behavioral Problems
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Sleep Problems
Night waking and difficulties settling to sleep are also common concerns
for parents of infants and toddlers.66 Nine
controlled studies were identified that examined common clinical approaches
to the management of sleep problems, including behavioral strategies and medications
(Table 3). Studies evaluating
the effectiveness of treatment with medication for children with settling
and night waking problems suggested that it was either minimally effective
or effective under limited circumstances in the short term and no more effective
than behavioral approaches in the long term.67, 68, 69
The adverse effects of medication use were particularly troubling to some
parents.67
Behavioral approaches to sleep disturbances were effective in general.
Extinction techniques (letting the child "cry it out"), "positive" bedtime
routines (activities are given praise and encouragement), and scheduled awakenings
were all effective in treating night waking and crying or tantrums at bedtime.70, 71, 72 Behavioral modification
techniques, however, may not be useful for children with particularly severe
sleep problems.73 The effectiveness of using
written information in the management of sleep problems is uncertain, with
2 studies74, 75 showing different
outcomes with respect to reducing night waking.
In summary, the literature addressing interventions for fussy infants
and poor sleepers demonstrates efficacious behavioral counseling approaches
that are accessible to most pediatricians in office settings. Efficacy was
demonstrated for different behavioral approaches to sleep problems. Again,
the potential effectiveness across different pediatric settings is implied
and remains to be demonstrated. The role of medication therapy to manage common
sleep problems is unclear, although the degree to which it is currently prescribed
for sleep problems in this age group probably is not warranted.66
CARE COORDINATION AND MONITORING PRACTICES
Coordinating and monitoring the service needs of children with developmental
and behavioral concerns is a necessary aspect of care, although it has received
little attention in the literature. Follow-up for office interventions and
monitoring of referrals to other specialists and services are included in
this category. No studies were found that addressed this issue in primary
care pediatrics.
COMMENT
In this article, we reviewed 2 decades of pediatric literature investigating
primary care activities to promote optimal child development in the first
3 years of life. We approached this issue from a service provision perspective
by specifying a continuum of services for promoting healthy development unbundled
from the larger group of activities that comprise well-child care. Our approach
differs from that of others in the child development literature by asking
whether these activities are effective health services for accomplishing their
specific assessment, education, or intervention goals instead of asking if
these activities are important within a specific domain of development, eg,
for improving cognitive development or language development.
This perspective is based on the premise that health services in primary
care should address the needs of the developing neurological system, taking
into account our clearer understanding of the role of experience and brain
development.76 The pediatric leadership has
responded to this in concept by developing health supervision guidelines for
children based on a science of child development.1
At the same time, the need for these services is growing from the consumer's
standpoint. Parents of young children from birth to 3 years of age want these
services and view pediatricians as resources for them.4
WHAT HAVE WE LEARNED ABOUT THE EFFECTIVENESS OF DEVELOPMENTAL SERVICES?
Although a wide range of topics was selected for review, the resulting
literature base was not extensive owing to relatively stringent methodological
criteria being used for selection. Nevertheless, there is reason to be optimistic
because this literature was compelling in identifying promising approaches
toward promoting optimal child development in health care settings, in raising
important issues relevant to provision of developmental services in pediatric
practice, and in suggesting avenues for future work.
ASSESSMENT IN CLINICAL PRACTICE
The available evidence suggests that assessment of developmental issues
might benefit from the wider use of structured, validated approaches. This
pertains to addressing parents' concerns about development and behavior as
much as other areas. In addition to facilitating discussion of these concerns,
systematic assessment of parents' concerns can play a role in identifying
children with developmental problems, replacing or supplementing longer and
more costly developmental screening assessment using instruments such as the
Denver II screening test. One drawback to this approach is that it may not
be tailored with enough sensitivity to the needs of parents during the child's
first 3 years, when child-rearing concerns are high priorities. Still, it
merits more attention as a strategy for improving developmental surveillance
and may help improve the current low rate of identification of children with
developmental problems before school entry.
There are other implications for structuring care through the targeted
use of specific assessment instruments that focus on a particular developmental
domain. For example, it seems that a temperament assessment timed for 4-month
health visits may provide useful information for parents and pediatricians.
Although the potential efficacy of a temperament assessment is suggested in
the studies that were reviewed, the feasibility and effectiveness of such
assessment strategies in real-world settings has not been evaluated. Introducing
such a routine assessment may require that the 4-month visit last a little
longer, requiring modification in front and back office administration procedures
and further training of pediatricians and office personnel, as well as other
practice modifications to accommodate such a change in routine procedures.
There are other concerns about adding standardized assessment to the
periodic developmental surveillance process. In addition to increased staff
time and paperwork, structured assessments may interfere with listening to
parents and may lead clinicians to forsake the use of clinical observation
skills. Use of structured instruments must be integrated with the clinical
interview, stressing basic communication skills and skilled observation honed
by experience. Other problems include accurately interpreting the information
obtained and having adequate or appropriate places to refer children and/or
families once a problem is discovered. Indeed, greater use of validated instruments
to assess developmental progress, the psychosocial context of development,
and children's temperament represents a significant technological advance
in pediatric practice. How practices should be restructured to use these new
effective tools and techniques and how communities respond to an increase
in service needs are critical questions. One possibility is to pay attention
to the timing of assessment insofar as more extensive assessment at less frequent
intervals or at particular office visits may be more efficient than a more
cursory and less sensitive assessment at every visit.
