Child development and pediatrics for the 21st century: the healthy steps approach

Improving preventive and health promotion care for children

The emerging science in early childhood development challenges past paradigms of health care. There is consideration within the profession of paediatrics, and health care more broadly, of how to make systems of care more responsive to the developmental and social needs of young children and their families. Some countries have physician-centric models, either general physicians or paediatricians, while others rely on nurses. There is increasing recognition that the goal of any model should be parent-professional partnership that puts families at the center, elicits and responds to family needs, anticipates and supports families with developmental transitions, and fits within a seamless system of services and supports.

A modified healthy steps model to improve resident training in behavioral and developmental care

OBJECTIVE

To assess whether implementing a modified Healthy Steps (HS) for young children program in residency clinics could improve resident education and their perception of the quality of care provided for common behavioral and developmental (B/D) issues.

METHODS

Residents and faculty blinded to study intent were surveyed to assess perceptions of resident preparedness and the quality of behavioral and developmental (B/D) care at 4 pediatric residency training sites in North Carolina. Initially, Program 1 (with an established HS program) was compared with 3 sites without established programs at baseline (Programs 2, 3, and 4), and then the results before and after implementation at Programs 2 to 4 were compared.

RESULTS

Initially, subjects at Program 1 were more likely than those at Programs 2 to 4 to rate residents as "well" or "very well" prepared to provide B/D care (63% vs 20% respectively, 95% confidence interval of the difference, 25-61%) and more likely to rate the overall quality of B/D care at their clinic as "high" or "extremely high" (94% and 47% respectively, 95% confidence interval for the difference, 34-59%). After implementation of HS at Programs 2 to 4, the mean percentage of subjects rating residents as "well" or "very well" prepared and the ratings of the care provided increased dramatically.

CONCLUSION

A modified HS model focusing on resident B/D education substantially increased attending and resident ratings of residents' preparedness to deliver B/D care and increased the ratings of the quality of B/D care provided.

Healthy Steps: a systematic review of a preventive practice-based model of pediatric care

The preventive role of anticipatory guidance in pediatric practice has gained increasing importance over the last two decades, resulting in the development of competing models of practice-based care. Our goal was to systematically evaluate and summarize the literature pertaining to the Healthy Steps Program for Young Children, a widely cited and utilized preventive model of care and anticipatory guidance, Medline and the bibliographies of review articles for relevant studies were searched using the keywords: Healthy Steps, preventive care, pediatric practice and others. Other sources included references of retrieved publications, review articles, and books; government documents; and Internet sources. Relevant sources were selected on the basis of their empirical evaluation of some component of care (e.g., child outcomes, parent outcomes, quality of care). From 21 identified articles, 13 met the inclusion criteria of empirical evaluation. These evaluations were summarized and compared. Results indicated that the Healthy Steps program has been rigorously evaluated and shown to be effective in preventing negative child and parent outcomes and enhancing positive outcomes. Despite limited information concerning cost effectiveness, the Healthy Steps Program provides clear benefit through early screening, family-centered care, and evidence-based anticipatory guidance. It is recommended that the Healthy Steps program be more widely disseminated to relevant stakeholders, and further enhanced by improved linguistic and cultural sensitivity and long term evaluation of cost effectiveness.

Improving health and building human capital through an effective primary care system

To improve population health, one must put emphasis on reducing health inequities and enhancing health protection and disease prevention, and early diagnosis and treatment of diseases by tackling the determinants of health at the downstream, midstream, and upstream levels. There is strong theoretical and empirical evidence for the association between strong national primary care systems and improved health indicators. The setting approach to promote health such as healthy schools, healthy cities also aims to address the determinants of health and build the capacity of individuals, families, and communities to create strong human and social capitals. The notion of human and social capitals begins to offer explanations why certain communities are unable to achieve better health than other communities with similar demography. In this paper, a review of studies conducted in different countries illustrate how a well-developed primary health care system would reduce all causes of mortalities, improve health status, reduce hospitalization, and be cost saving despite a disparity in socioeconomic conditions. The intervention strategy recommended in this paper is developing a model of comprehensive primary health care system by joining up different settings integrating the efforts of different parties within and outside the health sector. Different components of primary health care team would then work more closely with individuals and families and different healthy settings. This synergistic effect would help to strengthen human and social capital development. The model can then combine the efforts of upstream, midstream, and downstream approaches to improve population health and reduce health inequity. Otherwise, health would easily be jeopardized as a result of rapid urbanization.

