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Paul H. Dworkin, MD Annual Meeting New Jersey Chapter of the AAP May 13, 2015 Somerset, NJ Critical influence of early childhood years Less-differentiated brain of younger child amenable to intervention Neural plasticity

  1. Paul H. Dworkin, MD Annual Meeting New Jersey Chapter of the AAP May 13, 2015 Somerset, NJ • Critical influence of early childhood years • Less-differentiated brain of younger child amenable to intervention • Neural plasticity • Sensitive periods • Sequential development of brain structures • Activity-dependent neural differentiation • Role of experience in brain development • Biology of adversity/toxic stress • ACE Study • “Biological embedding of environmental events” Definition of surveillance Use of screening tools at  Flexible, longitudinal, continuous process periodic intervals to strengthen surveillance  Knowledgeable practitioners perform skilled observations during • Types child health encounters • Parent-completed questionnaires Components of surveillance: • Professionally-administered “tests”  Eliciting/attending to parents’ concerns • Frequency  Obtaining a relevant developmental history • 9, 18, 24-30 months  Making accurate observations of children • When concerns arise  Identifying risk and resiliency factors • (“second-stage”)  Maintaining record of process and findings  [Sharing opinions with other professionals] View child within context of overall well-being 1

  2. Criteria for judging conditions appropriate for the Criteria by which specific tests are judged appropriate screening process for use in screening programs • Must have significant morbidity or mortality and be sufficiently prevalent • Simple, convenient, acceptable • Screening program must include entire population • Reliable, valid (sensitive and specific) • Diagnostic tests must distinguish affected from non-affected • Economical persons • Lend themselves to easy interpretation • Condition must treatable or controllable • Detection and treatment during asymptomatic stage much improve prognosis • Adequate resources must be available for definitive diagnosis and treatment • Cost of screening must be outweighed by savings in suffering and alternative expenditures Concerns Information available from parents Information available from parents Accurate indicators of true problems • Speech and language Appraisals (opinions of children’s development) Appraisals (opinions of children’s development) • Fine motor • Concerns • Concerns • General functioning (“he’s just slow”) • Estimations • Estimations Self-help skills, behavior less sensitive • Predictions • Predictions “ Please tell me any concerns about the way your child Descriptions Descriptions is behaving, learning, and developing” • Recall • Recall • “Any concerns about how she…” • Report • Report Estimations Recall of developmental milestones • “Compared with other children, how old would you • notoriously unreliable say your child now acts?” • reflect prior conceptions of children’s development • correlate well with developmental quotients • accuracy improved by records, diaries o cognitive, motor, self-help, academic skills o less accurate for language abilities • even if accurate, age of achievement of limited Predictions predictive value • likely to overestimate future function o if delayed, predict average functioning o if average, “presidential syndrome” 2

  3. Report Advantages Advantages • accurate contemporaneous descriptions of current  ease of administration  ease of administration skills and achievements  do not require child’s cooperation  do not require child’s cooperation • importance of format of questions  broad sampling of skills  broad sampling of skills  flexible administration methods  flexible administration methods o recognition : “Does your child use any of the following words…” o mailed prior to visit o mailed prior to visit o identification: “What words does your child say?” o complete in waiting room o complete in waiting room • produces higher estimates than assessment o waiting room or telephone o waiting room or telephone o interview by staff o interview by staff o child within a familiar environment o combination o combination o skills inconsistently demonstrated • Expert opinion and research evidence support Caveat : developmental surveillance as “optimal” clinical practice for monitoring children’s development ( Arch Pediatr Adolesc Detection without Med 2001;155:1311-1322) referral/intervention is • Effectiveness is enhanced by incorporating valid measures ineffective and may be of parents’ appraisals and descriptions (i.e., parent judged unethical questionnaires) and/or objective measures of children’s (Perrin E. Ethical questions development (i.e., professionally-administered tools) about screening. J Dev Behav o surveillance and screening Pediatr 1998;19:350-352) o screening at 9-, 18-, and 24-30 month visits Current : Developmental Surveillance & Screening • Children with developmental/behavioral problems are eluding early detection • Many initiatives exist to provide services to young Children with a Parents’ Children Children children, their families concerns need identified screened referred receive appropriate elicited appropriately appropriately • A gap exists between child health and child services development/early childhood education programs in appropriate • Children and their families would benefit from a timeframe coordinated, region-wide system of early detection, Continuous Quality intervention for children at developmental risk Organizing Entity Proposed name change: Improvement Developmental promotion, early detection and intervention 3

