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Information on the science of early child development has become increasingly available to the public at large. Physicians have an important role in translating the science into accessible language as well as activities for parents and caregivers to foster healthy development. A strategy to engage primary care in Ontario through the use of an enhanced 18-month well-baby visit is described.
Le grand public a de plus en plus accès à l’information sur la science du développement de la petite enfance. Les médecins ont un rôle important à jouer en transférant cette science en une langue accessible et en proposant des activités à l’intention des parents et des éducateurs en vue de favoriser un développement sain. Le présent article décrit une stratégie en vue de faire participer les médecins de premier recours de l’Ontario grâce à une visite améliorée du bébé en santé à 18 mois.
’Twas a dangerous cliff, as they freely confessed,
Though to walk near its crest was so pleasant;
But over its terrible edge there had slipped
A Duke and full many a peasant.
So the people said something would have to be done,
But their projects did not at all tally;
Some said, “Put a fence around the edge of the cliff,”
Some, “An ambulance down in the valley”….
Said one, in his plea, “It’s a marvel to me
That you’d give so much greater attention
To repairing results than to curing the cause;
You had much better aim at prevention”….–From the Parable of the Dangerous Cliff, Joseph Malins (1895)
I am sure many of us can identify with this parable. As a child and adolescent psychiatrist practicing in Ontario for almost 25 years, I have repeatedly felt that many of the challenges faced by the families and children I see, could have been avoided or at least ameliorated if preventive strategies had been in place earlier. All practitioners know that normal child development entails more than the attainment of physical milestones: that physical and emotional development are inseparable, but issues such as attachment and emotional self-regulation are more subtle and not always addressed. My practice has changed significantly in the past five years as a consequence of new knowledge in neuroscience, and I am spending more than one-half of my time in advocacy and education activities.
It is somewhat ironic that our knowledge of neuroscience has never been greater, yet there is increasing concern that difficulties with self-regulation are becoming more prevalent, and that more children are, at an earlier age, experiencing developmental challenges. In Ontario, at least 25% of children are arriving at school without the skills they need to succeed, but we have no way of systematically monitoring children before this to find out why. In Ontario, 96% of children younger than two years of age receive preventive and episodic care from a physician. With this in mind, the Ministry of Children and Youth Services in Ontario, through the Best Start Initiative, is supporting the development of an enhanced 18-month well-baby visit, the last scheduled visit before school entry. Enhancement of the 18-month visit involves a consistent, focused developmental review and evaluation completed by a primary health care provider in collaboration with parents, via the use of standardized assessment tools (the Ontario Rourke Baby Record and the Nippissing District Developmental Screen) and a process to support discussions with parents on healthy child development, including connection to community resources and, when needed, timely referrals. As a whole, the provincial initiative seeks to enhance child development by building stronger partnerships among parents, primary care providers and community services, and aims to create a culture that enhances the developmental health and well being of children. Developing and evaluating strategies to educate primary care practitioners is presently a major focus of my work.
Child development is not, however, principally in the hands of physicians and health care providers. Obviously, parents and other primary caregivers, teachers and early child educators have a much more direct impact on the emotional and mental development of young children. What we learn through neuroscience research is directly applicable to the everyday interactions between adults and children, and so I now spend a great deal of my time teaching these groups about brain development and what they can do through play-based learning to enjoy their children while at the same time promoting development.
Finding ways to translate the science into an understandable message that informs child-adult interaction is an effective way to influence a child’s social and emotional development. Parents need to understand that the way they interact with their children and the way they look, laugh and play with them, have a drastic and tangible effect on the development of the brain. The simple message that “love builds brains...literally”, coupled with an accessible explanation of the neuroscience, has been very effective in how I deal with literally thousands of parents, teachers and caregivers. For example, I use very simple language and props to explain the impact of stress (see YouTube.ca and www.Offordcentre.ca). The amygdalae are likened to a porcupine that, when stressed, sends signals to release adrenaline and cortisol. Using a hippopotamus puppet, I explain that the homeostasis of cortisol is regulated by the hippocampus (hippo), the centre for new learning and memory, and that it gets shut down when there is too much cortisol – the nonteachable moment. One father said, “My ––– porcupine is going all the time”, and he was right! Another young person said, “Wow, now I can see how my OCD [obsessive compulsive disorder] works…. Where can I get one of those puppets to carry with me?” A child care provider asked me, “Does this mean that letting the infants in my room always cry it out is potentially actually damaging their brain?” As physicians, we have a unique opportunity to promote rich interaction and to correct misinformed beliefs about child development that lead to inappropriate behavioural strategies in dealing with children under stress.
Teachers, early childhood educators, family court lawyers and judges may also impact child development, and therefore require the knowledge and understanding that has been gained from neuroscience research. This knowledge, translated into a form that promotes understanding, will help ensure that their interactions with children are handled in a way that nurtures healthy outcomes. This has become a large part of my activity.
What we have learned from neuroscience research must inform our practice and alter the way we operate as physicians. We are now fully cognizant of the fact that we should not wait for social and emotional problems to become manifest, but rather must look for opportunities to ensure that adults who have important roles in the emotional and social development of children interact with children in ways that foster and nurture healthy development.