The timing of maternal depressive symptoms and mothers' parenting practices with young children: implications for pediatric practice

BACKGROUND

The prevalence of maternal depressive symptoms and its associated consequences on parental behaviors, child health, and development are well documented. Researchers have called for additional work to investigate the effects of the timing of maternal depressive symptoms at various stages in the development of the young child on the emergence of developmentally appropriate parenting practices. For clinicians, data are limited about when or how often to screen for maternal depressive symptoms or how to target anticipatory guidance to address parental needs.

PURPOSE

We sought to determine whether concurrent maternal depressive symptoms have a greater effect than earlier depressive symptoms on the emergence of maternal parenting practices at 30 to 33 months in 3 important domains of child safety, development, and discipline.

METHODOLOGY

Secondary analyses from the Healthy Steps National Evaluation were conducted for this study. Data sources included a self-administered enrollment questionnaire and computer-assisted telephone interviews with the mother when the Healthy Steps children were 2 to 4 and 30 to 33 months of age. The 30- to 33-month interview provided information about 4 safety practices (ie, always uses car seat, has electric outlet covers, has safety latches on cabinets, and lowered temperature on the water heater), 6 child development practices (ie, talks daily to child while working, plays daily with child, reads daily to child, limits child television and video watching to <2 hours a day, follows > or = 3 daily routines, and being more nurturing), and 3 discipline practices (ie, uses more reasoning, uses more harsh punishment, and ever slapped child on the face or spanked the child with an object). The parenting practices were selected based on evidence of their importance for child health and development, near complete data, and sample variability. The discipline practices were constructed from the Parental Response to Misbehavior Scale. Maternal depressive symptoms were assessed using a 14-item modified version of the Center for Epidemiologic Studies-Depression Scale. Multiple logistic regression models estimated the effect of depressive symptoms on parenting practices, adjusted for baseline demographic characteristics, Healthy Steps participation, and site. No significant interactions were found when testing analytic models with dummy variables for depressive symptoms at 2 to 4 months only, 30 to 33 months only, and at both times; reported models do not include interaction terms. We report main effects of depressive symptoms at 2 to 4 and 30 to 33 months when both are included in the model.

RESULTS

Of 5565 families, 3412 mothers (61%) completed 2- to 4- and 30- to 33-month interviews and provided Center for Epidemiologic Studies-Depression Scale data at both times. Mothers with depressive symptoms at 2 to 4 months had reduced odds of using car seats, lowering the water heater temperature, and playing with the child at 30 to 33 months. Mothers with concurrent depressive symptoms had reduced odds of using electric outlet covers, using safety latches, talking with the child, limiting television or video watching, following daily routines, and being more nurturing. Mothers with concurrent depressive symptoms had increased odds of using harsh punishment and of slapping the child on the face or spanking with an object.

CONCLUSIONS

The study findings suggest that concurrent maternal depressive symptoms have stronger relations than earlier depressive symptoms, with mothers not initiating recommended age-appropriate safety and child development practices and also using harsh discipline practices for toddlers. Our findings, however, also suggest that for parenting practices that are likely to be established early in the life of the child, it may be reasonable that mothers with early depressive symptoms may continue to affect use of those practices by mothers. The results of our study underscore the importance of clinicians screening for maternal depressive symptoms during the toddler period, as well as the early postpartum period, because these symptoms can appear later independent of earlier screening results. Providing periodic depressive symptom screening of the mothers of young patients has the potential to improve clinician capacity to provide timely and tailored anticipatory guidance about important parenting practices, as well as to make appropriate referrals.

Maternal depressive symptoms and children's receipt of health care in the first 3 years of life

BACKGROUND

Maternal depression is widely recognized to negatively influence mother-child interactions and children's behavior and development, but little is known about its relation to children's receipt of health care.

OBJECTIVE

To determine if maternal depressive symptoms reported at 2 to 4 and 30 to 33 months postpartum are associated with children's receipt of acute and preventive health care services in the first 30 months.

