EARLY INTERVENTION

FOR CHILDREN AT RISK

FOR DEVELOPMENTAL DIFFICULTIES
METHODS AND EVIDENCE FOR EFFECTIVENESS
DR. DOA CEREN TEKG
ANKARA UNIVERSITY SCHOOL OF MEDICINE
DEPARTMENT OF PEDIATRICS
DEVELOPMENTAL PEDIATRICS DIVISION

Theory of Child Development

Bronfenbrenner, 1982

The development of the cognitive, social-emotional, language

and movement functions of the young child are influenced by
the biological endowment and health of the child, as well as by
the relationships with the primary caregivers, family, and
support systems in the community.

Bronfenbrenner U, Ceci SJ (1994) Nature-nurture reconceptualized in developmental

perspective: a bioecological model. Psychol Rev. 101(4):568586
Ertem IO. Pruett K. (2010) Rudolph Textbook of Pediatrics

Early Brain Development

While neurons are formed before the third trimester, synaptogenesis occurs
largely in the early years.
The quality of the everyday actions of the parents and responding to the infant
shapes the circuitry of the developing brain.
Synapses that are not used or reinforced are pruned.
Birth

Synaptic Density
6 Years
14 Years

Shore R (1997) Rethinking the brain: new insights into early development.
New York: Families and Work Institute

Early Brain Development

Stressors during the early years negatively affect brain
architecture.
Toxic stress is strong, frequent, and/or prolonged activation of the
bodys stress-management systems in the absence of the
buffering protection of adult support.
Eg: extreme poverty, recurrent physical or emotional abuse,
chronic neglect, severe maternal depression, parental substance
abuse, family violence.
Increases the risk of stress-related physical and mental illness
throughout childhood and the adult years.
Shore R (1997) Rethinking the brain: new insights into early development. New York: Families and Work Institute
Hannon P (2003) Developmental neuroscience implications for early childhood intervention and education. Current Paediatrics. 13: 5863.
Shonkoff JP et al.(2000) From neurons to neighborhoods: the science of early childhood development.
Washington, DC: National Academy Press.
Shonkoff JP et al. (2012) The lifelong effects of early childhood adversity and toxic stress. Pediatrics. Jan;129(1):e232-46.

Terminology
Developmental diffculty (DD) is used to include conditions
that place a child at risk for suboptimal development, or that
cause a child to have a developmental deviance, delay,
disorder or disability.
The term is intended to encompass all children who have
limitations in functioning and developing to their full
potential.
Risks for suboptimal development:
Biological risks:
Premature birth
Low birth weight
Malnutrition
Infectious diseases
Genetic disorders

Psychosocial risks:
Poverty
Maternal depression
Child-caregiver interaction problems
Caregiver illness/stress
Human discrimination
Violence, war, natural disaster

Ertem IO (2012) Developmental Difficulties in Early Childhood. WHO Publications

Risk reduction

Barth PR et al. (2008) Developmental status and early intervention service needs of maltreated children, final report.
http://files.eric.ed.gov/fulltext/ED501753.pdf

Prevelance of DDs

Boyle CA et al. (1994) Prevelance and health impact of developmental disabilities in US children. Pediatrics ar;93(3):399-403.
Boyle et al. (2011) Trends in the Prevalance of Developmental Disabilities in US Children 1997-2008. Pediatrics; 127:1034-1042
Key Findings: Trends in the Prevalence of Developmental Disabilities in U. S. Children, 19972008
http://www.cdc.gov/ncbddd/developmentaldisabilities/features/birthdefects-dd-keyfindings.html

Prevelance of DDs
Prevalence of developmental difficulties in the U.S.A increased from 12.8%
to 15% over 12 years (an increase of 17%)
Prevelance %

Years
Boyle et al. (2011) Trends in the Prevalance of Developmental Disabilities in US Children 1997-2008.
Pediatrics; 127:1034-1042
Boyle
ve
ark.
Pediatrics
2011for Child and
National Survey of Children with Special Health Care Needs (NS-CSHCN) 2009/10). The Data Resource Center
Adolescent Health http://www.childhealthdata.org/

DDs in Early Childhoood

Developmental difficulties are the
most common causes of long-term
morbidity.
Infancy and early childhood are the
best time for the prevention and
amelioration of problems that could
potentially cause developmental
difficulties and affect brain
development across the lifespan.
Committee on Nervous System Disorders in Developing Countries (2001) Board on Global Health. Neurological, psychiatric,
and developmental disorders: meeting the challenge in the developing world. Washington, DC: National Academy Press
Ertem IO (2012) Developmental Difficulties in Early Childhood. WHO Publications

Economic Benefits of ECD

8

Return/
Investment
(Ratio)

Early childhood programs

School

4
R

Vocational training

2
Preschool
School age

Postgraduate

18

Age (years)

James Heckman J, Carneiro P (2003) Human capital policy. National Beureau of Economic Research.
Cambridge, MA. Working paper 9495. http://www.nber.org/papers/w9495

