Expert presentation by Ms. Bettina Schwethelm, Specialist, Early Child Development and Health,...
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Transcript of Expert presentation by Ms. Bettina Schwethelm, Specialist, Early Child Development and Health,...
Primary care and home visiting services for early identification and support for young children with
developmental difficulties and/or disabilities – What is available and what is needed in CEE/CIS?
Dushanbe, August 1, 2013
Bettina SchwethelmUNICEF CEECIS Regional Office
Content1. The Critical Window of
opportunity 2. The role of the health sector
in promotion, prevention, and early intervention
3. Mapping ECI services for children with disabilities & developmental difficulties in CEE/CIS
4. UNICEF’s work to strengthen the health sector for ECI
1. Maximizing the Critical Window of Opportunity for every child
• Every child is born with potential• Overwhelming evidence from neuro-science
and development research about what young children need “survive and thrive”
• Critical development during pregnancy and the first 1000 days of life– Sensitive periods of development– Depriving environments significantly affect
vulnerable children
0 1 4 8 12 16AGE
SensingPathways
(vision, hearing)
LanguageHigherCognitive Function
3 6 9-3-6Months Years
C. Nelson, in From Neurons to Neighborhoods, 2000
Conc
e ptio
nSensitive/critical periods
Critical/sensitive periods during which certain types of stimulation must be received
5
EARLY RELATIONSHIPS
HEALTH&
NUTRITION
FAMILY SUPPORT
PROTECTION&
INCLUSION
Predictable, responsive and affectionate care;
secure bonding and attachment; interaction
and communication
Access to child health and development knowledge
and information Child care services
Family and child benefits
Early detection and intervention for delays
and disabilitiesProtection from
violence, maltreatment and abuse
Promotive, preventive and curative health
care & adequate and appropriate nutrition
The Health Sector - A Part of the Problem?• More newborns are surviving, but only gradual
improvements in perinatal/neonatal care and lack of community-based services
• Providers continue to recommend and promote the move of newborns with medical conditions and/or disabilities to institutional settings
• Insufficient outreach to the more vulnerable groups for prevention and care due to pervasive stigma and discrimination
• Low level of reporting of abuse and neglect with severe consequences for development and lifelong wellbeing
• Low attention to maternal depression and other parental disabilities
2. Why Target the Health Sector?
Health Sector Advantage• Health workers often
trusted• Use of services not
stigmatizing• Continuum of care
allows for development of relationship of trust and entry into family micro-environment
Coverage Central Asia (range)
At least 1 prenatal visit 96-99%
Measles vaccine 97-99%
Hospital delivery 88-100%
Health sector home visiting systems
5 countries
WHO definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” requires a much broader role for the health sector.
Continuum of Health Care
Health promotion -> Prevention -> Early Intervention
Examples of Health Promotion• Promotion of healthy lifestyle
(exercise, rest, smoking and alcohol cessation, good nutrition) during pregnancy
• Birth preparedness & parenting information
• Provision of age-appropriate parenting advice– Information about child
developmental needs– Information on common
parenting issues (feeding, crying, toileting, discipline…)
– Injury prevention education…..
Examples of Prevention“The most effective interventions are often those that are preventative instead of reactive”
• Folic acid to prevent neural tube defect (also iodine and iron deficiency)
• Social workers in maternities to reduce abandonment/relinquishment in vulnerable women
• Breastfeeding, kangaroo care/skin-to-skin for low birth weight infants for bonding and development
• Social-emotional counseling/ support for mothers/parents experiencing depression
• Birthing/parent education to support nurturing parent-child relationship
• Counseling in responsive feeding
Examples of Early Intervention• Early interventions for infants
with very low birth weight, congenital conditions, disabilities and for young children with delays– Counseling and support to
caregivers, developmental surveillance, re/habilitation services, referral
– Hearing, vision, and child development services
• Early interventions for children and families experiencing abuse, neglect, mental health problems, or other adversities– Counseling, referral, treatment,
involvement of child and social protection services
3. Mapping of Early (0-3 years) Identification and Intervention Services in CEE/CIS
• All countries/entities in CEE/CIS participated• Approach based on global WHO study with 32
LMICs • Focus on health sector • Key informant approach (1-2 per country)• 37 respondents -- 28 medical doctors (13
pediatricians) and 9 professionals from other disciplines
a. ECI Mapping study - Policy environment
• 14/23 countries/entities have laws that mandate access to early intervention services
• Most laws recent (between 2004 – 2011)• 12 countries/entities have tools to classify developmental disorders and disabilities
b. ECI Mapping study - Access
• Basic health services accessible in 21 countries/entities
• Sufficient doctors and nurses in 17 countries/entities
