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Developmental paediatrics

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					Child Health Surveillance



   Where are we in 2011 ?
   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
    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
    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
                    - 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
    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
      Developmental screening
Conditions that can not screen for
 Cerebral palsy

 Developmental delay / disorder

 Language delay

 Language disorders

 Learning difficulties
          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
        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
      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
    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
   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
   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
     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
   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
   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
   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
   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

   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
   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
   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
   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
   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
      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”
     What to do if concerns following
      assessment in primary care ?
   Referral guidelines
   Clearly defined pathways
    ? Healthy Child Programme service
    specification and Delivery model
Break
        Developmental problems
   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
   Normal child development inc variants
   Abnormal child development
   Assessment, diagnosis, investigation
   Hearing
   Vision
   Screening
   Behaviour problems
   Interventions………..
       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
    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
                 Investigations
   Tailored to clinical profile / problem
   Metabolic
   Genetic
   Imaging
   Neurophysiology
   Special tests
        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
 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
    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
                  Resources
   Health Child Programme e-learning curriculum
    RCPCH
   www.dh.gov.uk/en/healthcare/children/matern
    ity/index.htm
   www.northyorkshireandyork.nhs.uk
    books ??

				
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