1. The Roots of Children’s Health and Well-being
Meeting Name
Presenter Name
Date
The health and well-being of children, from the physical to the emotional, has profound and powerful influences far beyond clinical walls. It reaches families, communities and policies that surround children. All of these can be key to a child’s health and well-being.
We know the depth of the social determinants of health and the power of early influences and experiences. This knowledge calls on us to rethink our model and our role. In many ways our practices and system are still set up to be “reactive” and disease-based as opposed to PROACTIVE and health promotion focused.
This is a very exciting time; never before have we known with so much clarity that a shift in paradigm is urgent! 1

2. Trusted and Effective Messengers
You, as a pediatrician, are uniquely positioned to make a profound impact in many ways.
First, it is clear that you hold a unique trust by the public and policymakers. Doctors who take care of children are repeatedly cited as society’s most trusted messengers. This allows you to be particularly effective as a public champion around early brain and child development (EBCD).
From Capitol Hill to state capitols to local policymakers, you are heard in a unique way and bring a specific credibility. This is confirmed by polls, historic impact and individual experiences and feedback from the public. Additionally, when you contribute and lend your voice to existing advocacy coalitions you are often very well received and wanted company!
It’s a win/win and everybody learns. 2

3. Levels of Opportunity Patient Community Legislative/Policy
- Preventive care - Care Coordination - Lobbying
- Screening - Coalitions - Legislation
- Referral - Media - Systems Building
- Innovative Models - Partnerships
- Partnerships - New initiatives
- Promotion and
Health Building
There is a broad spectrum of arenas for you to engage in and make a profound difference from the clinical to the community to the professional and policy arena.
By building bridges in all of these areas, you can be very effective. Just making a single step in that direction often sets the stage for a trajectory of engagement. Many clinicians are more comfortable starting at the clinical level and that is perfectly fine; we will explore opportunities to do so. What often grows from there is a natural flow into the community and policy arenas.
On the other hand, there have been great experiences supporting pediatricians with no prior experience in policy or the community; almost invariably they have a lot to offer and have a positive impact and experience that leads to many more opportunities. We will discuss the spectrum of opportunities starting with the clinical level. 3

4. Why the Early Childhood Medical Home?
Unique and comprehensive, unstigmatized access to early childhood
Public’s deep respect for pediatricians as trusted guardians of child health
Number of well-child visits from birth to age 5
97% of infants and toddlers have regular access to healthcare (CDC, 2006)
Your role as a front line messenger to our youngest children and families is irreplaceable and powerful. The primary care venue is a tremendous access point to young children and families. Its power as a portal for early childhood systems building is underutilized. There is no doubt that pediatricians are uniquely positioned to promote EBCD in their everyday work. 4

5. Children 0-5 Whose Parents Were Asked About Learning, Development or Behavior Concerns During their Well Child Visit
Despite what we know, many times opportunities to support children’s development, behavior and learning early are missed in the pediatric encounter. 5
National Survey of Child Health, 2003

6. Parents’ Top Reasons for Attending Well-Child Care Visits
Promoting Health
Immunizations
Screening
Referrals
Requirements
School, child care, sports
Reassurance
Is my child okay?
Am I doing okay as a parent?
Opportunities for Discussion
Parent priorities are key 6

7. It’s What Parents Want!
McCune et al reported that 81% of parental questions for pediatricians concerned psychosocial issues
In their study, parenting issues were parents' predominant concern: 70% of mothers were more worried about some aspect of their parenting or their child's behavior than they were about their child's physical health
In addition to the undeniable benefits of well-child visits, quite simply it’s what parents want! As a side note, it is also related to patient satisfaction. 7

8. Child/Family 8 Medical Home
Maternal Mental Health Promotion (awareness, screening, treatment)
Early Literacy and Early Care
Financial Literacy, Tax Credit, Education and Legal Supports
Community Linkages across Systems/ Relationships; Ongoing Care Management Team
Routine Screenings and Surveillance including Toxic Stress
Community Support and Advocacy (quality pre-k, child care, home visiting social services)
Parental Support and Education
Child/Family 8

