child health surveillance where are we in 2011 ?

Child Health Child Health SurveillanceSurveillance

Where are we in 2011Where are we in 2011 ? ?

Community paediatricsCommunity paediatrics Child Health screening, surveillance, Child Health screening, surveillance,

promotionpromotion Health Child ProgrammeHealth Child Programme Developmental paediatrics Developmental paediatrics

Aspects of paediatrics in Aspects of paediatrics in Child Health SurveillanceChild Health Surveillance

The normal childThe normal child Common childhood problems / issues Common childhood problems / issues ImmunisationImmunisation Child developmentChild development Neuro-disabilityNeuro-disability Behaviour problems / Clinical psychology Behaviour problems / Clinical psychology Growth and NutritionGrowth and Nutrition Health Promotion / preventionHealth Promotion / prevention Child protectionChild protection Looked after children / F+A Looked after children / F+A Social disadvantage / societySocial disadvantage / society

Community / general Community / general paediatrics / primary care / paediatrics / primary care /

HVHV GPGP HVHV Community paediatrics/ Developmental Community paediatrics/ Developmental

paediatricspaediatrics General paediatricsGeneral paediatrics Subspecialty paediatrics, neurology, neuro-Subspecialty paediatrics, neurology, neuro-

disabilitydisability Therapy servicesTherapy services Social ServicesSocial Services Education, nursery, preschool teachers, Portage, Education, nursery, preschool teachers, Portage,

EYSEYS

Some NHS and DOH Some NHS and DOH initiatives for Childreninitiatives for Children

Health For all children (Hall 4Health For all children (Hall 4thth edition 2006) edition 2006) NSF 2004NSF 2004 Every Child Matters 2004, 2007Every Child Matters 2004, 2007 ChildrenChildren’’s plan 2007s plan 2007 NHS PlanNHS Plan CAFCAF CNO review of nursing, midwifery and health visitingCNO review of nursing, midwifery and health visiting Laming/child protectionLaming/child protection Sure Start Sure Start Health Lives Brighter Futures DH + DCSFHealth Lives Brighter Futures DH + DCSF Healthy Child Programme 2009Healthy Child Programme 2009

26 government publications on child care referenced 26 government publications on child care referenced in Healthy Child Programme ! in Healthy Child Programme !

In the beginning….1989 In the beginning….1989 Hall 1Hall 1

Routine checks and screening first 5 years of life new Routine checks and screening first 5 years of life new proposal:proposal:

Oversight of - physicalOversight of - physical - social- social - emotional development - emotional development Measuring and recording growthMeasuring and recording growth Monitoring developmental progressMonitoring developmental progress Offering interventionOffering intervention Prim prevention of disease e.g immunisationPrim prevention of disease e.g immunisation Health education Health education Monitoring health of whole community Monitoring health of whole community

Change in emphasis in Change in emphasis in subsequent editions of Hallsubsequent editions of Hall

Developmental Screening Hall 1Developmental Screening Hall 1 Child Health Surveillance Hall 2/3Child Health Surveillance Hall 2/3 Child Health Promotion Hall 4Child Health Promotion Hall 4

Issues:Issues: Incidence / prevalence of conditionsIncidence / prevalence of conditions Defined aims / outcomes of programmeDefined aims / outcomes of programme ““ScreeningScreening”” AuditAudit

Developmental screeningDevelopmental screening

Conditions that can not screen forConditions that can not screen for Cerebral palsyCerebral palsy Developmental delay / disorderDevelopmental delay / disorder Language delayLanguage delay Language disordersLanguage disorders Learning difficultiesLearning difficulties

Developmental screeningDevelopmental screening

Recent review of screening programme using Recent review of screening programme using Denver developmental screening test, Goldman-Denver developmental screening test, Goldman-Fristoe Test of Articulation and clinical Fristoe Test of Articulation and clinical assessment indentified:assessment indentified:

Girls consistently performed at a higher Girls consistently performed at a higher developmental level than boys.developmental level than boys.

ParentParent’’s ratings of their childs ratings of their child ’’s abilities were highly s abilities were highly correlated with the childcorrelated with the child ’’s actual performance on s actual performance on screening measures. screening measures.

