Partnerships among Professionals and Families with Young Children: - - PowerPoint PPT Presentation

Partnerships among Professionals and Families with Young Children: Caring for the Whole Child

Bergen Nelson, MD UCLA Department of Pediatrics Association of Child Development Specialists May 15, 2016

Agenda

• 9:30 Introductions
• 9:45 Group Brainstorm
• 10:00-11:00 Research Examples
• 11:00-11:15 Break
• 11:15-11:45 Discussion
• 12:00 Close

Objectives

• Review a bio-psycho-social framework for

child health and development

• Understand the impacts of key risk and

protective factors in early childhood

• Articulate strategies and resources to support

professionals, children and families

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Determinants of Health

Shroeder S, NEJM 2007

• Health care services

contribute only about 10% to health (morbidity, life expectancy)

Social Determinants

From: www.healthypeople.gov

Health  Education

Education Health Early Childhood Development Parents and Professionals

Adverse Childhood Experiences (ACEs)

Spheres of Influence: What Can We Do?

• What can professionals

do to support child heath and development?

• Health care providers?
• Early childhood

educators?

• Social support programs

and providers?

• What can parents do to

support child health and development?

• Communities?
• Policy-makers?
• What can we do in

partnership with one another?

Schools Health  Education

Preconception and prenatal health; Maternal education Healthy babies, healthy development; school readiness

Children ready to learn in school; Attendance and school function

Prevention and health promotion in schools

Adolescent health, substance use prevention, reproductive health, graduation

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Research Project 1: Developing Tiered Approaches to Identify Young Children with Developmental Risks

Tiered model of risk in 0-5 year-olds

5-10% 25-30% 60-70%

Developmental delay: Formal intervention services IDEA Parts B and C High risk: Major risk factors, significant parental concerns, delays below formal intervention threshold Low risk: Screening and surveillance, parent support, high quality preventive services

1 2 3

Examples of Tiered Approaches

• Response to Intervention (RtI, also called Recognition

and Response in early childhood)

• Positive Behavior Intervention Support (PBIS)
• Center on the Social and Emotional Foundations of

Early Learning (CSEFEL)

• Tier 1 prevention, screening
• Tier 2 targeted initial therapies
• Tier 3 high-level, intensive, referrals

Preliminary Study

ACADEMIC PEDIATRICS 2013;13:145–151

British Birth Cohort Study 1970

Average Position in Distribution

Feinstein L. Inequality in the Early Cognitive Development of British Children in the 1970 Cohort. Economica 2003;70:73-97

Aim #1

To develop, using nationally representative early childhood longitudinal data, a clinically useful model that predicts, among 2 year-old children without overt developmental delay, downstream poor school readiness due to low cognitive performance and/or problem behaviors at school entry (ages 5-6 years).

Hypothesis #1

• Among children without overt developmental delay at

age 2 years, a discrete set of child- and family-level variables will predict poor school readiness at kindergarten entry.

Methods

• Early Childhood Longitudinal Survey- Birth Cohort

(ECLS-B)

• Nationally-representative sample of >10,000 children,

data collections at 9 months, 2 years, 3 to 4 years and at kindergarten entry

• Direct assessments of child development, parent and

teacher reports

Analyses

Outcome School Readiness at Kindergarten Entry

• Poor school readiness =

Low scores on either math OR language test; OR High problem behavior scores

Analyses

Tier 3  *Presumed eligible for early intervention services at age 2: >1.5 SD below mean on either cognitive OR motor developmental scale; OR > 1 SD below mean on cognitive AND motor; OR Birth weight ≤ 1500 grams

*Rosenberg SA, Zhang D, Robinson CC. Prevalence of Developmental Delays and Participation in Early Intervention Services for Young Children. Pediatrics. 2008; 121(6):e1503-1509.

