Running head: THE ENHANCED 18-MONTH WELL BABY VISIT
Research Proposal: Physician Barriers to Enhanced 18-month Well Baby Visit
The early period of the child's life is increasingly recognized as an important time for brain growth and a window of opportunity to optimize children's development. There has been recent focus at the state and national level into policy initiatives aimed at improving pediatric care, especially at this developmentally sensitive period. Although the importance of providing appropriate developmental services during this sensitive period is widely recognized, there are significant barriers in realizing these efforts in the current pediatric practice environment. This literature review will examine the pediatric services that promote the optimal development of developing children in their early years with the belief that improving the provision of effective developmental services can improve child developmental outcomes. The following five articles in this literature review will attempt to demonstrate and support this hypothesis.
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In the research article by Regalado & Halfon (2001) the specific question that guides the study: Is there is an evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years? Forty seven peer reviewed publications were selected that addressed clinical evaluations of primary care services. The results found that 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, the results support the efficacy of primary care education efforts toward promoting optimal parent-child interactions, parents' understanding of child temperament, book-sharing activities, and approaches to health sleep habits; and office interventions such as counseling for the management of excessive infant crying and sleep problems. The results confirm the hypothesis that many primary care activities promoting the optimal development of children are efficacious (Regalado & Halfon, 2001). The authors work provided a literature base although not extensive, which reduced the study's persuasiveness. Nevertheless, this literature identified promising approaches toward promoting optimal child development in health care settings and raised important issues relevant to the provision of developmental services in pediatric practice (Regalado & Halfon, 2001).
To address what is known about pediatric care overall and in particular the preventive and developmental health care, Bethell, Peck Reuland, Halfon, & Schor (2004) generated a national picture of performance in this area for children aged 4 to 35 months. The authors used 4 composite quality measures in the areas of anticipatory guidance and parental education, screening for family psychosocial risks, screening for smoking and drug and alcohol use in the home, and provision of family centered care. Using a standardized telephone interview of a randomized sample of 2068 participants, the authors found that performance was highest in the areas of family-centered care and screening for smoking and drug and alcohol use in the home; with lowest areas of anticipatory guidance and education and assessment for family psychosocial risks. The limitations of this study rested in the preference scoring method presuming no benefit to parents in unaddressed guidance topics and small sample size in subgroups of children with potential differences. This article agreed with Regalado & Halfon (2001) that primary health care can optimize development in young children, however confirming the need for improving the quality of preventive and developmental services for young children in the United States (Bethell, et al., 2004).
Families of children with a disability or at risk must enter the process of getting intervention services. Bailey, Hebbeler, Scarborough, Spiker, & Mallik (2004) studied the first experience on a national perspective, interviewing a nationally representative sample of 3338 families. The authors concluded that the beginning of early intervention services generally is highly successful and responsive; a finding that should give pediatricians more confidence in referring families for early intervention services. However, noting that efforts were needed to develop strategies to assure that all families received services in a timely and appropriate fashion. The findings that early intervention services were successful and could enhance quality of care for families with young children are reinforced by the results of Minkovitz, Strobino, Mistry, Scharfstein, Grason, Hou, Ialongo, & Guyer (2008) who showed that selected parent practices could last beyond the duration of the intervention. These researchers studied Health Steps for Young Children (HS) which was a universal, practice-based intervention that enhanced the delivery of behavioral and developmental services that relied on partnerships between developmental specialists and families introduced in the first 3 years of life. HS families (n=1724) and controls were interviewed at 5.5 years. The study was limited by reliance on parental reports for children's behavior and social skills, not considering other provider reports, however provided further evidence of the benefits of early childhood intervention.
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To effectively identify developmentally delayed children, Rydz, Srour, Oskoui, Marget, Shiller, Birnbaum, Majnemer, & Shevell (2006) assessed screening in a setting of a community pediatric clinic using a prospective assessment of parent-report questionnaires. The authors concluding that this was a feasible method, but also determined that the pediatrician's opinion had little effect on accuracy. This assessment however did not meet the requisite standard for developmental screening current recommendations.
This literature review found that promoting the optimal development of young children in their early years with the provision of effective developmental services can improve child development outcomes (Bailey, et al., 2004; Regalado & Halfon, 2001; Bethell, et al., 2004) with improved longer term benefits beyond the duration of the intervention (Minkovitz, et al., 2008). Rydz, et al. (2006) also provided an effective and cost effective tool for identifying developmentally delayed children. The 18-month well baby visit remains an important routine assessment, with the potential for enhancement, however further studies are required to identify barriers, particularly of the primary care giver, to effective developmental screening and linkages with appropriate early childhood intervention services.
Bailey, D. B., Hebbeler, K., Scarborough, A., Spiker, d., & Mallik, S. (2004). First experiences with early intervention: A national perspective. Pediatrics, 113(4), 887- 896.
Bethell, C., Peck Reuland, C. H., Halfon, N., & Schor E. L. (2004). Measuring the quality of preventive and developmental services for young children: National estimates and patterns of clinicians' performance. Pediatrics, 113(6), 1973-1983.
Minkovitz, C. S., Strobino, D., Mistry, K. B., Scharfstein, D. O., Grason, H., Hou, W., Ialongo, N., & Guyer, B. (2007). Healthy steps for young children: Sustained results at 5.5 years. Pediatrics, 120(3), 658-668.
Regalado, M., & Halfon, N. (2001). Primary care services promoting optimal child development form birth to age 3 years [Review of the literature]. Archives of Pediatric Adolescent Medicine, 155, 1311-1322.
Rydz, D., Srour, M., Oskoui, M., Marget, N., Shiller, M., Birnbaum, R., Majnemer, A., & Shevell, M. I. (2006). Screening for developmental delay in the setting of a community pediatric clinic: A prospective assessment of parent-report questionnaires. Pediatrics, 118(4), 1178-1186.