Transcript Developmental paediatrics - York General Practice VTS

Child Health Surveillance
Where are we in 2011 ?
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Community paediatrics
Child Health screening, surveillance, promotion
Health Child Programme
Developmental paediatrics
Aspects of paediatrics in Child
Health Surveillance
The normal child
Common childhood problems / issues
Immunisation
Child development
Neuro-disability
Behaviour problems / Clinical psychology
Growth and Nutrition
Health Promotion / prevention
Child protection
Looked after children / F+A
Social disadvantage / society
Community / general paediatrics /
primary care / HV
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GP
HV
Community paediatrics/ Developmental paediatrics
General paediatrics
Subspecialty paediatrics, neurology, neuro-disability
Therapy services
Social Services
Education, nursery, preschool teachers, Portage, EYS
Some NHS and DOH initiatives for
Children
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Health For all children (Hall 4th edition 2006)
NSF 2004
Every Child Matters 2004, 2007
Children’s plan 2007
NHS Plan
CAF
CNO review of nursing, midwifery and health visiting
Laming/child protection
Sure Start
Health Lives Brighter Futures DH + DCSF
Healthy Child Programme 2009
26 government publications on child care referenced in Healthy Child
Programme !
In the beginning….1989 Hall 1
Routine checks and screening first 5 years of life new proposal:
 Oversight of
- physical
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- social
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- emotional development
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Measuring and recording growth
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Monitoring developmental progress
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Offering intervention
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Prim prevention of disease e.g immunisation
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Health education
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Monitoring health of whole community
Change in emphasis in subsequent
editions of Hall
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Developmental Screening Hall 1
Child Health Surveillance Hall 2/3
Child Health Promotion Hall 4
Issues:
 Incidence / prevalence of conditions
 Defined aims / outcomes of programme
 “Screening”
 Audit
Developmental screening
Conditions that can not screen for
 Cerebral palsy
 Developmental delay / disorder
 Language delay
 Language disorders
 Learning difficulties
Developmental screening
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Recent review of screening programme using Denver
developmental screening test, Goldman-Fristoe Test of
Articulation and clinical assessment indentified:
Girls consistently performed at a higher developmental level
than boys.
Parent’s ratings of their child’s abilities were highly correlated
with the child’s actual performance on screening measures.
Socioeconomic status was also significantly related to the child
performance on screening measures.
The most frequent referrals for follow-up evaluation were in
speech, language, dental and health areas.
N.b. Criteria for screening tests
Wilson and Junger criteria for
screening
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Important public health problem
Accepted treatment/ intervention
Facilities for diagnosis available
Latent or asymptomatic stage
Suitable test
Natural history of condition understood
Agreed definition of target disorder
Earlier treatment in asymptomatic phase should alter prognosis
Economically viable/ Continuous case finding
Surveillance for developmental
problems
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Listening to the parent’s report of the child’s
progress
Observation of the child at each contact,
Parental questioning and observation of the
child to assess developmental normality.
Should consciously focus on each of the 4 key
areas of development
Surveillance for developmental
problems
With or without specific instrument depends on:
 Training,
 Knowledge,
 Experience,
 Skills
 Participation / uptake (n.b. Inverse Care Law)
Health Promotion
Key shift in emphasis from detection to promotion
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Health promotion and primary prevention activities for
young children are mainly directed at parents.
It is still possible for information to be aimed directly at
children, by parents or others.
Attitudes are often formed at an early age and even
degenerative disease like atheroma starts early in life.
Parents are strongly motivated to do the best for their
children and so are receptive to education from well
before the child is born.
Health Promotion
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Immunisation
Breast feeding
Smoking
Alcohol
Drugs
Nutrition
Dental health
Hazards / accident prevention
Behaviour
Parenting
Child development
Other issues…….
Service “re-disorganisations”
 Child health surveillance programme HV / GP
 Re - organisation of Health services
 Relocation of HV to Children Centres
 GP contract
 PCT commissioning
 GP commissioning
 Little or no input from paediatricians
Healthy Child Programme
In October 2009 the Department of Health
issued the 'Healthy Child Programme'. This
gives comprehensive advice on health and social
care throughout a child's life.
Healthy Child Programme
“ Is the universal public health programme for all
children and families. It consists of several
reviews, immunisations, health promotion,
parenting support, and screening tests that
promote and protect the health and wellbeing of
children from pregnancy through to adulthood”
Healthy Child Programme
National Document
but “locally commissioned and implemented”
3 main parts:
 Pregnancy and the first 5 years of life
 The two year review
 5-19 years
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Healthy Child Programme
It differs from the previous schedule of child
health surveillance in several key ways:
 Greater focus on antenatal care
 A major emphasis on support for both parents
 Early identification of at risk families
 New vaccination programme
 New focus on changed public health priorities
Healthy Child Programme
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Protective factors should also be assessed, e.g.
breast feeding and authoritative parenting
combined with warmth and affectionate
attachment being built between the child and the
primary care giver from infancy.