Sample

Sample with assessments at both 2yo and kindergarten entry wave N = 6250 Analytic Sample N = 4800 Adequate School Readiness (Tier 1) N = 3450 Poor School Readiness (Tier 2) N = 1350 Excluded: likely eligible for EI (Tier 3) N = 1450

Weighted Proportions

3 = 12% 2 = 24% 1 = 64%

Results: Low Academic Scores

Predictor

Adjusted Odds Ratio 95% Confidence Interval Child doesn’t combine words 1.7 1.25-2.31 Parent’s expectation for child’s highest education is < 4-year degree 1.3 1.04-1.66 Highest level of parental education: (≥ Bachelor’s degree is reference) Some college High school diploma or equivalent Less than high school diploma 1.8 3.3 5.4 1.29-2.58 2.34-4.50 3.62-8.10 Parent health status is fair or poor 1.6 1.14-2.15 Household income is < 185% of FPL 1.4 1.11-1.82 Frequency of shared reading at home: (Every day is reference) 3-6 times per week 1-2 times per week Not at all 1.4 1.6 2.1 1.01-1.81 1.18-2.09 1.27-3.58 Family has food insecurity 1.6 1.12-2.34 Family history of Learning Disability 1.6 1.23-2.11 Parent rates quality of house as good, fair or poor for raising children (vs. very good or excellent) 1.4 1.14-1.80

Results: High Problem Behaviors

Predictor

Adjusted Odds Ratio 95% Confidence Interval Male gender 1.8 1.38-2.44 Highest level of parental education: (≥ Bachelor’s degree is reference) Some college High school diploma or equivalent Less than high school diploma 1.4 1.9 1.5 1.04-1.93 1.33-2.67 0.97-2.30 Parent health status is fair or poor 1.8 1.21-2.60 Single-parent household 1.5 1.17-2.02 Parental depression 1.4 1.02-2.05 Parental smoking 1.8 1.42-2.38 Frequency of shared reading at home: (Every day is reference) 3-6 times per week 1-2 times per week Not at all 0.9 1.1 1.7 0.65-1.26 0.78-1.60 1.07-2.85 Family has food insecurity 1.6 1.07-2.50 Parent rates neighborhood as fairly or very unsafe (vs. fairly or very safe) 2.0 1.38-2.76

Maslow’s Hierarchy of Needs

Sensitivity and Specificity of Prediction Models

Low Academic Scores High Problem Behaviors Sensitivity Specificity Cut-off score Proportion positive Sensitivity Specificity Cut-off score Proportion positive .60 .79 37 0.28 .60 .72 27 0.32 .70 .67 30 0.40 .70 .60 22 0.41 .80 .56 24 0.49 .80 .46 16 0.57

Areas Under the Curve (AUC): Academic model: 0.76 Behavior model: 0.71 2yo Bayley: 0.66

Next Steps

• What are “care bundles” for children at different tiers?
• Translate risk stratification and care bundles into a

feasible clinical decision support (CDS) tool:

1)

Systematic literature review and expert panel process to determine potentially effective interventions for Tier 2 children

2)

Develop and test CDS tool, incorporated into an electronic health record, with clinical partners, community advisory board and stakeholder input, and informatics support

Research Project 2: Clinical-Community Partnerships and 2-1-1 Technology to Improve Early Childhood Developmental Screening and Care

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Trabajando Juntos por Nuestros Niños (Working Together for Our Kids)

Background: Developmental Screening is a Recommended Preventive Service

The American Academy of Pediatrics (AAP) recommends universal screening and surveillance:

• Ask about and document family concerns at every well visit
• Use a validated screening tool at 9, 18 and 24-30 months
• Use an autism-specific screening tool at 18 and 24-30 months
• Refer promptly to evaluation and intervention services when

concerns are detected

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AAP Council on Children with Disabilities. Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118 (1):405-420.

Education Health Education Early Childhood Development

Early Detection Early Intervention Developmental Screening

Improved Developmental, Social, Educational and Health Outcomes Adverse Childhood Experiences (ACEs)

?

Background: Early Brain Development

34 Source: Center on the Developing Child at Harvard University; http://developingchild.harvard.edu/

Developmental Screening in Pediatrics

Need for Quality Improvement:

• Despite AAP recommendations, many families’ needs are not

met in the child health services system.

• ~30-50% of parents with young children report having had a

developmental assessment in primary care (Halfon, et al., 2004; Guerrero, et al., 2010).

• Many parents would like more guidance from their children’s

health providers about learning, development and behavior.

• 30-40% of parents with young children have concerns
• 4-5% of children ages 0-5 have a written intervention plan
• Many children with problems are identified too late, and this is

worse for low-income and racial/ethnic minority families.

