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Globally, the ‘burden’ of speech and language difficulties, learning disabilities, emotional difficulties and behavioural disorders is between 10% and 20% in children <5 years of age [1, 2]. Disparities in early childhood development between socially advantaged and disadvantaged children are also apparent early in life . Poor children are twice as likely to be developmentally vulnerable than non-poor children at school entry [3, 4]. This developmental discrepancy should not be inevitable. All children have the right to achieve their full neurodevelopmental potential and contribute constructively to society.
There is clear evidence that early intervention programmes can reduce inequalities and improve health and developmental outcomes [5, 6]. Data from early enrichment programmes demonstrate positive effects on school achievement, job performance, social behaviours and cognitive skills, which persist well beyond the duration of the intervention [3, 5, 7–9]. Enhancement of caregiver mental health, play and communication are crucial components of these programmes and can be used in low-resource settings. Enhanced caregiver–child interaction is associated with better confidence to manage their children, better knowledge of child development issues, a better home environment and improved neurodevelopmental outcomes [10, 11].
Primary care providers work at the first level of the health system in clinics and health centres and include generalist nurses, remote area nurses, doctors, community health workers and indigenous health workers. Primary care providers are in a unique position to enhance early child neurodevelopment before school entry. Community child health nurses are considered to be the traditional providers of neurodevelopmental care in primary care settings in high-income countries. However, generalist nurses, general practitioners and community health workers at government and non-government health clinics and general practice surgeries provide >90% of the care for families globally during the first 5 years of life . These health professionals are not seen as traditional providers of early neurodevelopmental care and many staff lack confidence and skills in managing young children. Few primary care providers also receive appropriate education, training and tools for implementation of basic neurodevelopmental care for young children. A child health assessment may only result in recommendation for review or referral to a specialist service that visits infrequently and has a long waiting list. A primary care provider can play an active role in improving child neurodevelopment, as opposed to simply screening and referring to other services.
Child health surveillance and screening (often called child health checks) is a core component of primary care in many high-income countries. It includes assessment of weight, oral health, hearing, vision and developmental milestones . However, this type of child health surveillance has limited ability to address ‘high burden’ speech, language and behavioural issues in young children . Many skills lie on a continuum of ability rather than reflecting a specific deficit or defect, and it can be difficult to define what does or does not constitute a problem while using current tools [2, 13].
There is emerging evidence that anticipatory guidance and brief interventions implemented by primary care providers can improve social and emotional well-being and long-term neurodevelopmental outcomes in socially disadvantaged children [9, 14, 15]. ‘Anticipatory guidance’ includes practical information about ‘what to expect’ in behavioural and neurodevelopmental milestones in the immediate and longer term. Anticipatory guidance aims to equip caregivers with knowledge and skills to provide positive experiences and environments for their child [16, 17]. ‘Brief interventions’ have been defined as time-limited interventions implemented by primary care providers that focus on changing caregiver behaviour. They are usually motivational in nature and use counselling skills to change behaviour [3, 18, 19]. Many countries and jurisdictions include anticipatory guidance in their child health surveillance schedules, but this can be implemented poorly if primary care providers have not been specially trained .
Models that include both anticipatory guidance and brief intervention training for ‘mainstream’ primary care providers are emerging [9, 14, 15]. In the UK, many staff who work with preschool children have neurodevelopmental training [2, 20]. Preschool services staff observe children in education centres over days or weeks, rather than just in a single short encounter as in traditional surveillance procedures. Early years staff advise parents, discuss worries, developmental needs and language, speech and behavioural problems. A family services plan is agreed jointly by the family and health professional, and completed by the child’s first birthday. A more targeted approach follows with fewer routine health professional contacts, which releases staff to offer intensive educational and social support for those who need it [2, 20]. This has been called progressive universalism ‘support for all but more support for those who need it most’ [21–23].
‘Care for Development’ is a training program developed by the World Health Organization (WHO) and the United Nations Children’s Fund to support health professionals in using anticipatory guidance, brief interventions and counselling parents in play and communication techniques to stimulate their child’s development . The package consists of simple recommendations health workers can make to families, training materials for health workers and advocacy materials. Effectiveness studies have identified substantial effects on child development in low- to middle-income countries including Pakistan, China and Bangladesh [9, 14, 19, 24].
In Australia, a number of jurisdictions have moved towards progressive universalism . Brief interventions based on the WHO care for development models have also been developed. A primary care provider training program includes guidance on how to teach families about age-appropriate play and communication activities. It includes demonstration, teachable moments, observation, checking understanding and counselling families in early child development. Implementation guides are being developed and tested. They include ‘scripts’ for ‘one on one’ sessions between a family and primary care provider that can be conducted over 15–30min at the time of child health check. Specialist services such as social workers, psychologists and child development service staff provide ‘train the trainer’ sessions and ongoing ‘on the job’ support .
Recognition of the importance of continuous quality improvement (CQI) initiatives for child neurodevelopment is also increasing [27–29]. Recent CQI systematic reviews concluded that CQI has enhanced efficacy if it includes on the job support and clinical governance. It can be delivered through a combination of strategies including local priority setting, development of targeted tools, on the job education and training, targeted electronic primary care systems, review and reflection, feedback and problem solving .
Given the substantial potential gains from investment in early childhood neurodevelopmental programs globally, there is an urgent need for robust health service evaluation methodologies of these and other innovative approaches. More cluster randomized and stepped wedge trials are needed. Studies such as inference modelling and instrumental variable methodology should also be embedded within routine programs in health services that manage infants at high risk of neurodevelopmental delay. All studies should include both short- and long-term health, social and neurodevelopmental outcomes.