9. How are You Addressing EBCD?
How are you currently supporting EBCD?
How can you enhance what you are doing with current resources?
What is your vision for supporting EBCD in the future?
Who are your partners (potential and existing)?
Next steps/action plan?
One way to think this through is to ask yourself these questions around the array of issues that can support EBCD (e.g., social-emotional health, early literacy, executive function, quality early education). Also consider the topic areas listed on the previous slide.
NOTE TO SPEAKER: you may want to have the worksheet from the toolkit, SUPPORTING EBCD IN THE CLINICAL VENUE, and have your audience think about populating the different areas. 9

10. Promotion Opportunities Within the Clinical Setting
Encourage families to consider emotional development prior to visit (by using questionnaires, DVDs, newsletters, community events, parent groups etc.)
Develop or promote a mental health section on your Web site (include questions, facts, resources etc.)
These are examples of some of the ways to support EBCD in the clinical setting.
This highlights the idea that the clinical encounter includes the entire interface and the access that your practice has to families: virtually, pre-visit, at registration in the waiting room, etc. It is not limited to the 15 minutes you spend with patients. 10

11. Promotion in the Waiting Room
Posters
Books/pamphlets (low-literacy, multi-lingual)
DVD (“I am Your Child” or maternal depression awareness)
Waiting room questionnaires
Volunteers to role-model positive interaction or group-talks in waiting room
Parenting groups
Parent support resources
Are you taking advantage of your windows of opportunity throughout the spectrum of the clinical encounter? The Center on the Social and Emotional Foundations for Early Learning (CSEFEL) and Zero-to-Three have great handouts for parents. 11

12. Promotion in the Clinical Encounter
Use relationships as a VITAL SIGN!
The importance of positive, nurturing relationships is a key ingredient to healthy development that cannot be overemphasized, nor can the opportunities you have to promote positive relationship building.
Think about ways of checking in on the dynamic of the attachment /interaction of relationships. Promoting positive relationships and noticing and intervening /referring regarding concerns may have much more impact on the lifelong health of the child than many traditional signs we are well trained in observing!
Remember, relationships are a critical vital sign. 12

13. Ways to Evaluate & Support Relationships
Ensure the mental health of parent and child are addressed at each visit
Use open-ended questions as well as screens
Adapt Bright Futures Guidelines
Use screening protocols
Have other staff to engage in education
Connect families with resources (child care, parenting groups, etc.)
Link into Patient Centered Medical Home (PCMH) and Quality Improvement (QI) efforts
PCMH = Patient Centered Medical Home
QI = Quality Improvement 13

14. Every Day, Every Child: 5 Rs of Early Childhood
Routines help children know what to expect of us and what is expected of them
Reading together daily
Rhyming, playing and cuddling
Rewards for everyday successes – PRAISE is a powerful reward
Relationships, reciprocal and nurturing – foundation of healthy children
Basic messaging to parents and providers: can you integrate this into your routine anticipatory guidance and materials? How else can you reinforce this? 14

15. Exemplary Programs Supporting Healthy Child Development…and Many More!
ABCD
Assuring Better Child Health & Development
Connecticut’s Help Me Grow program
There have been great success stories in transforming the clinical venue and work across settings to more holistically support the needs of children and families 15

16. “Reach Out and Read”
Integrated into primary care clinical practice (in approximately 5,000 hospitals and health centers today)
At 6-month visit through age 5, medical providers:
Give child a developmentally-appropriate, culturally sensitive book
Model effective reading techniques for the parents/caregivers and encourage routine reading with child at home
Help families understand developmental milestones and provide guidance to foster stable relationships with their child
Reach Out and Read National Center provides training, materials, technical assistance, and funding for books
Reach Out and Read is a prime example of an innovative program that is evidence-based and highlights the value of the clinical venue as an access point to early childhood: it is achievable and has impact.
Do you have a Reach Out and Read in your setting?
For more information, visit: 16

