Developmental difficulties in early childhood


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Developmental difficulties in early childhood

  1. 1. CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■  ■ DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOOD Prevention, early identification, assessment and intervention in low- and middle-income countries A REVIEW CAH
  2. 2. WHO Library Cataloguing-in-Publication Data Developmental difficulties in early childhood: prevention, early identification, assessment and intervention in low- and middle-income countries: a review. 1.Child development. 2.Child welfare. 3.Child health services. 4.Health promotion. 5.Developing countries. I.Ertem, Ilgi Ozturk. II.World Health Organization. ISBN 978 92 4 150354 9 (NLM classification: WS 105)© World Health Organization 2012All rights reserved. Publications of the World Health Organization are available on the WHO web site ( can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland(tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distri-bution – should be addressed to WHO Press through the WHO web site ( designations employed and the presentation of the material in this publication do not imply the expression ofany opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines onmaps represent approximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed orrecommended by the World Health Organization in preference to others of a similar nature that are not mentioned.Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the World Health Organization to verify the information contained inthis publication. However, the published material is being distributed without warranty of any kind, either expressedor implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall theWorld Health Organization be liable for damages arising from its use.The named author is responsible for the views expressed in this publication.Design by minimum graphicsPrinted and disseminated with support from UNICEF (Turkey Country Office and CEECIS Regional Office).Printed in Turkey
  3. 3. CONTENTSAcknowledgements vChapter 1. Introduction and overview 1 Scope of the review 2 Terminology 2 The WHO Developmental Difficulties in Early Childhood Survey 3 Construction of the survey 3 Identification of respondents 3 Limitations of the survey 4 Outline of chapters 4Chapter 2. Early childhood development and health care systems 6 Purpose of chapter and additional key references 6 Conceptualization of child development 7 The importance of the early years 8 The role of the health care system 9 Summary of research 10 The role of primary health care 11 Developmental–behavioural paediatrics 12 Conclusions and implications for action 13Chapter 3. Epidemiology of developmental difficulties in young children 14 Purpose of chapter and additional key references 14 Conceptualization 14 Summary of research from LAMI countries 14 Conclusions and implications for action 17Chapter 4. Developmental risks and protective factors in young children 18 Purpose and scope of chapter 18 Conceptualization of risk and protective factors 18 Resilience and protective factors 18 Risk factors 19 The life-cycle approach to developmental risk factors 20 Summary of research from LAMI countries 21 Resilience and protective factors in young children 21 Risk factors in young children 22 Conclusions and implications for action 31Chapter 5. Prevention of developmental difficulties 33 Purpose of chapter and additional key resources 33 Conceptualization 34 A model for preventing developmental difficulties in early childhood 34 Research in LAMI countries 35 iii
  4. 4. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOOD An exemplary model from a developing country: the WHO/UNICEF Care for Child Development Intervention 38 Conclusions and implications for action 39Chapter 6. Early detection of developmental difficulties 41 Purpose of chapter 41 Conceptualization 41 Research in LAMI countries 42 An example from a developing country 47 Conclusions and implications for action 50Chapter 7. Developmental assessment of young children 51 Purpose of chapter and additional key references 51 Conceptualization 51 Research in LAMI countries 53 Assessment processes 53 Assessment instruments 54 Conclusions and implications for action 57Chapter 8. International classifıcation systems for developmental difficulties in young children 59 Purpose and scope of the chapter and additional key resources 59 Conceptualization 59 The Diagnostic Classification of Mental Health and Developmental Disorders   of Infancy and Early Childhood 60 The International Classification of Diseases 61 International Classification of Functioning, Disability, and Health 61 Application of classification systems 62 Strengths of the classification systems and areas that require improvement 63 Research in LAMI countries 65 Conclusions and implications 65Chapter 9. Early intervention (EI) 67 Purpose and scope of the chapter and additional key resources 67 Conceptualization 68 What are EI services? 69 Who are EI services for? 69 What major improvements are needed in the conceptualization of EI? 70 Evidence-based best practices in early intervention 71 Summary of research in LAMI countries 71 Important questions for future research 74 An exemplary model from LAMI countries 75 Conclusions and implications for action 77Chapter 10. From prevention to intervention: consensus of experts 78 Advancing policy related to developmental difficulties in early childhood at national levels 78 Bringing down barriers using common international approaches and platforms 79 Increasing local capacity by training personnel 79 Increasing capacity in other specialities related to developmental difficulties 80 Empowering caregivers 80 Conducting research 80References 81Annex 1 101 iv
  5. 5. ACKNOWLEDGEMENTST he World Health Organization wishes to express its deep gratitude to the author of this review, Dr Ilgi Ozturk Ertem, Professor of Pediatrics, Director, Developmental-Behavioral Pediatrics Divi-sion, Ankara University School of Medicine, Ankara, Turkey, and visiting professor (2006–2007) at YaleUniversity School of Medicine Department of Pediatrics, New Haven, CT, USA. The project was led and supervised by Dr Meena Cabral de Mello, Senior Scientist, Department ofMaternal, Newborn, Child and Adolescent Health, WHO, Geneva. This document was reviewed internally by members of the WHO Department of Child and AdolescentHealth and the Disability and Rehabilitation Team, and externally by international experts in the fieldincluding: Dr Vibha Krishnamurty, Director, Ummeed Child Development Centre, Mumbai, India; Profes-sor Nicholas Lennox, Director, Queensland Centre for Intellectual and Developmental Disability, Brisbane,Australia; Dr Shamim Muhammed, Sangath Organization, Goa, India; Dr Olayinka Omigbodun, Depart-ment of Psychiatry, University of Ibadan, Ibadan, Nigeria; Professor Trevor R Parmenter, Director, Centrefor Developmental Disability Studies, Sydney, Australia; Professor Atif Rahman, Chair, Department of ChildPsychiatry, University of Liverpool, Liverpool, England; Dr Chiara Servili, WHO Eritrea Country OfficeAsmara (2008); Professor Rune Simeonsson, Professor of School Psychology and Early Childhood Educa-tion, University of North Carolina, Chapel Hill, USA; Dr Aisha Yousafzai, Child Health and Disability, AgaKhan University Human Development Program and Aga Khan University Medical College, Department ofPaediatrics and Child Health, Karachi, Pakistan, and Dr Nurper Ulkuer, Chief, Early Childhood Develop-ment Unit/PDO, United Nations Children’s Fund, USA. Federico Montero and Alana Officer, WHO Disability and Rehabilitation Team, Dr