• Health Sector home visiting in 20 countries/entities (social services: 7)
• > 75% of young children routinely visited in their home in 14 countries
• Home visiting for special groups in 10 countries (e.g., Roma)
• Continuity of care is essential for children with disabilities and delays – but likelihood of seeing the same provider is less for chronic conditions (which includes disabilities)
Availability of Child ECI Specialists (Urban Areas)
Pediatric
Neurogis
t
Developmental
Pediatric
ian
Child Psyc
hologist
ECI S
pecialist
Infant m
ental healt
h specia
lists
Pediatric
physiotherap
ist
Child la
nguag
e therap
ist
05
10152025
SufficientInsufficientNot at all
c. ECI Mapping - Skills of Doctors (1)
Id. biological.-develop-mental risk Assess social emotional risk
(mat. depression) Assess comprehensive child development Use standardized tools
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Few
Some
Many
Most
Skills of doctors (2)
Use standardized methods to assess malnutrition
Assess for suspicion of autism during first 3 years
Assess for visual deficiency
0
5
10
15
20
25
Number of Countries/Entities Providing Services to Most (>75%) Young Children and Mothers
Folic acid during pregnancy
Prenatal screening for Down syndrome
Ultrasound for neural tube
Screening of neonate for PKU
Screening of neonate for hypothyroidism
Developmental surveillance
Developmental screening
Counseling during home visit on enhancing development
Identification of intra-family violence
0 2 4 6 8 10 12 14 16(23 countries/entities)
Services for One-Year Old with Down Syndrome
White: services not available * countries/entities in random order
Services for six-month old, born prematurely, birth weight 1400 grams, poor weight gain, mild spasticity,
not vocalizing
White: services not available * Countries/entities in random order
Services for 6-months old with severely depressed mother
White: services not available * Countries/entities in random order
Likelihood of Institutional Placement by Condition
*Countries/entities in random order
ECI mapping - Service Delivery Approach
Services provided in home
Services provided to the individual
Services provided in groups
Caregiver present
Caregiver not present
Family-centered
Child-centered
0 2 4 6 8 10 12 14 16 18 20
Conclusion from ECI Mapping Study and other Assessments
• Medical model and defectology approach are changing slowly• Information about young children with disabilities and delays remains
limited– Outdated classification systems– Role of role of social determinants (poverty, ethnicity…) and family needs
not addressed• Lack of trained professionals• Low use of evidence-based approaches for promotion, prevention,
and intervention• Low use of evidence-based screening and diagnostic tools• Lack of community-based services for early intervention in most
countries• Limited understanding of the critical importance of early intervention
4. HEALTH AND WELLBEING FOR YOUNG CHILDREN - UNICEF CEE/CIS APPROACHES
• Multi-sectoral focus• Regional agreement on key
approaches, strategies, and results indicators based on best available evidence
• Regional support to development of advocacy tools, human capacity building in ECD/ECI, research to generate a regional evidence base, and M&E
• A shared web-based platform for collaboration centering on young child wellbeing (including ECI) and health promotion
Focus on Early Identification and Intervention
• Disseminate knowledge about ECI and child wellbeing
• Promote professionalization of ECI services (“export of Turkey DPU approach”, ECD/ECI skills building)
• Strengthen universal and enhanced home visiting services for promotion, prevention and early identification
Home Visiting – The Global Evidence
Home visiting can contribute to improved:
• Parental wellbeing (affect spacing of pregnancies, maternal health, maternal depression, substance abuse)
• Parenting skills and behaviours (e.g., breastfeeding/ responsive feeding, nurturing responsiveness to infant, less harsh discipline, stimulating & safer home environment…)
• Child outcomes (health, nutrition, and vaccination; infant sociability, exploration, cognitive growth, executive function…)
Home Visiting Activities (2012 – 2015)
• Country assessments (9 completed)• International Expert Group • Development of home visiting policy
guidance with focus on vulnerable groups (young children with disabilities/ developmental difficulties)
• Regional training package for home visiting personnel with focus on early child development and developmental difficulties
• Tool kit to enhance screening and developmental monitoring capacities
• Innovation projects and research
The first 3 years of a child's life are a time when a child has the greatest plasticity for growth and development, even under adverse circumstances. The health sector therefore has a unique responsibility, because it has the greatest reach to children and their families during pregnancy, birth, and early childhood. Universal health coverage provides the platform to achieve impact in a fair, integrated, and efficient way. …
By ensuring that all children have the best first chance in life, we can help individuals and their communities to realise their maximum potential, thereby expanding equality and opportunity for all.
(M. Chan, Director General, WHO, 2013)
Thank you!
Contact:Bettina [email protected]