17. “Reach Out and Read” Research Findings
Families read together more often
Children enter kindergarten with:
Larger vocabularies
Stronger language skills and
A six-month developmental edge
Program is located in approximately 5,000 hospitals and health centers and expanding 17

18. Professional Opportunities
Child Health & Development Interactive System (CHADIS): potential “game changer”
Electronic Health Record (EHR) opportunity
Alignment with Patient Centered Medical Home (PCMH) standards
Quality Improvement (QI)
Maintenance of Certification (MOC) 18

19. Assessment How are we currently supporting this issue?
How can we enhance our efforts with existing resources?
What is our vision for this area?
Who are our partners?
What are our next steps?
One way to start to explore these questions is to take a given issue or area of concern that relates to EBCD; for example, social-emotional health, early literacy, executive function or school readiness. We know that all of these areas are intertwined, but start by asking yourself the above questions.
Some efforts require a lot of capacity and you will need to be purposeful and strategic in getting there. Other efforts may require a much smaller intervention that is within your current capacity, such as having brochures for local child care resource and referral readily available or incorporating the 5 Rs into your routine guidance. These types of actions can be easily implemented, whereas implementing a screening protocol or working towards a co-location of mental health services model would take increasingly more planning and capacity.
Having momentum and moving in the areas that you are able to, as well as having a long term vision are helpful approaches to evolving your practice. 19

20. Core Community Connections: It Takes a Village
Child Care Resource & Referral (CCR&R) agencies
Early Education and Child Care Systems
Women, Infants, and Children (WIC)
Mental Health Support
Parenting Groups (Fatherhood Initiatives)
Domestic Violence Support
Breast Feeding Support
Early Intervention
There are many community services that are available to children and families: connecting and partnering with these services can dramatically improve the care and opportunity that you give to your patients.
You do not have to be an expert in all areas of EBCD support. That is clearly unrealistic and also not necessary, but you should be adept at being aware of and cultivating partnerships with a range of community-based services to easily refer your patients and to partner with in other ways.
This is an important competency for your toolbox, but one that is often overlooked in training and practice. For example, a recent survey of NY pediatricians revealed that 88% have never heard of a child care resource and referral agency. A recent survey of pediatricians in Queens revealed that nobody was able to name a specific agency to which to refer patients for maternal depression; the list could continue. The value of being aware of community resources is tremendous and can yield many positive returns in future health outcomes as well as in patient and provider satisfaction. 20

21. Approaches Awareness and referral Sharing materials “Promoting”
Co-location: service and education models
Contributing
Project
Working to achieve a common vision
NOTE TO SPEAKER: you may want to change the list on this slide based on the specific community.
Here, we will highlight a few potential community partners. There are many more general, as well as many specific, partners that may be available in your community or areas of interest.
Please refer to the Relationship Builder worksheet and ask yourself:
What is this service?
What is their contact information/location?
What is the status of our current relationship?
What are the opportunities we have to partner and what actionable next step can I take to move this relationship forward?
Remember to be realistic. A first step may simply be to search the internet to find out more about them and be aware of them. Have their contact information readily available for a referral.
There is tremendous value at being able to easily refer patients to a broad range of EBCD promoting services so ask yourself the following: can you go further?
Can you reach out to the agencies and identify yourself as a partner? Ask them if they have helpful materials you can share with patients, put posters up in your waiting room or links on your website.
Can you educate staff to promote a given service? Do they have any capacity to brainstorm some co-location services? A possibility for staff to promote services is by educating patients or providers in your practice about EBCD? Could they provide direct services? How can you be helpful to them? Maybe by serving on boards, providing knowledge, working on a project together or working together to support a common cause and vision. 21

22. CCR&R: Child Care Resource and Referral Agency
Help parents take the guesswork out of choosing care by providing:
Referrals to local child care providers
Information on state licensing requirements
Information on availability of child care subsidies
CCR&Rs provide guidance by phone, in person, and even online, that is tailored to each family FOR FREE!
This is an example of one very helpful community partner. With over 70% of children attending out of home early education and child care programs, identifying quality care that meets a family’s needs is most important. In the minds of parents and caregivers, simply referring them to this valuable service available in your community can provide much needed support.
This is another example of how you don’t have to be the expert about all early education and child care programs in your community. There are also many other benefits to working with your local CCR&R. Identifying yourself as a partner to them can result in many other partnership opportunities. 22