Mercedes de Onis,WHO Department of Nutrition and Dr Tarun Dua, WHO Department of Mental Health provided invalu-able comments and suggestions. Thanks are due to Professor Michael Guralnick (President of the International Society of Early Interven-tion), Professor David J Schonfeld (past President of the Society of Developmental Behavioral Pediatrics anddirector of the Developmental Behavioral Pediatrics Division, Cinninnati Children’s Hospital), ProfessorMatthew Melmed (Director of Zero to Three), and Drs John M Levental, Brian Forsyth and Carol Weitz-man (Yale University School of Medicine) for their review and comments on the survey, DevelopmentalDifficulties in Early Childhood. Dr Ertem’s consultations with Professor Barry Zuckerman (Chairman of Pediatrics, Boston UniversitySchool of Medicine, Boston, USA), for this review was supported by a Leadership Development, Fellow’sCollaboration grant from Zero to Three. We also thank Zero to Three for providing the gift of an issue ofZero to Three Journal for the respondents of the survey. Most importantly, we are grateful to the numerous experts around the world for their invaluable con-tributions to the Developmental Difficulties in Early Childhood Survey. These include:Argentina: Horacio Lejerraga, MD, Head of Depart­ment of Growth and Development. Hospital de Pediatría Garrahan. Buenos Aires, Argentina. Frank Oberklaid, MD, Professor, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, Victoria, Australia. Naila Khan PhD, Professor, Child Development and Neurology Unit, Dhaka Shishu (Children’s) Hospital, Sher-e-Bangla Nagar, Dhaka, Bangladesh. naila.z.khan@gmail.comBrazil: Jose Salomao Schwartzman, MD, Professor, Developmental Disorders Postgraduation Program, Mackenzie Presbyterian University. São Paulo,Brazil v
  6. 6. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOODBulgaria: Aneta Popivanova, MD, Assistant Professor of Neonatology, University Clinic of Neonatology, University Hospital of Obstretics and Gynaecology, Sophia, apopivanova@abv.bgCanada: Emmett Francoeur, MD, Director, Child Development Program and Developmental Behavioral Pediatric Services, Montreal Children’s Hospital, McGill University Health Center, Montreal Children’s Hospital, Montreal, Quebec, Canada. emmett.francoeur@mcgill.caChile: Paula Bedregal, MD, MPH, PhD, Professor of Public Health, School of Medicine, Pontificia Univer- sidad Católica de Chile, Santiago, Chile, pbedrega@med.puc.clChina: Jin Xing Ming, MD, Department of Development and Behavioral Pediatrics, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China, zhujing7@ : Ala’a Ïbrahim Shukrallah MD, Head of Training and Research Unit, Development Support Centre, 30 Haroun St, Geiza, Egypt, alaashuk@yahoo.comFrance: Phillipe Compagnon, MD, Hôpital Sainte Thérèse, Bastogne, Belgium philippe.compagnon@ wanadoo.frGaza Strip and West Bank: Alam Jarrar, MD, Director, Rehabilitation Program, West Bank and Gaza, Ra- mallah, Palestine, allam@pmrs.psGeorgia: Nana Tatishvili, MD, Medical director and head of neurology service, M.Iashvili Central Childrens Hospital, Tbilisi, Georgia. n_tatishvili@mail.ruIndia: MKC Nair, MD, Professor of Pediatrics & Clinical Epidemiology Director, Child Development Centre Medical College, Thiruvananthapuram Kerala, India. nairmkc@rediffmail.comVibha Krishnamurthy, MD, Director, Ummeed Child Development Center, Mumbai, India. vibha.krish@ gmail.comIndonesia: Anna Alisjahbana, MD, PhD, Professor Emeritus, Founder and Chairperson Surya Kanti Foundation (YSK), “Center for the Development of Child Potentials” Consultant & Advisor, Bandung, Indonesia. Gary Diamond, MD, Director, Child Development Services, Clalit Health Maintenance Organization, Dan Region, Israel, and Vice Director Child Development Institute Schneider Childrens Medical Center of Israel, Petah Tikva, Israel. Saleh Al-Oraibi, PhD, MCSP, Assistant Professor, AL- Hashmite University , Faculty of Allied Health Sciences, Physical Therapy and Rehabilitation Department, Zarka, Jordan, Nurmuhamed Babadjan, Chief of pediatric rehabilitation department, National Center of Pediatrics. nurmuhamed-babad@mail.ruGulmira Nagimidinova, Director of IMCI Center of National Center of Pediatrics and Child Surgery, assistent of department of family medicine of Kyrgyz State Medical Academy, Bishkek, Krygyzstan. nt_gulmira@yahoo.comLebanon: Moussa Charafeddine, Vice President Inclusion International, Secretary General Lebanese Parents & Institutional Associations for Intellectually Disabled, President Of MENA Region Inclusion International, President, Friends of Disabled Association-Lebanon, Beirut, Lebonon. moussa@friends- Amar Singh HSS, MD, Senior Consultant Paediatrician, Consultant Community Paediatrician Head of Paediatric Department, Ipoh Hospital, Perak, Malaysia. amimar@pc.jaring.myPakistan: Zeba A. Rasmussen, Vice Chairman, Chief Executive Officer, Mehnaz Fatima Educational and Welfare Organization, Shahrah-e-Quaid-e-Azam Near Family Health Hospital, Jutial , Gilgit, Pakistan., Alexis Reyes, MD, Professor, Institute of Child Health and Human Development, University of the Philippines, National Institutes of Health, Manila, Philippines. alexis7591@gmail.comRomania: Adrian Toma, MD, Chief of the Neonatology Unit, “Panait Sarbu” Obstetrics and Gynecology Hospital, Bucharest, Romania. vi
  7. 7. ACKNOWLEDGEMENTSRussian Federation: Akaterina Klochkova, PhD, Head of physiotherapy department, St. Petersburg Pavlov Medical University, St Peterburg Early Intervention Institute, St Petersburg, Russian Federation. katya@ klo.ioffe.ruSaudi Arabia: Saleh M. Al Salehi Al Harbi, MD, Medical Director, Children’s Hospital, Consultant develop- mental behavioral pediatrics, King Fahad Medical City, Riyadh, Saudi Arabia,, Rosebeth Marcou, MD, Developmental and Behavioural Paediatrician, Raffles Hospital, Singa- pore. drmarcou@gmail.comSouth Africa: Colleen Adnams, MD, Senior Specialist and Lecturer Head, Developmental (Clinical) Service and Division of Paediatric Neurosciences, Red Cross War Memorial Children’s Hospital and School of Child and Adolescent Health, University of Cape Town, South Africa. Drs Ilgi Ertem, Derya Gumus Dogan, Bahar Bingoler Pekcici, Ozlem Unal. Developmental-Behavioral Pediatrics Division, Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey. ertemilgi@yahoo.comUnited Kingdom: Val Harpin, MD, Consultant Paediatrician (neurodisability), Ryegate Children’s Centre, Sheffield, United Kingdom, val.harpin@sch.nhs.ukUnited Republic of Tanzania: Augustine Massawe, MD, Senior Lecturer, Consultant Paediatrician and neonatologist, Muhimbili National Hospital, Muhimbili University College of Health Sciences, Dar es Salaam,Tanzania. draugustine.massawe@gmail.comUnited States of America: David J. Schonfeld, MD, Director, Division of Developmental and Behavioral Pediatrics Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States. david. schonfeld@cchmc.orgViet Nam: Tran Thi Thu Ha, MD, Vice Director of the Rehabilitation Department, National Hospital of Pediatrics, Rehabilitation Director, Hope Center, Hanoi, Vietnam. mdthuha@yahoo.comFor further information about this document please contact Meena Cabral de Mello, Senior Scientist andWHO Focal Person for Early Childhood Development in the Department of Child and Adolescent Health,WHO/HQ, who led and managed this project. This document is a part of a series of evidence based reviews intended to guide interventions to improvethe health, growth and development of children, particularly those living in resource-poor settings. Theother reviews of relevance are:● A critical link: Interventions for physical growth and psychological development. WHO/CHS/CAH/99.3 (1999).● Family and community practices that promote child survival, growth and development: A review of the evidence. WHO. ISBN 92 4 159150 1 (2004).● The importance of caregiver–child interactions for the survival and healthy development of young children. WHO. ISBN 924159134X (2004).● Mental health and psychosocial well-being among children in severe food shortage situations. WHO/MSD/ MER/06.1 (2006).● Responsive parenting: interventions and outcomes (2006). Bulletin of the World Health Organization, 84:992–999.● The role of the health sector in strengthening systems to support children’s healthy development in communities affected by HIV/AIDS: A review. WHO. ISBN 9241594624. (2006).● Early child development: A powerful equalizer (2007). Final Report for the World Health Organization’s Commission on Social Determinants of Health. ecd_final_m30/en/● The Lancet: Child development in developing countries series. The Lancet, Vol 369 January 6, 2007. vii
