The first three years of a child's life are an important time for brain growth: they offer a window of opportunity to optimize children's development in many ways. Increasing recognition of the developmental sensitivity of this period has heightened the attention of professionals, parents, and policymakers. Among the recent trends that provide the impetus for this report are research that validates the importance of early experience for child brain development, recognition of the importance of addressing psychosocial concerns in health care (Shonkoff & Green, 1998), parents' growing need and demand for child-rearing information, and the extension of the Individuals with Disabilities Education Act (Part C) to include services for infants and toddlers. Both the American Academy of Pediatrics (AAP) and the Maternal and Child Health Bureau support and encourage the increasing focus on the provision of these kinds of services in their respective health supervision guidelines, which emphasize the promotion of optimal development.
Pediatric health care providers are positioned to play a pivotal role in delivering a variety of these services. However, managed care and related reimbursement issues have imposed constraints on the range and scope of developmental services they can provide. Changes in the criteria for authorizing and reimbursing services require that medical necessity be justified with evidence of effectiveness, and in many cases, cost effectiveness (Eddy 1997). There are also questions about what constitutes routine developmental services and how they should be provided. Both clinical practice and health care policy decision-makers require answers to these questions.
This report defines and examines the evidence for the effectiveness of health services specifically targeted at promoting optimal development in children from birth to 3 years of age. The services reviewed are provided in general pediatric settings as part of routine well-child care and health supervision. This literature was compelling in identifying promising approaches toward promoting optimal child development in health care settings, in raising important issues relevant to delivering developmental services in pediatric practice, and in suggesting avenues for future work.
Methods and Findings
We used the two major health supervision guidelines for pediatricians—AAP and the Bright Futures Project—to define the scope and array of primary care services intended to promote child development during the first three years of life. This list was augmented with service enhancements derived from innovative primary care demonstration programs such as the Commonwealth Healthy Steps Program (Zuckerman et al. 1997) and Zero to Three's Developmental Specialist Program (Eggbeer et al. 1997). We then conducted a literature search for articles published between 1979 and 1999 that evaluated the efficacy, effectiveness, or cost effectiveness of services. The 47 articles that met criteria for review were separated into four categories—assessment, education, intervention, and care coordination. Our findings are summarized by category.
Seventeen articles examined the effectiveness of surveillance and screening assessments in identifying children's risk of developmental disability and evaluating the psychosocial context of development and child behavioral characteristics.
Assessment for developmental problems
The review raises important questions about the adequacy of clinical assessment for developmental problems. Physicians identify relatively few developmental problems that would qualify a child for early intervention or special education before school entry. The reasons for this are unclear, although a reliance on non-validated "informal" assessment practices and ineffective assessment strategies may be a factor. The review suggests two alternative strategies. First, if large populations are to be screened routinely, the use of a more structured assessment at less frequent intervals may be more effective than the current AAP recommendation to address development at every health-supervision visit. Second, a short, validated questionnaire (the Parents' Evaluation of Developmental Status, or PEDS) based on parental concerns shows promise as a cost-effective strategy that warrants further evaluation in pediatric settings. From a clinical standpoint, the elicitation of parents' concerns was shown to improve communication about behavior and development at the health visit.
Assessment of the psychosocial context of development
Articles reviewed examined the effectiveness of assessments of psychosocial risk factors associated with poor parenting practices (e.g., maternal depression, substance abuse, domestic violence, and parental history of abuse as a child), as well as the quality of the home environment and the quality of mother–infant interaction. Most approaches to the assessment of these risk factors used questionnaires that were brief adaptations of longer instruments, e.g., the Kemper Family Psychosocial Questionnaire. The use of structured questionnaires by and large identified more problems than clinical judgment alone. Brief adapted measures to assess the child's home environment were shown to compare favorably to the longer validated version. Finally, a valid assessment of mother–infant interaction (e.g., observing sensitivity to infant behavior, effectiveness at soothing the infant) in the office setting was demonstrated. Although efficacy studies of psychosocial, home, and parenting assessment lead to valid measures of function, their utility and effectiveness in general pediatric practices will require additional evaluation.
Child Behavior Assessment
The literature on the assessment of behavior in children from birth to 3 years is largely limited to the literature on the assessment of temperament. Studies that examine the use of temperament questionnaires—e.g., the Infant and Toddler Temperament Questionnaires—in pediatric practice garnered general acceptance and ratings of usefulness from parents of children whose temperament was perceived as difficult. Limited validation in different practice settings and the length of the questionnaires may pose barriers to the routine use of temperament assessment in clinical practice. On the other hand, targeted assessment of temperament at certain ages—at age 4 months for example—may be a feasible and useful strategy for parents with concerns relevant to temperament. An automated system for assessing temperament, studied in a large managed care organization, shows promise.