Socioeconomic status was also significantly related to Socioeconomic status was also significantly related to the child performance on screening measures.the child performance on screening measures.

The most frequent referrals for follow-up evaluation The most frequent referrals for follow-up evaluation were in speech, language, dental and health areas. were in speech, language, dental and health areas.

N.b. Criteria for screening testsN.b. Criteria for screening tests

Wilson and Junger criteria Wilson and Junger criteria for screeningfor screening

Important public health problemImportant public health problem Accepted treatment/ interventionAccepted treatment/ intervention Facilities for diagnosis availableFacilities for diagnosis available Latent or asymptomatic stageLatent or asymptomatic stage Suitable testSuitable test Natural history of condition understoodNatural history of condition understood Agreed definition of target disorderAgreed definition of target disorder Earlier treatment in asymptomatic phase should Earlier treatment in asymptomatic phase should

alter prognosis alter prognosis Economically viable/ Continuous case findingEconomically viable/ Continuous case finding

Surveillance for Surveillance for developmental problemsdevelopmental problems

Listening to the parentListening to the parent’’s report of the s report of the childchild’’s progresss progress

Observation of the child at each Observation of the child at each contact, contact,

Parental questioning and observation Parental questioning and observation of the child to assess developmental of the child to assess developmental normality.normality.

Should consciously focus on each of Should consciously focus on each of the 4 key areas of development the 4 key areas of development

Surveillance for Surveillance for developmental problemsdevelopmental problems

With or without specific instrument With or without specific instrument depends on:depends on:

Training,Training, Knowledge,Knowledge, Experience,Experience, SkillsSkills Participation / uptake (n.b. Inverse Participation / uptake (n.b. Inverse

Care Law)Care Law)

Health PromotionHealth Promotion

Key shift in emphasis from detection to Key shift in emphasis from detection to promotionpromotion

Health promotion and primary prevention Health promotion and primary prevention activities for young children are mainly directed activities for young children are mainly directed at parents. at parents.

It is still possible for information to be aimed It is still possible for information to be aimed directly at children, by parents or others. directly at children, by parents or others.

Attitudes are often formed at an early age and Attitudes are often formed at an early age and even degenerative disease like atheroma starts even degenerative disease like atheroma starts early in life.early in life.

Parents are strongly motivated to do the best for Parents are strongly motivated to do the best for their children and so are receptive to education their children and so are receptive to education from well before the child is born.from well before the child is born.

Health PromotionHealth Promotion ImmunisationImmunisation Breast feedingBreast feeding SmokingSmoking AlcoholAlcohol DrugsDrugs NutritionNutrition Dental healthDental health Hazards / accident preventionHazards / accident prevention BehaviourBehaviour ParentingParenting Child developmentChild development

Other issues…….Other issues…….

Service Service ““re-disorganisationsre-disorganisations”” Child health surveillance programme Child health surveillance programme

HV / GPHV / GP Re - organisation of Health servicesRe - organisation of Health services Relocation of HV to Children CentresRelocation of HV to Children Centres GP contractGP contract PCT commissioningPCT commissioning GP commissioningGP commissioning Little or no input from paediatriciansLittle or no input from paediatricians

Healthy Child Healthy Child ProgrammeProgramme

In October 2009 the Department of In October 2009 the Department of Health issued the Health issued the 'Healthy Child 'Healthy Child ProgrammeProgramme'. This gives '. This gives comprehensive advice on health and comprehensive advice on health and social care throughout a child's life. social care throughout a child's life.


““ Is the universal public health Is the universal public health programme for all children and programme for all children and families. It consists of several families. It consists of several reviews, immunisations, health reviews, immunisations, health promotion, parenting support, and promotion, parenting support, and screening tests that promote and screening tests that promote and protect the health and wellbeing of protect the health and wellbeing of children from pregnancy through to children from pregnancy through to adulthoodadulthood””


National DocumentNational Document

but -but -

““locally commissioned and implementedlocally commissioned and implemented””

3 main parts:3 main parts: Pregnancy and the first 5 years of lifePregnancy and the first 5 years of life The two year reviewThe two year review 5-19 years5-19 years