  8. 8. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOOD● The Lancet: Child Development 1. Inequality in early childhood: risk and protective factors for early child development. Lancet 2011; 378: 1325–38 6736%2811%2960555-2/fulltext.● The Lancet: Child Development 2: Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet 2011; 378: 1325–38.● Facts for life. UNICEF. Fourth edition (2010). ISBN: 9789280644661.To obtain copies of the above documents and for further information, please contact: Department of Maternal, Newborn, Child and Adolescent Health World Health Organization 20 Avenue Appia 1211 Geneva 27 Switzerland Tel: +41 22 791 3281 Fax: +41 22 791 4853 Email: Web site: viii
  9. 9. 1 Chapter Introduction and overviewT he majority of the world’s children live in low- and middle-income (LAMI) countries. Often,in these countries, the health care system is theonly system that has the potential to reach mostyoung children and their families. For centuries,clinicians, researchers and advocates around theworld have been working to prevent, diagnoseand treat childhood illness, so that children canenjoy good health and reach adulthood. Thistask continues to be a challenge. There is stillan unacceptable disparity between high-incomeand LAMI countries with respect to indicators forchild survival and health. Equally unacceptableis the disparity between countries in the range The majority of world’s children live in low- and middle-of supports available to help children develop income countries, Nicaragua. © WHO-342031/C.Gaggerooptimally, and to prevent, detect and managedevelopmental difficulties during infancy andearly childhood. development, countries are categorized as high- Despite long experience in fighting childhood income or low- and middle-income according toillness and mortality, health care providers in the World Bank definition (www.siteresources.LAMI countries face new challenges in promot- child development. There is, nevertheless, a XLS accessed 21.04.2011).wealth of information on this topic, generated by Developmental difficulties during earlyresearchers and clinicians working in resource- child­ ood are increasingly recognized in LAMI hpoor conditions. The main premise of the present countries as important contributors to morbidityreview lies in the words of the late Professor Mujdat in children and adults. Health care systems inBasaran, a renowned paediatrician in Turkey: “We high-income countries provide multiple oppor-must generate our own science. We must search tunities for the prevention, early identificationand research for information that is pertinent for and management of developmental difficultiesour own circumstances and we must contribute in young children. Interventions to improve theto the production of the science that will help us development of young children are becomingmove forward.” This review therefore compiles the increasingly available in LAMI countries, andwealth of information that has already accumu- include low-cost strategies, such as addressinglated in a systematic framework that can be used malnutrition and iron deficiency, training car-by health care providers in LAMI countries. egivers, increasing psychosocial stimulation and In this review, the term “developmental dif- providing community-based rehabilitation.ficulties” is used to refer to a range of difficulties Infancy and early childhood are the best timeexperienced by infants and young children, for the prevention and amelioration of problemsincluding developmental delay in the areas of that could potentially cause developmental dif-cognitive, language, social-emotional, behav- ficulties and affect brain development across theioural and neuromotor development. “Early lifespan. A focus on prevention and early inter-childhood” and “young children” relate to the vention for developmental difficulties requiresage range 0 to 3 years. Since economic status is an understanding of the magnitude and naturethe most important factor determining human of the problems, to ensure a match between the 1
  10. 10. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOOD interventions delivered and what is needed by the information on specific developmental risk fac- children, their families and their communities. tors, such as human immunodeficiency virus Many families have contact with the health care (HIV) infection and acquired immunodeficiency system most often – and sometimes only – when syndrome (AIDS), low birth weight, malnutrition their children are young. Health care encounters and chronic illness. This review should not be for young children are, therefore, important viewed as a general resource for early childhood opportunities for clinicians in LAMI countries to disability or for specific developmental disabili- have a positive influence on development. ties, such as cerebral palsy, genetic or metabolic In most LAMI countries, the health care sys- disorders, autism spectrum disorders, and cogni- tem does not have a model for the promotion tive or sensory impairments. These topics deserve and monitoring of the development of children, specific attention beyond the scope of this review. prevention and early identification of risk factors Where relevent and possible, reference is made associated with developmental difficulties, and to other reviews or documents on these topics. early interventions. Health care providers may not have appropriate knowledge and expertise, Terminology and service delivery systems may be inadequate. However, by building local capacity, a systematic During the first three years of life, even children approach, specific to the needs of LAMI countries, who are showing typical development may be at can be developed. This review seeks to help health risk and in need of early intervention services. care providers and systems in LAMI countries to Children may show differences from the broad build such local capacity. range of healthy development without necessar- ily having a specific disorder or disability. This review includes issues related to a broad spectrum Scope of the review of problems that may affect development. There- WHO has previously published three reports fore, the term “developmental difficulty” is used related to child development. The first, A critical to include conditions that place a child at risk for link (WHO, 1999) summarized the importance suboptimal development, or that cause a child to of addressing both the nutritional and psycho- have a developmental deviance, delay, disorder social aspects of malnutrition and was a seminal or disability. The term is intended to encompass report on the need for developmentally based all children who have limitations in functioning biopsychosocial approaches to child health. The and developing