Healthy Child Programme
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At-risk families There is a clear relationship
between the number of parent-based
disadvantages and a range of adverse outcomes
for children (Social Exclusion Task Force,
2007). It is estimated that around 2% of families
in Britain experience five or more of the
following disadvantages:
Disadvantaged Families
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Both parents are unemployed
The family live in poor quality or overcrowded housing
Neither parent has any educational qualifications
Either parent has mental health problems
At least one parents has longstanding illness or
disability
The family has low income
The family can not afford a number of food or clothing
items
Disadvantaged Families
Poverty and low SES have significant impact on early
childhood development with measurable adverse
effects on:
 Cognitive
 Health
 Behavioural outcomes
 Often co-exist with inter-related biomedical factors
 E.g. iugr, premature, deafness, poor access to
interventions - worse outcomes
Disadvantaged Families
Adverse Cognitive outcomes related to  Less access to stimulating resources
 Less parent/child learning activities
opportunities
 Poor parent / child interaction
 Eg studies of verbal interactions and language
outcomes
 Nb neuronal plasticity
Disadvantaged Families
Adverse Health outcomes related to:
 Nutrition
 Access to care transportation
 Accommodation / housing / adverse
environment (E.g. lead)
 Accidents
 Violence
Disadvantaged Families
Adverse emotional+behavioural outcomes:
 ADHD
 Depression
 Anxiety
 Teenage pregnancy
 Substance abuse
 Hunger
Evidence of interventions
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In USA - HIDP, Baltimore and Brookline
projects showed:
Groups with Biological and /or Social
disadvantage benefit from quality
comprehensive early child health development
and Family support
Early intervention better than late intervention
More cost effective than trying to remedy
deficits in later school years
Health and development reviews
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The core purpose of health and development
reviews is to:
Assess family strengths, needs and risks.
Give mothers and fathers the opportunity to
discuss their concerns and aspirations.
Assess growth and development.
Detect abnormalities.
Healthy Child Programme
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The programme will be delivered by midwifery
staff, health visitors and the primary care team.
GPs will be responsible for some newborn and
the majority of 6 to 8 week checks.
Health and development reviews
“The majority of children will be fine but others may need
more support and guidance, and a small minority will
need intensive preventative input. Reviews can provide
an opportunity to plan a package of support using local
services (such as those provided in a Sure Start
children's centre) or for referral to specialist services.
The Common Assessment Framework should be used
where there are issues that might require support to be
provided by more than one agency.”
Health and development reviews
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By the 12th week of pregnancy.
The neonatal examination.
The new baby review (around 14 days old).
The baby's 6- to 8-week examination.
By the time the child is one year old.
Between two and two-and-a-half years old
Health and development reviews
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This programme shares much with the National
Service Framework of 2004 but provides greater
detail and places an increased emphasis on the
review at two to two-and-a-half years.
The following are the most appropriate
opportunities for screening tests (?) and
developmental surveillance, for assessing
growth, for discussing social and emotional
development with parents and children, and for
linking children to early years services.
2 year review specific outcomes
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Improved emotional and social wellbeing through strong parentchild attachment, positive parenting and supportive family
relationships
Improved learning and Speech and language development
through home learning environment, access to early years leaning
Early detection of and action to address developmental delay, ill
health and growth impairments
High immunisation rates
Prevention of obesity
Early detection of and action to reduce poor parenting, domestic
violence, substance misuse through effective safeguarding
Address parental concerns effectively
2 year review – key messages
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Priorities are promotion of emotional development and
communication skills, support of positive relationships in
families and obesity prevention
Work effectively with mothers and fathers to develop self
efficacy and support change
Reduce unequal outcomes for children
Promote health of 2 yr olds through community and health
actions
Integrate with sure start centres
Need to get infrastructure right to support delivery
“2yr review will need to be delivered in innovative ways”
What to do if concerns following
assessment in primary care ?
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Referral guidelines
Clearly defined pathways
? Healthy Child Programme service
specification and Delivery model
Break
Developmental problems
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Main goal early identification of developmental
problems
Early assessment / diagnosis
Early intervention
“School readiness”
CDC
Preshool service:
Early diagnosis and intervention
 SALT, Physio, OT
 Preschool teachers
 Portage
 Assessment of Education Needs
 HV
 CAHMS
 Educational psychology
 Social workers
 Specialist services, nurses – condition specific
 Preschool nursery
Developmental paediatrics
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Normal child development inc variants
Abnormal child development
Assessment, diagnosis, investigation
Hearing
Vision
Screening
Behaviour problems
Interventions………..
Developmental disabilities
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Developmental disabilities are symptom
complexes
Not classified by aetiology
Diagnosed by observed clinical features
Overlap between domains
Definitions of normality not always clear
Diagnosed over time and not at one point
Developmental problems, concepts
and definitions
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Global developmental delay (mental retardation intellectual
disability, learning disability)
Speech, language, communication (DLI, SLI, ASD)
Motor - Gross / Fine (delay, cerebral palsy, ABI, NM, DCD)
Hearing and Vision impairments
International Classification of Functioning, Disability and Health
(holistic and bio-psychosocial model)
Level of Adaptive functioning
Investigations
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Tailored to clinical profile / problem
Metabolic
Genetic
Imaging
Neurophysiology
Special tests
Child development - Clinical
diagnoses
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Some already diagnosed and “in the system” e.g Downs
syndrome, ABI, prematurity, HIE, congenital
malformations
Serious illness ( cancer, heart, renal)
Duchenne MD
Cerebral palsy
Chromosomal / genetic
Language / communication - rare to find cause
Many no specific medical diagnosis
Most recent studies suggest diagnosis made in 50-65%
if children with global dev delay (not inc ASD)
5 main categories:
 Cerebral dysgenesis
 Intrapartum asphyxia
 Antenatal exposure to toxins
 Genetic / chromosomal (mCGH)
 Profound psychosocial neglect
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The new “paediatric morbidity” in
school age children
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ADHD ( nb infants of drug abusing mothers)
“dyspraxia” DCD
ASD - High functioning / Aspergers
Attachment disorder / looked after children
Tics/ tourettes
“dyslexia”
Behaviour problems
Poor school performance
Resources
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Health Child Programme e-learning curriculum
RCPCH
www.dh.gov.uk/en/healthcare/children/matern
ity/index.htm
www.northyorkshireandyork.nhs.uk
books ??