It differs from the previous schedule of child It differs from the previous schedule of child health surveillance in several key ways:health surveillance in several key ways:

Greater focus on antenatal careGreater focus on antenatal care A major emphasis on support for A major emphasis on support for bothboth

parentsparents Early identification of at risk familiesEarly identification of at risk families New vaccination programmeNew vaccination programme New focus on changed public health New focus on changed public health

prioritiespriorities


Protective factors should also be Protective factors should also be assessed, e.g. breast feeding and assessed, e.g. breast feeding and authoritative parenting combined authoritative parenting combined with warmth and affectionate with warmth and affectionate attachment being built between the attachment being built between the child and the primary care giver child and the primary care giver from infancy.from infancy.


At-risk familiesAt-risk families There is a clear There is a clear relationship between the number of relationship between the number of parent-based disadvantages and a parent-based disadvantages and a range of adverse outcomes for range of adverse outcomes for children (Social Exclusion Task children (Social Exclusion Task Force, 2007). It is estimated that Force, 2007). It is estimated that around 2% of families in Britain around 2% of families in Britain experience five or more of the experience five or more of the following disadvantages:following disadvantages:

Disadvantaged FamiliesDisadvantaged Families Both parents are unemployedBoth parents are unemployed The family live in poor quality or overcrowded The family live in poor quality or overcrowded

housinghousing Neither parent has any educational Neither parent has any educational

qualificationsqualifications Either parent has mental health problemsEither parent has mental health problems At least one parents has longstanding illness or At least one parents has longstanding illness or

disabilitydisability The family has low incomeThe family has low income The family can not afford a number of food or The family can not afford a number of food or

clothing itemsclothing items

Disadvantaged FamiliesDisadvantaged Families

Poverty and low SES have significant Poverty and low SES have significant impact on early childhood development impact on early childhood development with measurable adverse effects on:with measurable adverse effects on:

CognitiveCognitive HealthHealth Behavioural outcomesBehavioural outcomes Often co-exist with inter-related biomedical Often co-exist with inter-related biomedical

factorsfactors E.g. iugr, premature, deafness, poor access E.g. iugr, premature, deafness, poor access

to interventions - worse outcomesto interventions - worse outcomes


Adverse Cognitive outcomes related to Adverse Cognitive outcomes related to - - Less access to stimulating resourcesLess access to stimulating resources Less parent/child learning activities Less parent/child learning activities

opportunitiesopportunities Poor parent / child interactionPoor parent / child interaction Eg studies of verbal interactions and Eg studies of verbal interactions and

language outcomeslanguage outcomes Nb neuronal plasticityNb neuronal plasticity


Adverse Health outcomes related toAdverse Health outcomes related to:: NutritionNutrition Access to care transportationAccess to care transportation Accommodation / housing / adverse Accommodation / housing / adverse

environment (E.g. lead)environment (E.g. lead) AccidentsAccidents ViolenceViolence


Adverse emotional+behavioural Adverse emotional+behavioural outcomes:outcomes:

ADHDADHD DepressionDepression AnxietyAnxiety Teenage pregnancyTeenage pregnancy Substance abuseSubstance abuse HungerHunger

Evidence of interventionsEvidence of interventions

In USA - HIDP, Baltimore and In USA - HIDP, Baltimore and Brookline projects showed:Brookline projects showed:

Groups with Biological and /or Social Groups with Biological and /or Social disadvantage benefit from quality disadvantage benefit from quality comprehensive early child health comprehensive early child health development and Family supportdevelopment and Family support

Early intervention better than late Early intervention better than late interventionintervention

More cost effective than trying to More cost effective than trying to remedy deficits in later school yearsremedy deficits in later school years

Health and development Health and development reviewsreviews

The core purpose of health and The core purpose of health and development reviews is to:development reviews is to:

Assess family strengths, needs and risks. Assess family strengths, needs and risks. Give mothers and fathers the Give mothers and fathers the

opportunity to discuss their concerns opportunity to discuss their concerns and aspirations. and aspirations.

Assess growth and development. Assess growth and development. Detect abnormalities.Detect abnormalities.