to their full potential, e.g. those second, The importance of caregiver–child interac- living in hunger and social deprivation or born tions for the survival and healthy development of with low birth weight, as well as those with cer- young children (Richter, 2004) contained impor- ebral palsy, autism, cognitive imparments such tant information on the most critical component as Down syndrome, sensory problems, or other of child development, physical disabilities, such as spina bifida. the relational aspect. There is no universally accepted definition of The third, Early child- developmental pathology during infancy and early During the first hood development: a pow- childhood (Msall, 2006). “Developmental delay” three years of life, even erful equalizer (Irwin, is often defined as a deviation of developmentchildren who are showing Siddiqi & Hertzman, from the normative milestones in the areas oftypical development may 2007), prepared for the cognitive, language, social, emotional and motor be at risk and in need WHO Commission on functioning. Neurodevelopmental disorders have of early intervention the Social Determinants been categorized as cerebral palsy, autism, genetic services. of Health, provided an syndromes and metabolic diseases affecting the in-depth look at the central nervous system (Batshaw, 2002). Often importance of social infants and young children with any kind of dif- determinants in shaping child development ficulty require a broad range of services, referred This fourth report includes information to as early intervention. While some disabilities from low- and middle-income countries on the merit specified services, there are widely rel- conceptualization, epidemiology, prevention, evant common approaches that can be delivered detection, assessment and early management of through health systems for the prevention, early the broad spectrum of developmental risk factors detection and management of developmental dif- and developmental difficulties in children aged ficulties. An in-depth knowledge of the function- 3 years and under. It does not contain in-depth ing and needs of the child, family and community 2
  11. 11. CHAPTER 1. INTRODUCTION AND OVERVIEWis often more important than the category of the The following WHO projects also informed thepathology. For this reason, this review adopts construction of the DDEC Survey:a non-categorical approach, as recommended ● Atlas: Country Resources for Neurologicalby pioneers in the fields of early intervention Disorders (WHO 2004b)and children with special needs (Msall et al., ● Mental Health Atlas, (WHO 2005a)1994; Msall, 2006; Stein & Silver, 1999; Stein, ● WHO AIMS: Mental Health Systems in low-2004). This non-categorical approach parallels and middle-income countries: a WHO-AIMSthat of the WHO International Classification of cross-national analysis (WHO 2005b)Functioning, Disability and Health for Children ● Atlas: Child and adolescent mental healthand Youth (ICF-CY) framework (WHO, 2007), resources: Global concerns, implications forwhich is explained in detail in Chapter 8 (Lollar the future (WHO 2005c)& Simeonsson, 2005; Simeonsson, 2007). ● Atlas: Epilepsy care in the world (WHO 2005d) ● Atlas: Global resources for persons with intel-The WHO Developmental Difficulties lectual disabilities (WHO 2007b).in Early Childhood Survey A broad literature search was conducted to iden-There is little information available about how tify key publications that examined similar con-health care systems are functioning with regard structs. A study conducted by the Internationalto the prevention, early detection and early man- Society of Prevention of Child Abuse and Neglectagement of developmental difficulties. The Devel- (ISPCAN, 2008) and another of structures andopmental Difficulties in Early Childhood (DDEC) practices of well-child care in ten high-incomeSurvey was therefore developed to identify the countries (Kuo et al., 2006) provided useful inputstructures and practices in different countries. to the DDEC.Sample results from this survey are provided in The reliability of the questions was checkedsummary form at the beginning of the relevant by giving the survey to two expert respondentschapters in this review. The detailed results will in each of four countries. When major disaggre-be presented elsewhere. ments were found, questions were removed; for minor disagreements, questions were reworded.Construction of the survey Identification of respondentsA number of key questions were identified anddiscussed with a group of experts within the The networks of WHO, UNICEF, the Society forWHO Departments of Child and Adolescent Developmental Behavioral Pediatrics, the Inter-Health and Development, Mental Health, and national Society for Early Intervention and ZeroNutrition, and the Disability and Rehabilitation to Three were contacted to identify key expertsTeam. In addition, a number of internationally around the world who met all of the followingrenowned experts in the fields of early childhood three criteria.development, developmental difficulties and early 1. The person was the key expert (or one of theintervention provided input to and comments key experts) in the country on early identifica-on the content and structure of the survey (see tion, early intervention and rehabilitation ofAcknowledgements). young children aged 0–3 with developmental risks (such as low birth weight or malnutrition) and difficulties (such as developmental delay, cerebral palsy, Down syndrome). 2. The person had in-depth knowledge about the health care system and the training of primary child health care providers in the country. Pref- erence was given to academic paediatricians responsible for training health care providers. 3. The person had good command of English. A literature search was also conducted to identify professionals who had published on the conceptsSocial interactions begin early in life: 3-month old, Niger.© UNICEF/NYHQ2009-2569/Holtz in the DDEC Survey. When an expert was identi- 3
  12. 12. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOOD of the early years and the role of the health care system in ensuring the optimal development of all children. The term “child development” indicates the advancement of the child to reach his or her optimal potential in all areas of human function- ing – social, emotional, cognitive, communication and movement. In the past few decades, new imaging techniques have enabled us to visualize how the human brain develops. This chapter sum- marizes comtemporary theory on early childhood development and provides a framework for why this concept deserves to be addressed in detail within health systems around the world.Early stimulation is crucial to optimal development: one-year old with Down syndrome, Turkey. Photo: Canan Gul Gok Chapter 3 provides a framework for under- standing the epidemiology of developmental difficulties in young children by reviewing thefied, at least one of the networks was contacted existing confirm that he or she was suitable to be the Chapter 4 introduces a conceptual framework,respondent for the country. In total, experts from the “Life cycle approach to developmental risk35 countries were identified and invited to par- factors”, which organizes the risk factors and pro-ticipate in the Web-based survey. tective factors for child development in a way that Respondents from 31 countries completed helps countries and communities determine whatthe survey, comprising 94% of those identified needs to be done. Research in LAMI countries onand eligible. Of these, 6 were from low-income preconceptional developmental risk factors thatcountries, 17 from middle-income countries and have not previously