Child Health Surveillance

1. Child Health Surveillance Where are we in 2011 ?

2. Community paediatrics • Child Health screening, surveillance, promotion • Health Child Programme • Developmental paediatrics

3. 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

4. Community / general paediatrics / primary care / HV • GP • HV • Community paediatrics/ Developmental paediatrics • General paediatrics • Subspecialty paediatrics, neurology, neuro-disability • Therapy services • Social Services • Education, nursery, preschool teachers, Portage, EYS

5. Some NHS and DOH initiatives for Children • 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 !

6. In the beginning….1989 Hall 1 Routine checks and screening first 5 years of life new proposal: • Oversight of - physical • - social • - emotional development • Measuring and recording growth • Monitoring developmental progress • Offering intervention • Prim prevention of disease e.g immunisation • Health education • Monitoring health of whole community

7. Change in emphasis in subsequent editions of Hall • 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

8. Developmental screening Conditions that can not screen for • Cerebral palsy • Developmental delay / disorder • Language delay • Language disorders • Learning difficulties

9. Developmental screening 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

10. Wilson and Junger criteria for screening • 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

11. Surveillance for developmental problems • 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

12. Surveillance for developmental problems With or without specific instrument depends on: • Training, • Knowledge, • Experience, • Skills • Participation / uptake (n.b. Inverse Care Law)

13. Health Promotion Key shift in emphasis from detection to promotion • 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.

14. Health Promotion • Immunisation • Breast feeding • Smoking • Alcohol • Drugs • Nutrition • Dental health • Hazards / accident prevention • Behaviour • Parenting • Child development

15. 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

16. 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.

17. 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”

18. 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

19. 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

20. Healthy Child Programme • 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.

21. Healthy Child Programme • 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:

22. Disadvantaged Families • 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

23. 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

24. 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

25. Disadvantaged Families Adverse Health outcomes related to: • Nutrition • Access to care transportation • Accommodation / housing / adverse environment (E.g. lead) • Accidents • Violence

26. Disadvantaged Families Adverse emotional+behavioural outcomes: • ADHD • Depression • Anxiety • Teenage pregnancy • Substance abuse • Hunger

27. Evidence of interventions • 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

28. Health and development reviews • 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.

29. Healthy Child Programme • 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.

30. 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.”

31. Health and development reviews • 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

32. Health and development reviews • 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.

33. 2 year review specific outcomes • Improved emotional and social wellbeing through strong parent-child 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

34. 2 year review – key messages • 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”

36. What to do if concerns following assessment in primary care ? • Referral guidelines • Clearly defined pathways • ? Healthy Child Programme service specification and Delivery model

37. Break

38. Developmental problems • Main goal early identification of developmental problems • Early assessment / diagnosis • Early intervention • “School readiness”

39. 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

40. Developmental paediatrics • Normal child development inc variants • Abnormal child development • Assessment, diagnosis, investigation • Hearing • Vision • Screening • Behaviour problems • Interventions………..

41. Developmental disabilities • 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

42. Developmental problems, concepts and definitions • 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

43. Investigations • Tailored to clinical profile / problem • Metabolic • Genetic • Imaging • Neurophysiology • Special tests

44. Child development - Clinical diagnoses • 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

45. 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

46. The new “paediatric morbidity” in school age children • 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

47. Resources • Health Child Programme e-learning curriculum RCPCH • www.dh.gov.uk/en/healthcare/children/maternity/index.htm • www.northyorkshireandyork.nhs.uk • books ??