23. You Can Find Your Local CCR&R with a Click!
Child Care Aware is a national organization for child care resource and referral agencies. Both child care providers and parents and families (as well as potential partners) can benefit from their services. 23

24. Head Start & Early Head Start
Federal programs designed to promote school readiness for low-income children ages 0-5
Early Head Start: for pregnant women and families with children under age 3 (with strong home-based component)
Head Start: for children ages 3-5 and their families, in preschool center model
Use a comprehensive approach: whole child and family
Cognitive, social, and emotional development
Screenings and referrals to health, nutrition, and social services
Family support and family/community engagement 24

25. Early Head Start: National Evaluation Documents Strong Positive Impacts
Positive child outcomes (at 36 months) include :
Larger vocabularies
Greater ability to solve problems and understand basic concepts
Higher levels of functioning
Better outcomes on several aspects of social-emotional development
Positive parent outcomes include:
Parents more likely to read to their children daily
Parents more positive with their child and greater repertoire of discipline strategies
This evaluation was a rigorous, large-scale, random-assignment evaluation. 25

26. Home Visiting Programs
A voluntary service, designed to reach expectant parents, babies and young children, who face barriers in supporting their child’s healthy development
Offers support and information in the home environment
Increasing recognition of the need to coordinate with other early childhood programs (e.g. Early Head Start)
Services can include parenting education, healthcare education, child abuse prevention, home safety education and referrals to needed services. 26

27. The Research on Home Visiting Programs
High quality programs have positive outcomes for parents and children including:
Improved parenting skills and quality of home environment
Improved intellectual development
Enhanced maternal employment and education
Improved detection and management of postpartum depression
Improved childhood immunization and breastfeeding rates
Nurse Family Partnership Home Visiting Model has $5.70 Return on Investment per Tax Dollar Spent*
*As home visiting programs expand, evaluation is increasingly important to determine which delivery models have greatest impact and savings.
AAP 2009 Policy Statement: Summary of Characteristics of Successful Home Visiting Programs
● Socially deprived mothers show the greatest benefits from home visiting.
● Professional or nurse-based home visiting is generally advantageous for families.
● Home visits may be useful for children born preterm or with low birth weight and may result in positive effects on child development. Without sustained support, these positive effects may fade as children grow older.
● Services of longer duration and greater intensity correlate with higher degrees of effectiveness.
● Generally, the more risk factors present in a child’s life, the more likely that developmental outcomes will be affected. However, those families with the poorest functioning are often unresponsive to engagement and intervention.
2009 AAP , Council on Community Pediatrics Policy Statement: The role of preschool home-visiting programs in improving children’s developmental and health outcomes. Pediatrics 2009;123; 27

28. EI: Early Intervention Program for Infants and Toddlers (IDEA Part C)
A system of services that helps babies and toddlers with developmental delays or disabilities.
Serve eligible to children from birth through age two
Eligible children have an Individualized Family Service Plan (IFSP) developed by team of professionals with the family
Services vary based on individual child’s needs
May include: assistive technology, audiology or hearing services, medical services, nutrition services, physical therapy, speech therapy, psychological services, and/or counseling and training for the family
Note: EI assessment, evaluation, IFSP planning, and care coordination are free, but states can choose to charge for EI services on a sliding fee scale or bill to the family’s health insurance. However, the Part C law requires that no child can be denied EI services because their family cannot afford to pay for them. 28

29. Positive Impacts of EI
Specialized services and support increase the chances young children will develop to their full potential
Young children who receive EI are better prepared for school and later life
Family needs are addressed by providing emotional support and information to help them promote their child’s development and function as their child’s best advocate 29