been fully explored, such8 from high-income countries. Despite the small as adolescent parenting, unintended pregnancy,number of countries included, the total popula- inadequate birth interval and consanguinity, aretion of the countries in the survey is approxi- also reviewed.mately 70% of the world population. Chapter 5 provides a new conceptual frame- work of interventions that can be delivered within the health care system for the prevention of devel-Limitations of the survey opmental difficulties in young children. ExamplesThere are two main limitations of the DDEC of research on prevention in LAMI countries aresurvey – generalizability and reliability. Its gen- given, and an exemplary programme, the WHO/eralizability is limited by the fact that countries UNICEF Care for Child Development Interven-that were included comprise a portion of the world tion, is summarized.population. Countries particularly in Africa may Chapter 6 deals with early recognition ofnot be well represented in this survey. Further- developmental difficulties in young children.more, since this survey represents information Early recognition allows both preventive andprovided by one expert opinion from each coun- therapeutic approaches to be implemented andtry, the question of reliability and generalizability is a crucial step in addressing the problems. Inof the responses remains a limitation. Respond- high-income countries, the integration of devel-ents were knowledgeable, were asked to report opmental monitoring into health care encountersabout their country as a whole, and to use data has been recognized as an important strategyand other expert opinions to respond to the ques- for the early detection of developmental dif-tions when possible. However, their views may ficulties. This chapter promotes developmentalnot reflect the situation in all parts of the country. monitoring in LAMI countries, summarizing its conceptualization and addressing key ques- tions of importance for LAMI countries. A novelOutline of chapters method of developmental monitoring, which isThe body of this review comprises nine chapters. currently being used in Turkey and which hasAt the beginning of the first eight chapters, the been specifically developed by the author withrelevant results from the DDEC Survey are given. attention to the needs of health care providers in Chapter 2 provides a summary of the concep- LAMI countries, is also introduced. This methodtualization of child development, the importance is fully complementary with the WHO/UNICEF 4
  13. 13. CHAPTER 1. INTRODUCTION AND OVERVIEWCare for Child Development Intervention. Whenused together, these two methods may provide a “…in the context of the successes ofsystematic, family-centred and strengths-based current primary health care child survival initiatives,approach to monitoring the development of young it is essential in low-income countries that increasedchildren, to prevent the most common cause of emphasis be placed on prevention and earlydevelopmental delay (understimulation), to detect identification of developmental disabilities withindevelopmental difficulties and to provide early the primary and maternal and child health careintervention. systems. Those systems must in turn be linked to and Chapter 7 focuses on the developmental supported by secondary and tertiaryassessment of young children, to establish a medical services.”diagnosis, ascertain their level of functioning,determine their needs for additional support and Committee on Nervous System Disordersservices, and enable them to reach such services. in Developing Countries, 2001In many resource-rich countries, a team of clini-cians from multiple disciplines evaluate the childand the family. In countries with fewer resources,the evaluation of the child may be conducted by and Youth (WHO, 2007), and provides examplesone or two clinicians with a less broad experience. of how this system can be applied to capture theThe basic principles of developmental assess- functioning and needs of young children. It alsoment, however, can be applied by an experienced provides a summary of the framework developedclinician in any setting, to give a comprehensive by Zero to Three (2005).assessment leading to appropriate interventions. Chapter 9 provides a summary of early inter-This chapter, therefore, provides information on ventions to guide health care providers and healththe basic principles of developmental evaluation, care policy-makers in LAMI countries in theirthe types of developmental assessment that are efforts to improve the lives of developmentallydesirable and how to begin building an infrastruc- vulnerable children and their families.ture for such assessments. Chapter 10 presents the key actions suggested Chapter 8 summarizes information on clas- by the respondents to the DDEC Survey. Thesesification systems for developmental difficulties have been compiled under headings that emergedin young children that can be used in LAMI from a qualitative analysis of the open-endedcountries. Internationally endorsed classifica- questions in the survey, i.e. (a) advancing policytions facilitate the gathering, conceptualiza- related to developmental difficulties in early child-tion, interpretation and sharing of information hood at national level; (b) breaking down barri-between clinicians and researchers around the ers using common international approaches andworld. Countries may also use classifications to platforms; (c) increasing local capacity by train-determine whether children are eligible for certain ing personnel; (d) increasing capacity in otherservices. This chapter places specific emphasis specialities related to developmental difficulties;on the WHO International Classification of (e) empowering caregivers; and (f) conductingFunctioning, Disability and Health for Children research. 5
  14. 14. 2 Chapter Early childhood development and health care systems Purpose of chapter and additionalDDEC Survey results key references TA number of questions in the DDEC he recent Lancet series, “Early childhoodSurvey requested information on the development in developing countries”,infrastructure and role of the health services estimated that over 200 million children inin addressing developmental difficulties in developing countries are not reaching their fullyoung children. In most countries, access developmental potential (Grantham-McGregor etto health care providers was not an issue. al., 2007). The Disease Control Priorities projectTrained health care providers were either has stated that 10–20% of individuals have learn-within walking distance or accessible by ing or developmental difficulties (Durkin et al.,transportation that was affordable to most 2006). Developmental difficulties are the mostof the population. Continuity of health care, common causes of long-term morbidity (Com-however, was a problem. Child development mittee on Nervous System Disorders in Develop-can best be addressed if the same health ing Countries, 2001). This chapter summarizescare provider follows the child over time. the conceptualization of child development, theIn most countries, however, children did importance of the early years of life and the rolenot receive primary preventive health of the health care system in ensuring optimalcare, or care for acute or chronic illness, development of all children.continuously from the same providers. In In-depth information on the theoretical con-most low-income countries, but not high- ceptualization of child development is beyond theand middle-income countries, home-visiting scope of this review. Readers are referred to otherwas available for the majority of children. key documents that contain detailed