The programme will be delivered by The programme will be delivered by midwifery staff, health visitors and midwifery staff, health visitors and the primary care team. the primary care team.

GPs will be responsible for some GPs will be responsible for some newborn and the majority of 6 to 8 newborn and the majority of 6 to 8 week checks.week checks.


““The majority of children will be fine but others The majority of children will be fine but others may need more support and guidance, and a may need more support and guidance, and a small minority will need intensive small minority will need intensive preventative input. Reviews can provide an preventative input. Reviews can provide an opportunity to plan a package of support opportunity to plan a package of support using local services (such as those provided in using local services (such as those provided in a a Sure Start children's centre) or for referral children's centre) or for referral to specialist services. The Common to specialist services. The Common Assessment Framework should be used where Assessment Framework should be used where there are issues that might require support to there are issues that might require support to be provided by more than one agency.”be provided by more than one agency.”


By the 12th week of pregnancy. By the 12th week of pregnancy. The neonatal examination. The neonatal examination. The new baby review (around 14 The new baby review (around 14

days old). days old). The baby's 6- to 8-week examination. The baby's 6- to 8-week examination. By the time the child is one year old. By the time the child is one year old. Between two and two-and-a-half Between two and two-and-a-half

years oldyears old


This programme shares much with the This programme shares much with the National Service Framework of 2004 but National Service Framework of 2004 but provides greater detail and places an provides greater detail and places an increased emphasis on the review at increased emphasis on the review at two two to two-and-a-halfto two-and-a-half years. years.The following are the most appropriate The following are the most appropriate opportunities for screening tests opportunities for screening tests (?)(?) and and developmental surveillance, for assessing developmental surveillance, for assessing growth, for discussing social and growth, for discussing social and emotional development with parents and emotional development with parents and children, and for linking children to early children, and for linking children to early years services.years services.

2 year review specific 2 year review specific outcomesoutcomes

Improved emotional and social wellbeing through strong Improved emotional and social wellbeing through strong parent-child attachment, positive parenting and parent-child attachment, positive parenting and supportive family relationshipssupportive family relationships

Improved learning and Speech and language Improved learning and Speech and language development through home learning environment, development through home learning environment, access to early years leaningaccess to early years leaning

Early detection of and action to address developmental Early detection of and action to address developmental delay, ill health and growth impairmentsdelay, ill health and growth impairments

High immunisation ratesHigh immunisation rates Prevention of obesityPrevention of obesity Early detection of and action to reduce poor parenting, Early detection of and action to reduce poor parenting,

domestic violence, substance misuse through effective domestic violence, substance misuse through effective safeguardingsafeguarding

Address parental concerns effectivelyAddress parental concerns effectively

2 year review – key 2 year review – key messagesmessages

Priorities are promotion of emotional development Priorities are promotion of emotional development and communication skills, support of positive and communication skills, support of positive relationships in families and obesity preventionrelationships in families and obesity prevention

Work effectively with mothers and fathers to Work effectively with mothers and fathers to develop self efficacy and support changedevelop self efficacy and support change

Reduce unequal outcomes for childrenReduce unequal outcomes for children Promote health of 2 yr olds through community Promote health of 2 yr olds through community

and health actionsand health actions Integrate with sure start centresIntegrate with sure start centres Need to get infrastructure right to support Need to get infrastructure right to support

deliverydelivery ““2yr review will need to be delivered in innovative 2yr review will need to be delivered in innovative

waysways””

What to do if concerns What to do if concerns following assessment in following assessment in

primary care ?primary care ? Referral guidelinesReferral guidelines Clearly defined pathwaysClearly defined pathways ? Healthy Child Programme service ? Healthy Child Programme service

specification and Delivery modelspecification and Delivery model

BreakBreak

Developmental problemsDevelopmental problems

Main goal early identification of Main goal early identification of developmental problemsdevelopmental problems

Early assessment / diagnosisEarly assessment / diagnosis Early interventionEarly intervention ““School readinessSchool readiness””

CDCCDC

Preshool service:Preshool service:Early diagnosis and interventionEarly diagnosis and intervention SALT, Physio, OTSALT, Physio, OT Preschool teachersPreschool teachers PortagePortage Assessment of Education NeedsAssessment of Education Needs HVHV CAHMSCAHMS Educational psychologyEducational psychology Social workersSocial workers Specialist services, nurses – condition specificSpecialist services, nurses – condition specific Preschool nursery Preschool nursery

Developmental Developmental paediatricspaediatrics

Normal child development inc Normal child development inc variantsvariants

Abnormal child developmentAbnormal child development Assessment, diagnosis, investigationAssessment, diagnosis, investigation HearingHearing VisionVision ScreeningScreening Behaviour problemsBehaviour problems Interventions………..Interventions………..