DESIGN

Cohort study of data collected prospectively as part of the National Evaluation of Healthy Steps for Young Children (HS). Data sources included medical records abstracted for the first 32 months, enrollment questionnaires, and parent interviews when children were 2 to 4 and 30 to 33 months old. Acute care use included hospitalizations and emergency department visits. Preventive care included well-child visits and vaccinations. Maternal depressive symptoms were assessed by using the Center for Epidemiologic Studies-Depression Scale. Generalized linear models (logistic regression for dichotomous outcomes and Poisson regression for count outcomes) were used to estimate the effect of maternal depressive symptoms on children's receipt of care. The models were adjusted for baseline demographic characteristics, child health status, participation in HS, and site of enrollment.

RESULTS

Of the 5565 families enrolled in HS, 88% completed 2- to 4-month parent interviews, 67% completed 30- to 33-month parent interviews, and 96% had medical records abstracted. The percentages of mothers reporting depressive symptoms were 17.8% at 2 to 4 months, 15.5% at 30 to 33 months, and 6.4% at both. Children whose mothers had depressive symptoms at 2 to 4 months had increased use of acute care reported at 30 to 33 months including emergency department visits in the past year (odds ratio [OR]: 1.44; confidence interval [CI]: 1.17, 1.76). These children also had decreased receipt of preventive services including age-appropriate well-child visits (eg, at 12 months [OR: 0.80; CI: 0.67, 0.95]) and up-to-date vaccinations at 24 months for 4 doses of diphtheria, tetanus, pertussis, 3 doses of polio vaccine, and 1 dose of measles-mumps-rubella (OR: 0.79; CI: 0.68, 0.93). There was no association of maternal depressive symptoms at 30 to 33 months with children's preceding use of care.

CONCLUSIONS

Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children. Increased provider training for recognizing maternal depressive symptoms in office settings, more effective systems of referral, and development of partnerships between adult and pediatric providers could contribute to enhanced receipt of care among young children.

Narrowing the income gaps in preventive care for young children: families in healthy steps

Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern. Recently, there have been efforts to promote developmental services as part of primary care for all young children. However, there is limited research to determine whether the neediest families are well in universal interventions. In our study, we assessed if disparities persist in utilization of developmental services, well child care, and satisfaction with care among low-, middle-, and high-income families participating in Healthy Steps for Young Children. Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age. In the United States, 15 pediatric practices participated in this prospective study. At birth, 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age. The utilization of developmental services, satisfaction with care, and receipt of age-appropriate well child visits were measured at 30-33 months and adjusted for demographic and economic covariates. We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more Healthy Steps services, a home visit, or discussing five or more child rearing topics. Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read. The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits. A universal practice-based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services, timely well child care, and satisfaction with care.

Developmental services in primary care for low-income children: clinicians' perceptions of the Healthy Steps for Young Children program

Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians' ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N = 104) and at 30 months (N = 91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reimbursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program.

Expanding developmental and behavioral services for newborns in primary care: implications of the findings

BACKGROUND

In two other papers in this issue, the rationale, development, implementation, experimental design, approach to evaluation, and early results of a program to deliver developmental and behavioral services to all infants in primary care practice were described. Positive effects were seen for parental satisfaction, including decreased disenrollment, provider satisfaction, parenting practices, and health outcomes.

METHODS

In the present article, the results are reviewed and implications of our findings for the delivery of care, families, healthcare systems, and further research are discussed.

RESULTS

Findings that have broad implications are as follows: (1) developmental and behavioral services can be delivered successfully in practice using dedicated professionals to deliver and integrate services; (2) the "planned care model" was useful in program implementation for making "the right thing to do, the easy thing to do"; (3) the added focus on satisfaction and cost helps to develop the "business case" for broad scale implementation; (4) bonding of parents to organizations has marketing implications; (5) the program provides positive effects for all parents, not just high-risk parents; and (6) several research questions emerge, including persistence of effects on health outcomes, costs, and utilization.

CONCLUSIONS

The authors conclude that study results have implications for preventive services, families, child healthcare in office practice, healthcare systems, and healthcare policy. In this ongoing study, examination of intervention effects at 30 months of age shoud be informative. Further research is warranted as it remains to be seen whether or not these interventions can become viable ongoing programs.