informationIn all LAMI countries, there was a shortage on contemporary developmental theories andof primary health care personnel. General interventions during infancy and early childhoodpaediatricians, paediatric subspecialists, (Shonkoff & Phillips, 2000; Shonkoff & Meisels,and professionals trained to deal with 2003; Guralnick, 2005a; Myers, 1995; Zeanah,children with special needs were also few 2000; National Scientific Council on the Develop-in number. Although some preservice or ing Child, 2007).in-service training programmes existed, The Institute of Medicine has published aprimary health care providers did not book specifically intended to guide health caregenerally have the expertise to deal with systems, which reviewed in detail the potentialdevelopmental difficulties. response of such systems to developmental disor- ders (Committee on Nervous System Disorders in Developing Countries, 2001). Durkin et al. (2006) reviewed the disease burden of learning and developmental difficulties and ways to address these problems. A number of recent Lancet series – on neonatal survival (Darmstadt et al., 2005; Knippenberg et al., 2005; Martines et al., 2005, Lawn, Cousens & Zupan, 2005), child development in developing countries (Engle et al, 2007; Grantham-McGregor et al., 2007; Walker et al., 2007,), maternal and child undernutrition (Black et al., 2008), global 6
  15. 15. CHAPTER 2. EARLY CHILDHOOD DEVELOPMENT AND HEALTH CARE SYSTEMSmental health (Barret, 2007; Bhugra & Minas, cal link (WHO, 1999) documented the critical2007; Chisholm et al., 2007; Dhanda, 2007; Her- relationship between the nutritional status of arman & Swartz, 2007; Horton, 2007; Jacob et child and his or her psychological development,al., 2007; Patel et al., 2007; Prince et al., 2007; and demonstrated the effectiveness of combin-Saraceno et al., 2007; Sartorius, 2007; Saxena et ing interventions to promote early childhoodal., 2007) and disability (Groce & Trani, 2009; development with efforts to improve child healthGottlieb et al., 2009; Trani, 2009) – contain infor- and nutrition, in an integrated care model. Themation on addressing developmental difficulties report highlighted the importance of addressingin young children within health care systems. both the nutritional and psychosocial aspects of There are many international resources related malnutrition and was a seminal report on theto children with developmental difficulties. The need for developmentally based biopsychosocialUnited Nations (UN) has two conventions related approaches to child health. The second publica-to children with developmental difficulties: tion, The importance of caregiver–child interactionsthe UN Convention on the Rights of the Child for the survival and healthy development of young(United Nations, 1989), and the UN Convention children (Richter, 2004) contained importanton the Rights of Persons with Disabilities (United information on the most critical component ofNations, 2006). Both affirm that children have the child development, the relational aspect. Theright to develop to their full potential and that third, Early childhood development: a powerful equal-countries should guarantee that children with izer (Irwin, Siddiqi & Hertzman, 2007), preparedspecial needs receive the services they require. for the WHO Commission on the Social Deter-The second convention promotes and protects minants of Health, provided an in-depth look atthe full and equal enjoyment of all human rights the importance of social determinants in shapingand fundamental freedoms by people with dis- child development. This report highlighted theabilities, and is legally binding for all Member need for sustained research activities to under-States. Article 25 of the Convention requires stand the effects of the environment on biologicalMember States to ensure access for persons with endowment and early childhood development,disabilities to health services that are gender- and for available evidence to inform actions tosensitive, including health-related rehabilitation. further child development social investmentHowever, the Convention does not explicitly strategies at all levelsdefine disability. The UN Standard Rules for theEqualization of Opportunities for Persons with Dis- Conceptualization ofabilities, which was recognized by the UN General child developmentAssembly in 1993 (United Nations, 1993), is usedfor monitoring progress in addressing disability The term “child development” indicates advance-in countries. Importantly, this report addresses ment of the child in all areas of human functioning:the basic preconditions that need to be in place social and emotional, cognitive, communicationto improve the quality of life of children with and movement. A long-standing debate in childdevelopmental difficulties. development theory relates to the relative influ- WHO has previously published three reports ence of nature versus nurture. If nature is assumedrelated to child development. The first, A criti- to be predominant, child development follows a genetically programmed progression, influ- enced by biomedical risks. On the other hand, if nurture is considered more important, then the child’s development is primarily influenced by the caregiving environment – proximally by the primary caregivers and more distally by the larger community. The contemporary theoretical conceptual- ization of child development incorporates the importance of both nature and nurture, parallels the biopsychosocial model of health (Engel 1977), and builds on Bronfenbrenner’s bioecological model (Bronfenbrenner & Ceci, 1994). This modelThe health system has a key role in monitoring andpromoting child development: Developmental Pediatrics postulates that human development takes placeDivision, Turkey. Photo: Dr. Ilgi Ertem through progressively more complex interactions 7
  16. 16. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOODFigure 1. Conceptualization of child child, through the living and working conditions development (reproduced from of the caregivers, the educational, social and Ertem, 2011) health services, and the physical environment. For example, the child may be affected by the mother D IS T AL ENVIRONMENT or father being stressed because the workplace Co m m u ni ty oeconomic milieu is not accommodating their needs and desires S oc i as new parents. Bioecological theory holds that • • E N V IR O N H e all components – the biological, psychological, t IM AL M OX er s , f a m ENT P R a re g iv and social functioning of the child and his or al en il y th C m her dynamic interactions with the proximal and on Se rv vir distal environments – must be addressed when ice en Child supporting and monitoring child development s • Physical in primary care. Bronfenbrenner’s bioecological rvices perspective offers a useful lens for understanding and supporting young children and their fami- • Li l Se Mother Father lies. This conceptualization can be used in both vin cia individual clinical work and in developing model g So an programmes. Bronfenbrenner himself has stressed • d o w n rk ti the importance of recognizing and accepting o in g en rv n co nd in te t io the uniqueness and strength within each family ition s • Early ca du system and in crafting empowering relations with • E families (Swick & Williams, 2006). A more detailed explanation of how distal environments influence child development can be found in the Total Environmental Assessmentbetween a “biopsychosocial” human being and the Model of Early Childhood Development (TEAM-persons, objects, symbols and systems in his or ECD) framework developed for the WHO Com-her proximal and distal environment. This inter- mission on Social Determinants