Twenty articles qualified for review. Although there has been much emphasis on anticipatory guidance in general health supervision, surprisingly few studies examine the effectiveness of this time-honored practice. The only reviewed study of the overall effectiveness of physician teaching efforts directed toward increasing positive contact between parent and child showed that physician teaching was indirectly related to child development outcome. Yet physicians actually spend very little time encouraging positive and harmonious social interaction between parents and their children. Instead, most educational efforts that address development are limited to the discussion of developmental stages and common behavioral problems. This practice may in fact increase knowledge without necessarily having any effect on outcomes like developmental performance, mother–child interaction, or maternal perceptions and attitudes. Smaller, more narrowly focused studies demonstrate the efficacy of efforts to enhance mother–infant interaction, optimize infant sleep habits, help parents promote their children's learning, and encourage the use of time-out as a discipline technique. Taken together, this literature suggests that the straightforward teaching role in which the pediatrician's goal is increasing parents' knowledge of child development in and of itself may less be effective than assumed and, in fact, may be somewhat misguided.
Finally, several studies suggested that group well-child care is at least as good as traditional well-child care in providing basic services. The group well-child care setting appears to foster the discussion of non-medical issues, e.g., personal and child-rearing concerns, and may be an option for delivering services in certain settings.
Pediatricians are consulted frequently to help manage developmental and behavioral concerns. Fourteen studies that examine the management of two concerns often brought to their attention—excessive infant crying (infant colic) and pediatric sleep disturbances (night waking and bedtime settling disturbances)—were reviewed as representative of a wide range of potential concerns. Counseling that addressed soothing techniques was effective in reducing infant crying duration in most studies. Behavioral approaches that included ways to respond to children's crying at night or tantrum behaviors at bedtime were effective to varying degrees in managing night waking and settling problems. These studies were largely experimental studies of efficacy, and, again, their potential effectiveness as part of routine pediatric care is implied and remains to be demonstrated. The role of medication is uncertain and, at best, very limited.
We found no studies that addressed this issue in primary care pediatrics. Yet strategies for coordinating and monitoring the service needs of children with developmental and behavioral concerns are integral aspects of comprehensive care. This includes follow-up for office interventions and the monitoring of referrals to other specialists and services. Most of the few studies available in this area were program descriptions of approaches to case management outside of primary care settings for children with disabilities, e.g., during the transition from hospital to home. This aspect of care represents a constant logistical problem for many practices and a source of frustration for parents who must confront an overwhelming and fragmented service network for early intervention, special education, and social services. Pediatric providers would most likely benefit from more information about effective practices in this aspect of care.
Summary and Recommendations
Most of the studies we reviewed documented the efficacy of various screening and surveillance, educational, and intervention activities in small-scale efficacy trials, usually at one practice site or location. These studies show that the services and interventions can work. Unfortunately, and for the most part, there have been no wide-scale, multi-site effectiveness studies of these delivery approaches. The literature suggests avenues for further investigation and evaluation and makes a compelling case that these seemingly effective developmental services can be more generally employed to promote optimal child development during the first three years of life. Many of these promising approaches should be tested in broad-based effectiveness trials.
The review also suggests a need to develop more specific service-delivery pathways to improve the feasibility of wide-scale implementation. This process should include reconsideration of currently recommended clinical approaches to developmental and behavioral activities that are largely based on consensus opinion and traditions of practice. Finally, the review raises important issues relevant to the training of pediatricians and to health care policy in general. The following recommendations are offered:
- Future studies of effectiveness should examine cost- and time-efficient approaches to developmental assessment in the first three years of life.
- Further evaluation of efficient, validated approaches to developmental, psychosocial, and behavioral assessment should be done to determine the best use of these techniques in pediatric practice. Specific clinical strategies for these types of assessment are needed.
- Studies examining the effectiveness of physician teaching activities should be expanded to address methods for promoting positive social experiences between the parent and child that are harmonious in the emotional sense as much as stimulating in the cognitive sense.
- Although the literature suggests that counseling and behavioral interventions for common developmental and behavioral concerns are efficacious, their effectiveness in pediatric settings remains to be explored. The feasibility of pediatric management of developmental and behavioral concerns for today's practitioners is uncertain. Boundary issues between other behavioral subspecialties (e.g., with psychology and psychiatry) have not been defined. Guidelines for evaluating and managing concerns about development and behavior and criteria for referral to other sub-specialists should be defined and empirically evaluated.
- Strategies for care coordination and monitoring of services for children with developmental and behavioral concerns should be elaborated.
- Training should target physician attitudes toward and understanding of the concepts of developmental surveillance, screening, and early intervention.
Although most of the studies addressing the effectiveness of physicians' efforts to identify developmental disabilities predate Part C of the Individuals with Disabilities Education Act, there appears to be continued and widespread misunderstanding of these concepts and their application in routine pediatric care.