Early Intervention (EI)

EI programmes are designed to support children
who are at risk of developmental delay
who have been identified as having developmental
delays or disabilities

EI comprises a range of services and supports to

ensure and enhance
childrens personal development and resilience
strengthen family competencies
promote the social inclusion of families and children
Ertem IO (2012) Developmental Difficulties in Early Childhood. WHO Publications

Aims of EI
Assess developmental risk factors
Prevent developmental difficulties in
vulnerable children
Prevent progression of difficulties
Ameliorate the effects of difficulties
on child fuctioning
Adress curable causes of
developmental risks or difficulties
detected in young children and their
families.
Shonkoff JP, Meisels SJ (1990) Handbook of early childhood intervention. Cambridge, Cambridge University Press
Ertem IO (2012) Developmental Difficulties in Early Childhood. WHO Publications

Principles of EI
Family centered
True partnership with families equal partners
Inclusion and participation of families are maximized
Intervention should be delivered through the family

Strengths based
Comprehensive

Longitudinal
Evidence based
Individualized
Guralnick MJ (2005) The developmental systems approach to early intervention. Paul H. Brookes Publishing

Home Based EI Services

Home visits for children at risk for
developmental difficulties
=
Home based early intervention

Evidence for EI comes from home based family centered EI

Center Based EI Services

Evidence for center based EI is not robust

EI Services

Family education
Physical therapy
Orthoses and prosthetics
Nursing care services
Nutritional support
Psychological and psychiatric support
and treatment for child and family
Special education
Occupational therapy
Audiological services
Speech and language therapy
Special care for visual and hearing
impairment

Examples of EI Programs

Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC

Benefits of EI
Outcomes of 20 early intervention programs are summarized
Statistically significant improvements and measured outcomes:

Better cognitive outcomes

Less special education
Less grade retention
More years of completed schooling
More high school graduation
More attendance to collage
Less behavioral problems
Better social competence
Less child abuse

More skilled employment

More earnings
Less days in hospital
Less ER visits
More possitive health behaviors
Less use of social service
Less arrests
Less crimes
Less time in prison
Less teen pregnancy

Barnett WS. (1995) Long-term effects of early childhood programs on cognitive and school outcomes. Future Child. 5:2550
Yoshikawa H (1995) Long-term effects of early childhood programs on social outcomes and delinquency. Future Child. 5:5175
Campbell FA, Ramey CT (1995) Cognitive and school outcomes for high-risk African American students at middle adolescence;positive effects of early
intervention. Am Educ Res J. 32:743772
Campbell FA et al. (2002) Early childhood education: Young adult outcomes from the Abecedarian Project. App Dev Sci. 6:4257
Reynolds AJ et al. (2001) Long-term effects of an early child childhood intervention on educational achievement and juvenile arrest. JAMA. 285:23392346
Gray SW, Ramsey B, Claus R. (1982) From 3 to 20: The Early Training Project. Baltimore, MD: University Part Press
Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC

Economical Benefits of EI

Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC
Heckman JJ, Moon SH, et al. (2009) The Rate of Return to the High/Scope Perry Preschool Program. National Bureau of Economic Research. Working Paper
No. 15471
Adams RC et al. (2013) Early intervention, IDEA part C services, and the medical home: collaboration for best practice and best outcomes. Pediatrics, 132;
e1073-1088

Measured Outcomes and Program Effects for EI

Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC

Measured Outcomes and Program Effects for EI

Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC

Measured Outcomes and Program Effects for EI

Karoly LA, Kilburn MR, Cannon JS.(2005) Early Childhood Interventions: Proven Results, Future Promise.
Santa Monica, CA:RAND Corp. Publication No. MG-341-PNC

EI for Children at Risk of DDs

Early experiences have a uniquely powerful influence on child
development , brain architecture and neurochemistry
Capacity for change in neural circuitry is highest earlier in life,
decreases over time
Most efficient strategy for strengthening the future workforce is:
to invest in the environments of disadvantaged children
during the early childhood years
Best targeted services for vulnerable children:
Skilled home visiting (prenatal to age 3)
Combined home + very high quality center- based services
(birth to age 3)
Shonkoff J (2012) An integrated scientific framework for child survival and early childhood development.
Pediatrics;129;e460
nd
Shonkoff JP, Meisels SJ (2000) Handbook of early childhood intervention 2 ed. Cambridge, Cambridge University Press

Ankara University Developmental

Pediatrics Division (AUDPD)

Ankara University Developmental Pediatrics Division

(AUDPD)

EI practices in AUDPU
Family-centred and transdisciplinary developmenatal
assessment, diagnosis, treatment, follow-up
Development of an EI plan
Coordination of care
Family education
Interactive guidence
Play therapy
Arranging disability benefits report
Referral for appropriate EI services

CEECIS DDEC Survey in 23 Countries

Access to Services

Ertem IO. UNICEF Central and Eastern Europe and the Commonwealth of Independent States (CEECIS) Region
Developmental Difficulties in Early Childhood (DDEC) Survey, UNICEF CEECIS publications in print