  4. 1 6 2 6 Provider Well-Child Solicit Core Components Centralized Telephone Community & Family Gets Visit Parent Feedback Access Point Outreach Opinions Help Me Grow Child Health Provider Data Collection & 1-800-505-7000 Outreach Analysis 3 5 4 3 5 Parent 4 Contact Connected Care Continuous Help Me Grow Statewide to Resource Coordinator Quality Organizing Entity provides Expansion Improvement resources Structural Requirements Child Development Infoline , a specialized call center of United Way 2- 1-1, helps families with children who are at risk for or experiencing developmental delays or behavioral health issues find appropriate services. Care Coordinators Provide • Assessment of needs & referrals to services • Education on development, behavior management and programs • Ongoing developmental monitoring • Advocacy and follow up Child Development Infoline Child Development Infoline STATE TEAM LOCAL PARTNERS Karen Benjamin , Program Manager NJ Department of Children and Families Essex Pregnancy and Parenting Connection, Prevent Child Abuse ‐ NJ Ericka Williams , ECCS/HMG Grow Coordinator Deepa Srinivasavaradan , CDC Act Early Ambassador to NJ Andrea O’Neal , NJ Project Launch Coordinator Family Resource Specialist – Salem County CNNH Statewide Parent Advocacy Network (SPAN) NEW JERSEY’S HELP ME GROW SYSTEM NEW JERSEY’S HELP ME GROW SYSTEM • Central Access: NJ’s telephone access system will be linked to 21 county ‐ level central intake hubs (support from NJ Departments of Children & Families, and Health). Central intake is now in place in 15 counties, and will expand to all 21 counties by May 2015. • Community Outreach: State ‐ level outreach is aligned with the NJ Council for Young Children (NJCYC), the state early childhood advisory council. The NJCYC Infant Child Health Committee is a cross sector stakeholder group that supports the work of HMG ‐ NJ, as well as NJ’s other federal systems grants. At the local level each county has a central intake stakeholder group that will now be partnered with a County Council for Young Children (provider and parent partners). • Provider Outreach: HMG ‐ NJ has an active state ‐ level Physician/Healthcare Provider Workgroup that is co ‐ led with the AAP ‐ NJ Chapter. This group works to strengthen developmental screening and referral linkages between pediatric medical home and community based providers (home visiting, early intervention, child care, etc.). • Data Collection: NJ will use central intake, home visiting and other early childhood initiatives to strengthen data collection efforts. 4

  5. • Glascoe FP, Dworkin PH. Obstacles to effective developmental surveillance: errors in clinical reasoning. J Dev Behav Pediatr 1993;14:344-349. • Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics 1995;95:829-836. • Dworkin PH. Historical overview: From ChildServ to Help Me Grow . J Dev Behav Pediatr 2006;27:S5-S7. • McKay K, Shannon A, Vater S, Dworkin PH. ChildServ : Lessons learned from the design and implementation of a community-based developmental surveillance program. Infants Young Child 2006;19:371-377. • Dworkin P, Honigfeld L, Meyers J. A Framework for Child Health Services. Supporting the Healthy Development and School Readiness of Connecticut’s Children. Farmington, CT: Child Health and Development Institute of Connecticut, 2009. [Monograph] • Dworkin P, Bogin J, Carey M, Duplessis K, Honigfeld L, Hernandez R, and Hughes M. How to Develop a Statewide System to Link Families with Community Resources: A Manual for Replication of the Help Me Grow System. New York, NY: The Commonwealth Fund, 2010. [Monograph] <http://newsletters.commonwealthfund.org/t/6067/9354/2396/0> 5

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