Developmental Developmental disabilitiesdisabilities

Developmental disabilities are symptom Developmental disabilities are symptom complexescomplexes

Not classified by aetiologyNot classified by aetiology Diagnosed by observed clinical featuresDiagnosed by observed clinical features Overlap between domainsOverlap between domains Definitions of normality not always clearDefinitions of normality not always clear Diagnosed over time and not at one Diagnosed over time and not at one

pointpoint

Developmental problems, Developmental problems, concepts and definitionsconcepts and definitions

Global developmental delay (mental retardation Global developmental delay (mental retardation intellectual disability, learning disability)intellectual disability, learning disability)

Speech, language, communication (DLI, SLI, Speech, language, communication (DLI, SLI, ASD)ASD)

Motor - Gross / Fine (delay, cerebral palsy, ABI, Motor - Gross / Fine (delay, cerebral palsy, ABI, NM, DCD)NM, DCD)

Hearing and Vision impairmentsHearing and Vision impairments International Classification of Functioning, International Classification of Functioning,

Disability and Health (holistic and bio-Disability and Health (holistic and bio-psychosocial model) psychosocial model)

Level of Adaptive functioningLevel of Adaptive functioning

InvestigationsInvestigations

Tailored to clinical profile / problemTailored to clinical profile / problem MetabolicMetabolic GeneticGenetic ImagingImaging NeurophysiologyNeurophysiology Special testsSpecial tests

Child development - Child development - Clinical diagnosesClinical diagnoses

Some already diagnosed and Some already diagnosed and ““in the systein the systemm ”” e.g Downs syndrome, ABI, prematurity, e.g Downs syndrome, ABI, prematurity, HIE, congenital malformationsHIE, congenital malformations

Serious illness ( cancer, heart, renal)Serious illness ( cancer, heart, renal) Duchenne MDDuchenne MD Cerebral palsyCerebral palsy Chromosomal / geneticChromosomal / genetic Language / communication - rare to find Language / communication - rare to find

causecause Many no specific medical diagnosisMany no specific medical diagnosis

Most recent studies suggest diagnosis Most recent studies suggest diagnosis made in 50-65% if children with made in 50-65% if children with globalglobal dev delay (not inc ASD)dev delay (not inc ASD)

5 main categories:5 main categories: Cerebral dysgenesisCerebral dysgenesis Intrapartum asphyxiaIntrapartum asphyxia Antenatal exposure to toxinsAntenatal exposure to toxins Genetic / chromosomal (mCGH)Genetic / chromosomal (mCGH) Profound psychosocial neglectProfound psychosocial neglect

The new The new ““paediatric paediatric morbiditymorbidity”” in school age in school age

childrenchildren ADHD ( nb infants of drug abusing ADHD ( nb infants of drug abusing

mothers)mothers) ““dyspraxiadyspraxia”” DCD DCD ASD - High functioning / AspergersASD - High functioning / Aspergers Attachment disorder / looked after Attachment disorder / looked after

childrenchildren Tics/ tourettesTics/ tourettes ““dyslexiadyslexia”” Behaviour problemsBehaviour problems Poor school performancePoor school performance

ResourcesResources

Health Child Programme e-learning Health Child Programme e-learning curriculum RCPCHcurriculum RCPCH

www.dh.gov.uk/en/healthcare/children/maternity/index.htm

www.northyorkshireandyork.nhs.uk books ??books ??

child health surveillance where are we in 2011 ?

Documents

child health promotion

child health surveillance

children health

child care

child matters

community monitoring

children hall

aspects of paediatrics