30. Role in the Community It is limitless! Connections Advising Presenting
Media
Projects
Outreach
There are so many roles that you can play within your community in general and within community-based organizations. Also, don’t forget about your medical community as an opportunity to educate and engage groups of people with your message. 30

31. The Win/Win
Healthy, thriving children as a result of building lifelong health and an economically sound and thriving community/society
Opens up professional doors and opportunities for you and the families and communities you serve
It’s fun and rewarding!!!! 31

32. Barriers Time, time, time “One more thing” Reimbursement
Education and knowledge
Perceived or real lack of community resources
“I identified an issue, now what?”
Remember that reaching out to partners, while it takes some time investment, can definitely expand your current capacity.
We also know that there is a limit to what can be accomplished in 15 minutes with a patient on a good day. The team approach and viewing your entire clinical interface as part of the encounter, from pre- and inter-visit communication, to waiting room time and interaction with your entire staff, is one way to expand the scope of what can be addressed.
The growing list of important issues to address is real. Pediatric surveys often reveal that pediatricians may not know how to implement a service or screen, or they feel adept around an issue area and are particularly concerned in instances when they are unaware of what to do if a concern is identified (who to refer to/what next). 32

33. Making Bright Futures Real!
There can be a disconnect between the goal and practice
Back to original vision: child-centered goals and outcomes with community support and implementation
Bright Futures is a national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities. Whether you are a health care or public health professional, a parent, or a child advocate, Bright Futures offers many different resources for your use in improving and maintaining the health of all children and adolescents. We need to be voice in supporting its full implementation.
There is an opportunity for us to communicate and ensure that the vision of Bright Futures is real. Many people consider it a recipe for well-child care. Many states say that they “cover” Bright Futures services. We know that it is a set of outcomes with wonderful tools, recommended screens, anticipatory guidance, prevention and promotion.
How can we contribute to supporting children with this vision, both within our practices and within our communities? 33

34. Professional/Institutional Advocacy
What are you doing within your own institution? How can you take it further?
Working with your AAP Chapter
Working to promote change in medical students, residents, or physician training is a policy mechanism for change
Methods to take EBCD outreach within your own institution are: administrative support, policies, CMEs, or alignment with ongoing Health Care Assurance Program initiatives)
There are also many opportunities to work on a professional/institutional level to be a champion for EBCD. Again, highlighting the fact that pediatrics is an access point to young children is key. By working to support medical education and practice this can be considered a method of change. 34

35. Systems Building: What is it All About?
Comprehensive health services that meet children’s vision, hearing, nutrition, behavioral, and oral health as well as medical health needs.
Early care and education opportunities in nurturing environments where children can learn what they need to succeed in school and life.
Early Learning
Health, Mental Health and Nutrition
Family Support
This is a representation of some key components of an early childhood development system. The bridge building piece of this diagram lies in the intersection. The relationships, planning, policies, funding streams, and thinking that needs to occur innovatively and across systems can present challenges and tremendous opportunities. However, many lessons learned reveal that it is at that intersection where innovation and positive outcomes happen.
Early identification, assessment and appropriate services for children with special health care needs, disabilities, or developmental delays.
Special Needs/ Early Intervention
Economic and parenting supports to ensure children have nurturing and stable relationships with caring adults. 35

36. Restating the Framework
Clinical
Community
Professional
Policy
There are opportunities for you to support children’s EBCD on all of these levels. 36

37. A journey of a thousand miles begins with a single step
A journey of a thousand miles begins with a single step.- Lao-tzu, The Way of Lao-tzu, Chinese philosopher (604 BC BC) 37

38. Educational Achievement Economic Productivity Responsible Citizenship
What Are We Building?
Healthy Economy
Strong Communities
Successful Parenting
of Next Generation
Educational Achievement
Economic Productivity
Responsible Citizenship
Lifelong Health
As a pediatrician, the role that you have to play to support Early Brain and Child Development is an important part of the mortar for the strong foundation needed to build brains and healthy futures.
Healthy Child Development 38

39. For More Information
Contact Name
Chapter Web link 39