Expanding developmental and behavioral services for newborns in primary care; Effects on parental well-being, practice, and satisfaction

BACKGROUND

Healthy Steps (HS) was designed to address, prospectively, behavioral and developmental support needs of young families in pediatric clinical care settings. PrePare (PP) initiates these services prenatally, whereas HS begins services in the postnatal period. Both interventions have universal and risk-directed components. Intervention effects in the first 3 months after birth are reported here.

METHODS

A quasi-experimental design was used to allocate 439 participants to intervention or usual care conditions. Within the intervention group, enrollees were randomly assigned to receive HS or PP+HS services. Early outcomes were assessed by telephone survey at 1 week and 3 months postpartum.

RESULTS

Mothers in either intervention condition were less likely to report depressive symptoms and more likely to describe themselves as pleased in their role as parents. Intervention families were more likely to continue breastfeeding and more likely to read to their 3-month-old. Knowledge of infant development and recognition of appropriate discipline was greater among intervention recipients. Satisfaction with pediatric care was higher among intervention recipients and the rate of health plan disenrollment was 75% lower at 3 months among those enrolled in the prenatal intervention. No other outcome difference emerged between HS and PP+HS enrollees.

CONCLUSIONS

Receipt of either intervention was associated with positive effects on health, safety, and developmentally appropriate parenting, as assessed in early infancy. There were positive effects on health plan disenrollment. No additional benefit could be ascribed to prenatal institution of services. A combination of universal and risk-based support for new parents is recommended, rather than the provision of risk-based services alone.

Expanding developmental and behavioral services for newborns in primary care: program design, delivery, and evaluation framework

BACKGROUND

Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP).

METHODS

The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan.

RESULTS

The sample of 439 families was distributed as follows: usual care (n=136), prenatal initiation of services (PP+HS; n=151), and postnatal Healthy Steps (HS; n=152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services.

CONCLUSIONS

The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.

Effectiveness of anticipatory guidance: recent developments

PURPOSE OF REVIEW

Anticipatory guidance is a key component of child health supervision. This review discusses the latest evidence on the effectiveness of anticipatory guidance and its impact on child and family functioning.

RECENT FINDINGS

Anticipatory guidance on parent-infant interaction, sleep patterns, and injury prevention improve functional outcomes of children and their families. Recent findings also demonstrate that encouraging parents to share books with their children and free book distribution during well child care visits are associated with improved child language development and increased home literacy activities. Guidance promoting injury prevention and reading at home is supported by the best evidence.

SUMMARY

Future models of child health supervision should address missed opportunities for anticipatory guidance and parents' desire for more information about what they can do to enhance their children's growth, development, and functioning.

Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff

OBJECTIVE

To investigate how introducing early child-development specialists (Healthy Steps Specialists) and enhanced developmental services into routine pediatric care affects perspectives of clinicians and staff.

METHODS

Self-administered questionnaires were completed at baseline and at 30 months by clinicians, clinical staff, and nonclinical staff at pediatric sites participating in the evaluation of the Healthy Steps for Young Children Program. The evaluation included 6 randomization and 9 quasi-experimental sites. Barriers to providing well-child care, visit length, perceptions of care provided, and topics discussed with parents were assessed.

RESULTS

Over time, despite persistent barriers to delivering high-quality services, clinicians were more likely to report being satisfied with their clinical staff's ability to meet developmental and behavioral needs of children. Moreover, clinicians were more likely to report discussing the importance of routines with control rather than with intervention families, suggesting a reliance on Healthy Steps Specialists. There was no effect on visit length. Thirty months after introducing Healthy Steps Specialists and enhanced services, nearly all clinicians agreed or strongly agreed that the Healthy Steps Specialists talked with parents about their child's development, showed them activities to do with their child, and provided emotional support. Involvement of the Healthy Steps Specialist in these activities was reported more by clinicians than by clinical staff and least by nonclinical staff.

CONCLUSIONS

Clinicians acknowledged the activities performed by and contributions of the developmental specialists. Differences in perspectives of personnel may reflect different interactions among families, developmental specialists, and practice staff.