DEVELOPMENTAL EDUCATION IN CLINICAL PRACTICE
The studies reviewed highlight several important issues relevant to
promoting optimal development in clinical practice, ie, what is largely considered
anticipatory guidance. Studies demonstrated that physicians' teaching efforts
can be effective in promoting healthy development. Advising parents about
social interaction with infants, temperament, healthy sleep habits, children's
learning, and the use of discipline were all efficacious to some degree. However,
the only direct examination of physicians' teaching efforts from 2 decades
ago suggested that these activities are not part of practicing physicians'
repertoires. The recent Commonwealth Survey of Parents suggests that little
has changed in this regard and that the needs of most parents for help and
advice with child-rearing concerns are not being met.4, 5
Part of the reason may be that physicians' teaching efforts emphasize general
development instead of more specific topics. Furthermore, activities that
do impact later development, ie, efforts to promote more positive and harmonious
social relationships and cognitively stimulating experiences between parents
and their children in the first 3 years of life, are not within the pediatric
clinical repertoire. This literature suggests that pediatric anticipatory
guidance requires restructuring to meet the demand for these activities and
to affect later development.
PRIMARY CARE INTERVENTIONS FOR DEVELOPMENTAL AND BEHAVIORAL PROBLEMS
The literature demonstrated that counseling and behavioral interventions
for excessive infant crying behavior and night waking and settling disturbances
are efficacious. The review also highlighted the limitations of medications,
which are widely prescribed, in treating infant sleep disturbances.66 The effectiveness of these interventions in pediatric
settings remains to be explored, and many questions are raised, eg, regarding
feasibility and time costs. There are also boundary issues between other behavioral
subspecialties (eg, developmental-behavioral pediatrics, psychology, and psychiatry)
that have not been defined, primarily for the management of severe sleep problems.
Health service pathways that address evaluation and management of developmental
and behavior problems and referral criteria to other subspecialists are needed.
COORDINATION OF CARE AND MONITORING OF SERVICES
This aspect of care has been neglected in the literature, although it
represents a constant logistical aggravation for many practices and a source
of frustration for parents. Pediatricians report that they are less likely
to conduct psychosocial assessments if there is not a reliable network of
family support services to refer the families that are identified as needing
care.77 Confronting an overwhelming and fragmented
service network for early intervention, special education, and social services
requires a staff with both broad and local knowledge of the service system
and a commitment to advocacy. Pediatric providers cannot be expected to assess
families for maternal depression if there is no place to send that mother
for treatment. Primary care practices expecting to provide the full range
of developmental services would benefit from information about effective practices
and the costs of addressing this aspect of care.
IMPLICATIONS FOR CLINICAL PRACTICE
Although the evidence base for developmental services has expanded since
1979,78 it is still composed primarily of efficacy
studies that demonstrate the validity of interventions or procedures in controlled
situations. Therefore, we can only note the potential of these services for
effectiveness in actual practice. The question still remains whether a difference
in the care of children can be made if pediatricians provide developmental
services more often and more effectively. It is also unclear whether pediatricians
will be able to implement these innovative practices. A recent national survey6 of selected, developmentally oriented pediatric practices
suggests that few practices actually provide formal developmental or psychosocial
assessments. At present, there seems to be a variety of barriers to the effective
provision of these services, including training and expertise, adequate reimbursement,
and availability of appropriate referral services to address discovered needs,
among other organizational constraints.
The challenge for improving the quality of pediatric health care is
to institute the most effective service package(s) and processes for providing
those services. We suggest 2 major barriers to reaching these goals. First,
the typology highlights the wide array of potential activities that can be
provided as developmental services. A major challenge is to organize these
developmental services into a practical strategy that can be provided effectively
and, at the same time, integrate other health priorities, eg, nutrition and
safety counseling. This must be done in a time-efficient manner that makes
sense within the constraints of today's busy practices. Although more recommended
activities have been added to the list of services to be provided at a routine
health supervision visit, little has been done to provide an organizational
and provision framework that would permit the effective and efficient provision
of all these services. Other than more general guidelines by the American
Academy of Pediatrics and the Maternal and Child Health Bureau, no overall
strategy exists, to our knowledge, and what actually happens in practice is
anyone's guess. We believe that an individualized approach to parents' needs
and concerns is in order, ie, one based on an assessment of parents' knowledge,
resources, attitudes, and capabilities that would enable the physician to
provide services selectively from a broader array of potential services suggested
by the overall typology.79
IMPLICATIONS FOR PHYSICIAN TRAINING
A second challenge is bridging the gap between the knowledge and skills
required in providing these services and the limited training that many clinicians
receive. The clinical skills required to determine children's and parents'
developmental and psychosocial needs, or the most appropriate intervention
for bringing about and maintaining a change in parents' behaviors, have not
been the major focus of either pediatric or family medicine training. Data
from a recent study76 of pediatric practices
highlighted that many pediatricians report the need for additional training
to appropriately address parents' psychosocial concerns. Defining these knowledge
and skill criteria is a necessary first step for evaluating effectiveness
because they enable a more accurate determination of the intensity or adequacy
of service. The outcome of this process has direct implications for physician
training.