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Developmental Screening in Pediatrics

Barriers to screening in clinical settings:

• Lack of time
• Limited training in development and behavior
• Lack of familiarity with screening tools
• Perceived lack of referral resources
• Challenges to follow-up

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Developmental Screening in Pediatrics

Screening Alone is Not Enough:

• QI programs have increased screening rates
• Follow-up is still a major challenge
• Families may not follow up with referrals

(Jimenez, et al. 2012)

• Few clinics have good tracking systems or care

coordination (King, et al. 2010)

Research Question

• Does centralized, telephone-based early childhood

developmental screening and care coordination improve quality of care for young children and their families?

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Partners

• Federally-qualified

community health center, in Pico/Union area of LA, with long-standing mission to provide high-quality care to vulnerable families

39

• County-wide information

and referral services

• 211 Call centers cover

>90% US population

• Developmental screening

and care coordination project in LA since 2009

40

Developmental Screening at 211LA

• Since 2009, has screened and coordinated care for
• ver 11,000 children from birth to 5
• Families call for variety of reasons initially– offered

screening if children 0-5 in household

• Overall higher risk than general population
• Connected with a wide range of services
• Pilot data published in Roux, et al. Am J Prev Med

2012;43(6S5):S457–S463

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Potential Advantages

211:

• More time available
• Standardized, validated

screening tools online

• Extensive resource directory
• Connects to resources

across developmental spectrum

• Care coordination
• Data

Clinic:

• Continuity of care,

longitudinal relationships

• In-person observations
• Capacity to address medical

complexity

• Clinical settings in general–

nearly universal entry point

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Study Design

Procedures* Randomization Recruitment & Informed Consent

Children ages 12-42 months who receive care at CR Intervention Group: Connect to 211 Conduct online screening, make referrals and follow-up Send screening report and referral plan to clinic provider Control Group: Usual Care Screening, referrals and follow-up done by clinic staff

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*Both groups: baseline and 6-month follow-up parent interviews, quarterly chart reviews and abstraction of 211 data, up to one year post-enrollment

Study Progress to Date (as of 4/15)

• We have enrolled and collected baseline data on

150 patients

76 intervention and 74 control

• Of 76 intervention subjects with completed baseline

interviews, 54 (71%) have been screened by 211LA

• Currently conducting 6-month follow-up interviews

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Baseline Results

Total Intervention Control p-value Data available 150 76 74 Child Age (mean) 24.6 months 25.8 months 23.4 months 0.10 Child Gender Male Female 75 (50%) 75 (50%) 43 (57%) 33 (43%) 32 (43%) 42 (57%) 0.12 Race/Ethnicity Latino Other 141 (94%) 9 (6%) 71 (93%) 5 (7%) 70 (95%) 4 (5%) 0.76 Language English Spanish 58 (39%) 92 (61%) 27 (36%) 49 (64%) 31 (42%) 43 (58%) 0.49

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Baseline Results

Total Intervention Control p-value 150 76 74 Parental concern about child’s development or behavior (DB) in past 6 months? 55 (37%) 27 (36%) 28 (38%) 0.47 PEDS Path A or B (high/moderate risk)? 59 (39%) 26 (34%) 33 (37%) 0.28 Developmental surveillance done by MD (EPIC milestone questions)? 128 (86%) 63 (84%) 65 (88%) 0.50

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Preliminary Results

Total Intervention Control p-value Validated screening done 54 (36%) 54 (71%) 0 (0%) 0.00 DB concerns noted in medical record? 15 (10%) 8 (11%) 7 (9%) 0.85 DB Referrals (Regional Centers, School Districts, speech) 24 (16%) 20 (34%) 4 (5%) 0.001

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Other Considerations

• Time from concern to referral to services
• Referrals to other early childhood programs (Head

Start, Early Head Start, child care, mental health, family literacy, financial supports, etc.) >90% of 211 group has received some kind of referral

• Eligibility and participation in services
• Family experiences with care
• Costs

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Next Steps

• Engage broader group of community stakeholders
• Dissemination plan
• First RCT Larger, cluster-randomized trial Implementation in

wider range of practices under more real-world conditions

• Spread to other county 211 call centers
• What public or private entities might be interested in funding?
• Questions/ Feedback?

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Discussion

Research Project 3: Health Promotion in Head Start

Background: Childhood Obesity

JAMA, February 1, 2012—Vol 307, No. 5

From 2009-2010 NHANES All children, 2-19 years: 17% obese, 32% overweight Young children, 2-5 years: 12% obese, 27% overweight Higher in Latino and African-American groups > 50% of obese children were already obese at age 2 years

Trends in Early Childhood

Background

• Few studies of obesity prevention efforts in preschools
• r preschool-age children.
• Most studies focus on either children or parents, not

both, and none focus on staff.

