Parent Health Beliefs, the Developmental Treatment Cascade, and the Need for Systems Thinking

By: Paul H. Dworkin, MD

A recent research article in the journal, Pediatrics,1 as well as a related commentary in the same issue,2 caused me both comfort and concern.  On the one hand, the research findings corroborated many of the key concepts regarding parents and their young children’s development that have informed our approach to developmental promotion, early detection, referral and linkage.  On the other hand, the call for new approaches to developmental screening and referral indicates the need for broader understanding of the role of such models as Help Me Grow in early childhood comprehensive system building.

Magnusson and colleagues explored differences between African American and Hispanic mothers in the role of health beliefs in shaping maternal decisions regarding help-seeking for children with developmental delay.  They conducted open-ended, semi-structured interviews with 22 mothers of children with developmental delay up to 36 months of age.   Using a technique called inductive content analysis, the identified five major themes describing the role of maternal health beliefs in shaping key stages of the help-seeking pathway for their children: observing other children and making comparisons; perceiving that their child might be different, but not necessarily delayed; relying on social networks rather than pediatricians to inform the help-seeking pathway; having difficulty prioritizing early intervention because of competing stressors; and delaying or forgoing early intervention because of limited or conflicting information.  Results confirm the importance of understanding parent perspectives on early detection and intervention.

In general, these findings are consistent with past research, including our own work.  For example, we have previously cited the clinical utility of parents’ direct comparisons of their children’s development with similarly-aged peers;3 the tendency of parents to overestimate their child’s developmental status and optimistically predict future functioning;3 and parents’ reliance on social networks, as opposed to pediatricians, especially when considering social-emotional developmental concerns.4  Thus, this study reinforces past research findings as to the importance of maternal health beliefs, social networks, and external stressors on the early detection, referral and linkage process.

The shortcoming of this research report lies in the limited implications derived by the authors to enhance the early detection, referral and linkage process.  While recommendations to use such approaches as video- or computer-assisted developmental screening tools during well-child visits, completion of screening tools by parents at home, parent decision aids to elicit developmental expectations and concerns, engagement of influential family members or friends, and exploration of families’ socioeconomic environment and experiences are worthy of consideration, the authors fail to emphasize the importance of considering detection and intervention within the context of a comprehensive, integrated approach to developmental promotion, early detection, referral and linkage.5  While the authors do appropriately cite evidence-based models such as Health Leads, Healthy Steps, and Safe Environment for Every Kid as helpful in enabling pediatricians to address families’ complex socioeconomic needs, they do not acknowledge the importance of such models as Help Me Grow that engage child health, early care and education, and family support providers in comprehensive, early childhood system building that enables practitioners to support strengthening families to promote their children’s healthy development.6  Indeed, many of the cited maternal health beliefs and expectations regarding developmental delays and early intervention are effectively addressed in the context of such a comprehensive systems approach that engages parents as partners throughout the decision-making process.

The accompanying commentary in the same issue by Chambers and Silverstein arouses similarly ambivalent reactions.  Most helpful is the authors’ description of the steps an individual must complete in the process of moving from screening to diagnosis to treatment for a variety of disorders.  They cite, for example, the reference in the HIV literature to the “HIV treatment cascade,” and helpfully propose that the Magnussen study justifies conceptualization of a “developmental treatment cascade.”

While their proposed model is inordinately focused on children with delays and disorders, and neglects to acknowledge the importance of eliciting concerns that also identify vulnerable children at risk for adverse developmental and behavioral outcomes, I certainly agree with their perspective that the current pediatric primary care system may exacerbate attrition along a developmental treatment cascade.  In emphasizing the lack of a common perspective between parents and physicians concerning child development, the authors call for “new system-level approaches to developmental screening and referral.”  As examples, they cite greater coordination between pediatric and early intervention providers and augmented models of primary care, such as Healthy Steps and the use of parent coaches.  While of proven benefit, such recommendations fall short of calling out the need for engaging all sectors in comprehensive, early childhood system building, as recognized by the Maternal and Child Health Bureau (MCHB).  Indeed, MCHB has encouraged and supported, since 2003, the development of Early Childhood Comprehensive Systems as partnerships between agencies/organizations representing physical and mental health, social services, families and caregivers, and early childhood education to develop seamless systems of care for children from birth to kindergarten entry.

Parental health beliefs are extraordinarily important considerations in engaging parents in early detection and intervention for developmental concerns.  While a variety of strategies may contribute to incremental practice improvements, the ultimate answer to promoting all children’s optimal healthy development lies in ensuring an integrated approach to developmental promotion, early detection, referral and linkage.  This can only be achieved when child health services and providers are considered in the context of comprehensive systems that engage all sectors, especially early care and education and family support, in strengthening the capacity of families.  Our ability to successfully apply the implications of our advanced knowledge of early brain development and child development, as well as the biology of adversity (e.g., toxic stress, adverse childhood experiences), demands that we think boldly, broadly, and more comprehensively than improvements to child health services alone.

Dr. Dworkin submitted a similar comment to the journal Pediatrics which is now published online.

References

  1. Magnusson DM, Minkovitz CS, Kuhlthau KA, et al.  Beliefs regarding development and early intervention among low-income African American and Hispanic Mothers.  2017;140(5):e20172059.
  2. Peacock-Chambers E and Silverstein M. Health beliefs and the developmental treatment cascade.  Pediatrics. 2017;140(5):e20172787.
  3. Glascoe FP and Dworkin PH. The role of parents in the detection of developmental and behavioral problems.  Pediatrics. 1995;95:829 836.
  4. Dumont-Mathieu T, Bernstein B, Dworkin P, et al. Role of pediatric health care professionals in the provision of parenting advice: a qualitative study with mothers from four minority ethno-cultural groups.  2006;118:e839-848.
  5. Dworkin PH.   Towards a critical reframing of early detection and intervention for developmental concerns.  J Dev Behav Pediatr. 2015; 36:637–638. DOI:  10.1097/DBP.0000000000000216.
  6. Dworkin PH, Sood B. A population health approach to system transformation for children’s healthy development.  Child Adolesc Psychiatric Clin N Am. 2016; 25(2):307-17. DOI: 10.1016/j.chc.2015.12.004.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center.  Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

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