A critical focus in training then must be the definition of competencies
in developmental and behavioral pediatrics. The Future of Pediatrics Education
II80 has reaffirmed the emphasis of the original
task force on training in child development and behavioral pediatrics in its
recommendations. The Society for Behavioral Pediatrics has released comprehensive
curriculum guidelines for residency training in developmental and behavioral
pediatrics.81 For many training programs, incorporating
those guidelines and recommendations creates significant challenges. One question
is how residency training should be restructured so that the appropriate learning
environment is created for residents. The tension created by this issue is
all too apparent in today's academic settings, which remain focused on acute
care and oriented toward the disease model. Another question pertains to the
teaching and clinical practice roles to be played by developmental-behavioral
and general pediatricians now that developmental and behavioral pediatrics
has moved closer to subspecialization. Defining and controlling a market share
is critical to the survival of a medical subspecialty,82
adding further complexity to the boundary issues raised in the "Primary Care
Interventions for Developmental and Behavioral Problems" subsection. These
factors will affect how training programs are structured and operated.
POLICY IMPLICATIONS
Although the existing literature suggests potential for the effectiveness
of several types of developmental services, policy questions remain. Who should
be responsible for the provision of developmental and behavioral assessments;
for the provision of health education and developmental promotion; and for
the payment of home-based, practice-based, and community-based interventions?
The boundary that designates where pediatric care ends and community-based
early intervention services begin is not well defined and is blurred in many
communities. This boundary is often determined by the availability of other
funding mechanisms, including local and state maternal and child health funds,
Individuals with Disabilities Education Act funding, and other early childhood
programs. In addition, because provision of developmental and behavioral assessments
can result in identification of a range of developmental and behavioral problems,
questions arise regarding payment for treatment and intervention programs.
Because a large proportion of children most at risk for adverse developmental
outcomes are also children covered by the Medicaid program (Title XIX) and
the State Child Health Insurance Program (Title XXI), these 2 governmental
programs potentially have a major role in determining what services are provided
and how they are paid for.
Therefore, although there are many convincing arguments for providing
optimal developmental support to families with young children, there are a
variety of unsettled issues regarding what services are most effective, how
these services should be provided, and who should bear the burden of payment.
At the same time, there is heightened public awareness of the importance of
early childhood development and of the need to act in the direction of providing
support and services to families. Future evaluation in this area should expand
the depth and breadth of topics investigated, involve practicing physicians
to a greater extent, and address important methodological details.
SUMMARY
In this review, we examined the evidence for the effectiveness of pediatric
health services to promote optimal child development using a new organizational
typology of the various types of activities that physicians provide in general
health supervision. Our approach was to conceptualize these activities as
an evidence-based service system that has relevance to today's clinical practice
orientation. Such an approach is necessary to develop appropriate service
provision models and systems for reimbursement and to evaluate quality of
care.
The review suggests that effective and efficient approaches to providing
developmental services exist, although most of the literature remains limited
to studies of efficacy. Nevertheless, important advances in the knowledge
base have been made with respect to assessment, education, and intervention
in this service area. Although the literature supported the efficacy of many
approaches to the provision of services in these areas, several challenges
remain in effectively implementing these services on a wide scale. Issues
related to organizing service provision packages, defining assessment and
treatment pathways, determining professional boundaries and role responsibilities
in the larger community, and implications for training and health care policy
must be addressed.
AUTHOR INFORMATION
Accepted for publication June 21, 2001.
This research was supported by The Commonwealth Fund of New York, New
York.
Presented at the Pediatric Academic Societies and American Academy of
Pediatrics Joint Meeting, May 13, 2000, Boston, Mass.
We thank Martin Stein, MD, Ed Schor, MD, Kathryn Taaffe McLearn, PhD,
and Claire B. Kopp, PhD, for their helpful comments and Phinney Ahn for her
library research assistance.
What This Study Adds
The first 3 years of a child's life are increasingly recognized as a
window of opportunity to optimize children's development. Little is known
about the effectiveness of primary health care activities intended to do so.
This study defines and examines the evidence base for services promoting child
development in the first 3 years of life with a systematic review of the literature
from the past 2 decades. The findings have implications for clinical practice,
physician training, and health care policy decisions.
From the Department of Pediatrics (Dr Regalado) and the Center for
Healthier Children, Families, and Communities (Dr Halfon), University of California–Los
Angeles Schools of Medicine and Public Health.
Corresponding author and reprints: Michael Regalado, MD, Cedars Sinai
Medical Center, 8700 Beverly Blvd, MOT 475W, Los Angeles, CA 90048 (e-mail: Michael.Regalado{at}cshs.org).
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