• The Healthcare Institute (HCI) at UCLA’s Anderson

School of Management has long history of engagement with Head Start to promote health literacy.

• HCI has trained over 150,000 Head Start families

across the US, on common childhood illnesses, with decrease in ER visits.

Pilot Implementation

• Building on community relationships and using their

train-the-trainer model, HCI developed a curriculum and educational materials targeted at healthy nutrition and physical activity.

• Head Start staff trained to deliver curriculum to children

and families, with emphasis on healthier lifestyles for everyone– staff, parents and children.

• National pilot: enrolled 6 Head Start agencies in 5

states, intervention period of 6 months during 2008- 2009 school year.

• Diabetes/Obesity Awareness
• Nutrition Education
• Shopping Education
• Physical Activity
• How to stretch your food $
• How to use your

environment to exercise

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Curriculum

Parents, Children and Staff Preparing Healthy Meals

Classroom Activities

Farmers Market

Children’s Activities

Pilot Implementation and Data Collection

Samples and Measurement

• Staff and parents (total N = 497) completed baseline

and follow-up surveys to measure changes in:

• Knowledge of food groups and healthy food choices;
• Eating behavior, shopping behavior and physical

activity.

• 417 adults (staff and parents) had baseline and follow-

up height and weight measurements.

• Subsample of 112 children, matched to parents, had

height and weight measurements at baseline and follow-up.

BMI Results

Mean BMI Baseline Mean BMI Follow-up 95% CI* Adults (n= 417) 30.1 29.2 [-1.08, -0.78] Staff (n= 266) 29.5 28.7 [-0.97, -0.65] Parents (n= 151) 31.2 30.1 [-1.44, -0.86] Children (n= 112) 17.0 16.7 [-0.57, -0.19]

*Difference in BMI tested using paired t-tests, all with p ≤ 0.001

Obesity Results

% Obese Baseline % Obese Follow-up P-value * Adults (n = 417) 45.1% 39.8% < 0.001 Staff (n = 266) 41.4% 36.8% < 0.001 Parents (n = 151) 51.7% 45% < 0.001 Children (n = 112) 30.4% 20.5% < 0.001

* Statistical significance tested using Fisher’s exact test

HCI Model for 0-3 year-olds

• Replicated in the Lennox School District school

readiness program in 2011-2012

• Children First (VFC) Early Head Start implementation in

2013-2014

• Similar results:
• High levels of adult obesity at baseline
• Significant decreases in adult BMI and child BMI z-scores from

pre to post

• Sustained decrease in child BMI one year later (adults returned

to baseline BMI on average)

Future Directions

• More controlled trials needed!
• Longer follow-up periods
• Implementation challenges– variable child care settings

and regulations

• Implications for policy and scale:
• National Center on Early Childhood Health
• Office of Child Care and Office of Head Start
• Child and Adult Care Food Program
• Let’s Move! Child Care

Strategies and Resources to Support Children and Families

Strengthening Families

• Parental resilience
• Social connections
• Concrete support in times of need
• Knowledge of parenting and child development
• Social and emotional competence of children

Center for the Study of Social Policy: http://www.cssp.org/reform/strengthening-families

Prevention

• Secure attachments
• Effective parenting
• Safe, structured environments, authoritative

parenting (high warmth/ high control)

• Address typical concerns early

– sleep issues, developmental crying peak (aka colic), temper tantrums/ “terrible twos”, child temperaments

Early Detection

• Screening = everyone
• What are platforms to achieve universal

screening and surveillance?

Evidence-Based Interventions

• e.g. Affordable Care Act: Maternal, Infant and

Early Childhood Home Visiting Program

– Nurse-Family Partnership – Early Head Start – Parents as Teachers – Healthy Steps – Child FIRST – Healthy Families America – Home Instruction for Parents of Preschool Youngsters (HIPPY) – Play and Learning Strategies (PALS) Infant

Evidence-Based Interventions

• e.g. LA County Department of Mental Health:

Prevention and Early Intervention (PEI)

– Parent-Child Interaction Therapy (PCIT) – Incredible Years – Strengthening Families Program (3-5) – Al’s Pals: Kids Making Healthy Choices – Triple P– Positive Parenting Program – Promoting Alternative Thinking Strategies – Trauma Focused Cognitive Behavioral Therapy

What can YOU do?

What did you learn?