of Health (Irwin,action is dynamic and the child plays an active Siddiqi & Hertzman, 2007). In the TEAM-ECDrole from birth onwards. Figure 1 offers a practical framework, there are “spheres of influence” onschema for this theory (Ertem, 2011). Here, the early childhood development. These spheres are:biological and genetic endowment of the child is (1) the individual child, (2) the family and dwell-represented by the circle labelled “child”. Within ing, (3) residential and relational communities,this endowment are included concepts such (4) national, regional and global environmentsas physical health, temperament, personality, (including global health status, ecological, eco-developmental abilities, strengths, coping skills nomic, political and social environments), and (5)and vulnerabilities. The two other circles, labelled early childhood programmes and services. In each“mother” and “father”, represent the equivalent sphere of influence, social, economic, cultural andcharacteristics of each member of the child’s gender factors affect the quality of the proximalproximal caregiving environment – often the caregiving environment, which is instrumental forparents, but also other key caregivers and siblings. healthy development in early childhood.The arrows between the different members signifyrelationships and interactions between them. Theintersecting arrows symbolize how relationships The importance of the early yearsbetween one pair shape and influence others in The importance of the early years in human devel-the system. The proximal environment includes opment is neither a new nor a Western concept;the child’s relationship with the primary caregiv- nor is it, in fact, a concept that is foreign to medicalers and everyday interactions, such as feeding, sciences. The works of Avicenna (980–1037), acomforting, playing and talking. This environ- Persian physician who is considered the father ofment is nested in a community of extended fam- modern medicine, and Darwin (1809–1882) theily, neighbours and friends, and a socioeconomic founder of the theory of evolution, demonstratemilieu, which includes the workforce, the wealth that the concept of early childhood developmentand well-being of the country, and the health of has occupied the minds of physicians, philoso-the population. This distal environment directly phers, scientists and caregivers for hundreds ofor indirectly influences the development of the years. According to Avicenna, the early years 8
  17. 17. CHAPTER 2. EARLY CHILDHOOD DEVELOPMENT AND HEALTH CARE SYSTEMSare the most important stage in the life of an This construct can help clinicians, who are inindividual: “the infant is exposed to problems fact a component of the holding environment forand difficulties soon after birth and in the early the mother. Approaches that foster the mother’sstages of childhood and these influence his psy- sense of competence and that empower her willchology and temperament, and hence his moral be effective; approaches that criticize her or makeand ethical development” http://www.ibe.unesco. her feel inadequate will be A relationship-based, supportive, non-critical,accessed 12.07.2007). non-didactic approach to parents is the hallmark Darwin, on the other hand, kept detailed of many successful interventions.records of the development of his son, providing In the past few decades, new imaging tech-one of the first systematic studies of child develop- niques have provided further information onment (Darwin, 1877). A large body of scientific the development of the human brain. Dynamicresearch has been conducted since these early brain-imaging technology has demonstratedattempts to understand, study and explain child that the full complement of neurons is formeddevelopment. before the third trimes- In addition to the bioecological model, two ter of pregnancy, butother theoretical concepts – attachment theory that the connections or Dynamic brain-and the concept of “the motherhood constellation” synapses between these imaging technology– provide guidance on how clinicians can support neurons largely develop has demonstrated thatchild development. Attachment theory, developed after birth. This synap- the full complement ofby Bowlby (1978), suggests that a stable, respon- togenesis, and the later neurons is formed beforesive, nurturing primary relationship enables the “pruning” processes that the third trimester ofchild to regulate his or her emotions and develop occur in the developing pregnancy, but that thea secure base from which to explore, learn and brain, are constructed connections or synapsesform relationships with others. Attachment theory to a large degree in the between these neuronsimplies that interventions in primary care should early years within the largely develop afteraddress the “caregiver–child” dyad and support caregiving environment. birth.parents in helping their infants develop secure The quality of the every-attachment. Research in developmental psychol- day actions of the par-ogy and child psychiatry has shown that a secure ents – smiling, talking,attachment to a primary caregiver is associated cuddling, singing, and responding to the infantwith healthy emotional and cognitive functioning – shapes the circuitry of the developing brainin later life (Boris et al., 2000). Recent research (Shore, 1997; Hannon, 2003).on children raised in orphanages supports the It has also been established that stressorsimportance of early relationships and stimulat- during the early years affect brain environments during the early years of life, Shonkoff (2006) defines toxic stress as “strong,showing that the cognitive outcome of abandoned frequent, and/or prolonged activation of the body’schildren brought up in institutions was mark- stress-management systems in the absence ofedly below that of abandoned children placed in the buffering protection of adult support”. Pre-institutions but then moved to foster care (Nelson cipitants of toxic stress include extreme poverty,et al., 2007). recurrent physical or emotional abuse, chronic “The motherhood constellation” is a theoretical neglect, severe maternal depression, parental sub-construct developed by Stern (1998), a pioneer stance abuse and family violence. An importantin infant development and mental health. He consequence of toxic stress is disruption of therefers to the birth of a child and the early years brain architecture, leading to stress-managementas a specific era of emotional development for systems that respond at relatively low thresholds.the mother. The pregnancy and the birth of the These low thresholds persist throughout life,baby change her mental organization, so that increasing the risk of stress-related physical andher primary preoccupations become keeping the mental illness throughout childhood and the adultinfant alive and protected, caring for the baby so years (Shonkoff, 2006).that he or she will become “her” baby and notjust any baby (enabling attachment), and creating The role of the health care systema supportive, psychologically “holding” environ-ment that supports her mothering. Stern calls Many LAMI countries already have the infra-this construct “the motherhood constellation”. structure needed to support child development 9