International Guide for Monitoring

Child Development (GMCD)
3 components:
Prevention - Identifiying risks
Monitoring - Early detection
Support - Early intervention
2O years of research in Ankara University
International standardization copmleted through 5 years in 4
countries on 12,000 children.
Free of charge, international, ready to be used by any country
Ertem IO et al.(2008) A guide for monitoring child development in low and middle-income countries. Pediatrics. 121:e581589.
Ertem IO et al. (2007) Mothers knowledge of young child development in a developing country. Child Care Health Dev.
33:728-737

Early Identification of DDs

Early
Without
identification instrument

With
instrument

Developmental
Difficulties

30% diagnosis

70-80% diagnosis

Palfrey et al., J Peds 1987

Squires et al., JDBP 1996

Mental health
problems

20% diagnosis

80-90% diagnosis

Lavigne et al. Pediatrics

1993

Sturner, et al., JDBP 1991

Take-home messages
Developmental difficulties are frequent (15%)
Early childhood is a critical period for impacting on a
range of outcomes through the life course

Early intervention is efficient and cost effective

Pediatricians are important

We are the front-line guardians

We have the power!!

Can reach all children and families

Monitoring child development
Identify risks
Early detection

Early intervention

Understand the
importance of ECD
Holistic approach
for ECD
Right instrument

The Infant Health and Development

Program (IHDP)

Sample: LBW, premature infants

Goals: Reduce developmental, behavioral and health problems
Sample size: Intervention: 377 Control: 608
Intervention:
Home visits: 1st year every week, 2nd and 3rd year every other week, health and developmental
information, family support.
Center based education: 12-36 moths corrected age, 5 days a week, at least 4 hours a day,
implementation of the curriculum used by the home visitors, tailored to each childs needs.
Parent support groups: Starting with center-based program, every other month, information on
child rearing, health, safety, social support

Intervention duration: discharge from nursery - corrected 36 months

Outcomes: better cognitive outcomes, less behavior problems, significant outcomes
found through 18 years
Cost per child: $15,146
IHDP (1990) Enhancing the Outcomes of Low-Birth-Weight, Premature Infants: A Multisite, Randomized Trial. JAMA, 263, (22); 3035-3042.
Brooks-Gunn et al. (1992) Effects of Early Intervention on Cognitive Function of Low Birth Weight Preterm Infants. Pediatrics,120, (3); 350-359.
Brooks-Gunn et al. (1993) Enhancing the Development of Low-Birthweight, Premature Infants: Changes in Cognition and Behavior over the First Three Years. Child
Development, Vol. 64; 736-753.
Bradley et al. (2001) Early Intervention: The Moderating Role of the Home Environment. Applied Developmental Science, Vol. 5, No. 1; 2-8.
McCarton et al. (1997) Results at Age 8 Years of Early Intervention for Low-Birth-Weight Premature Infants. JAMA, 277 (2); 126-132.

McComick et al. (2006) Early Intervention in LBW Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program. Pediatrics, 117 (3);771-780.

Nurse Family Partnership

Program (NFP)

Sample: Low-income, first time mothers

Goals: Improve prenatal health and birth outcomes, child health, development and safety,
improve maternal life course outcomes
Sample size: Intervention:119-245 Control:184-515
Intervention:
Home visits: Approximetely 32 home visits (6-9 visits during pregnancy , 20 visits 0-2 years) by
public health nurses, home visit schedule follows developmental stages, child health and
pregnancy

Intervention duration: up to 30th week of gestation 2 years

Outcomes: better cognitive outcomes, less child abuse, less hospital days, less ER visits,
less arrests, significant outcomes found through 15 years
Cost per child: $7,271
Benefit/cost ratio: 5,7

Olds, DL (2002) Prenatal and infancy home visiting by nurses: from randomized trials to community replication. Prevention Science 3: pp. 153172
Kitzman, H, Olds, DL, Cole, R, Hanks, C, Anson, E, Sidora-Arcoleo, K, Holmberg, J (2010) Enduring effects of prenatal and infancy home visiting by
nurses on children: age-12 follow-up of a randomized trial. Archives of Pediatric and Adolescent Medicine 164: pp. 412-418
Holland, ML, Xia, Y, Kitzman, HJ, Dozier, AM, Olds, DL (2014) Patterns of visit attendance in the nurse-family partnership program. American
Journal of Public Health 104: pp. e58-e65

Sensitivity and Specificy of Different

Developmental Assessment Tools
Denver II

PEDS*

ASQ*

GMCD

Sensitivity

0.56-0.83

0.74-0.79

0.70-0.90

0.84

Specificity

0.43-0.80

0.70-0.80

0.76-0.91

0.94

*PEDS: Parents Evaluation of Developmental Status

**ASQ: Ages and Stages Questionnaires-Erken Geliim Evreleri Envanteri (EGE)