  18. 18. DEVELOPMENTAL DIFFICULTIES IN EARLY CHILDHOODwithin the health care system. For example, Indiahas the world’s largest integrated early childhooddevelopment services; operational since 1975,functioning in thousands of centres and coveringmillions of children and mothers, these servicesaim to improve the health and development ofchildren and families. In 2004, there were 5652ICDS projects in India, 4533 in rural areas, 759in tribal areas and 360 in urban areas (Ministryof Women and Child Development, 2009). InTurkey, local health care facilities are located atvillage level throughout the country, staffed withphysicians, nurses and home-visiting midwives.Thus, the health care system in many countriescan have a crucial role in promoting child devel-opment and in the prevention, early detectionand management of developmental difficulties. The rationale behind this crucial role can besummarized in four key points, as noted below.1. In any country, the health care system is often the only system that can potentially reach all young children and their families.2. The biopsychosocial model of child develop- The health system in most countries is the only system ment recognizes that much, if not all, human that has potential to reach all families. © PAHO/WHO 319032 disease and disability are a function of the interaction between genes and the environ- 4. As a result of research showing the positive out- ment. Physical health and development, though comes of early intervention, there has been par- often viewed as separate components of child ticular emphasis in many developed countries well-being, are in fact inseparable. The factors on the early identification and management of that cause poor health, e.g. undernutrition, also developmental difficulties within health sys- affect development. Similarly, factors that cause tems. In most LAMI countries, the personnel poor development, e.g. an unresponsive caring and infrastructure for early intervention may environment, also affect health. WHO refers to not appear to be universally accessible. How- this as the “critical link” between physical health ever, most early intervention programmes for and psychosocial development (WHO, 1999). young children with developmental difficulties Any system intended to address one component, do not require extensive staffing, and work best therefore, must be equipped to address both. when administered through caregivers. The Often, this system is the health system. training of caregivers in early intervention is3. Caregivers, families and communities gener- feasible in LAMI countries. As the availability ally have trust in, and contact with, the health of early intervention and community-based care system (Durkin et al, 2006; Committee rehabilitation increases, the need for the early on Nervous System Disorders in Developing detection of problems through the health care Countries, 2001; Engle et al., 2007). This con- system is becoming more evident. tact is most frequent when the child is young, for example for immunizations and growth monitoring, as well as for acute and chronic Summary of research illnesses. Such health care encounters are Research in high-income populations has shown excellent opportunities to strengthen families’ that promotion of development in paediatric efforts to promote their child’s development, health care encounters has many potential and may be the only chance available for pro- benefits for children and families. For decades, fessionals in developing countries to positively high-income countries have included within the influence carers of young children and to pre- health care system efforts to promote child devel- vent developmental difficulties. opment. These countries have also mainstreamed 10
  19. 19. CHAPTER 2. EARLY CHILDHOOD DEVELOPMENT AND HEALTH CARE SYSTEMSthe early detection of developmental difficulties one of the features of the health system that makeand links to early intervention services. This it so important in addressing child developmentplacing of health care delivery in a developmental issues in LAMI countries.context has benefits for both physical health and There are, however, many potential barriersdevelopment. This is especially attractive where in the primary health care system that can makedevelopmental approaches are added to existing this task difficult. Continuity of care – receivingstructures in routine primary care. There are health care from the same provider over a periodmany examples in high-income countries of how of time – is one of the most important principlesa developmental approach has been incorporated and is crucial to the delivery of developmentallyinto primary care for young children (Regalado & appropriate health care. In the continuity-of-Halfon, 2001). These include Sure Start in Eng- care model, each child (and sometimes family)land (Roberts & Hall, 2000), the European Early is followed over time by the same health carePromotion Project which has taken place in eight provider. Studies in the United States during thecountries (Roberts et al, 2002), Help me Grow 1970s showed the beneficial effects of receiving(Dworkin, 2006), Bright Futures (Green, 1994; continuous health care from the same providerHagan, Shaw & Duncan, 2008; Knight, Frazer (Alpert et al., 1976; Gordis & Markowitz, 1971;& Emans, 2001), Healthy Steps (Niederman et Starfield et al., 1976). The benefits of continuousal., 2007; McLearn et al., 2004; Minkovitz et al., primary care over episodic care included: fewer2001; Zuckerman et al., 1997), Reach Out and hospitalizations, operations, visits for illness,Read (Needleman et al.,1991), and Touchpoints and breaking of appointments; more healthin the United States (Brazelton, 1999; Hornstein, supervision visits, use of preventive services, andO’Brien & Stadtler, 1997). In addition, research patient satisfaction; andhas focused on the early detection and manage- lower costs (Alpert et al.,ment of developmental difficulties (Council on 1976). Since the 1980s, Primary health careChildren with Disabilities, 2006). developed countr ies providers are in a key Child mortality and morbidity patterns in have tried to ensure that position to addressLAMI countries are changing dramtically. In each child has a continu- child development inmost countries, childhood mortality has declined ous primary health care developing countries.considerably in the past 20 years. The major provider. More research Often they are the onlycauses of death have also changed. For example, is needed on the effects service providers whoin Bangladesh, chronic diseases and injuries of continuity of care in reach young children andhave overtaken infectious diseases as the lead- LAMI countries and the their families, and theying causes of child death (Rahman et al., 2004c). changes to the system are generally trusted inFurther research is needed in LAMI countries that would be needed to their understand these changes and improve the ensure such continuity.planning of appropriate policies to address the The quality of thenew challenges. support given by the health care provider will depend on his or her training and experience in child developmentThe role of primary health care concepts. The DDEC Survey indicated that healthPrimary health care providers are in a key position care providers, particularly in the LAMI coun-to address child development in developing coun- tries, generally do not have adequate trainingtries. Often they are the only service providers and experience in the prevention, early detectionwho reach young children and their families, and and management of developmental difficulties inthey are generally trusted in their communities. young children. The limited research from LAMIIn addition, their background enables them to countries also indicates that primary health careidentify and take action against the biological and clinicians require training in counselling car-psychosocial causes of developmental difficulties. egivers on child development and detecting and The DDEC Survey found that, in most of the managing related difficulties (Powell et al., 2004;countries, health centres were readily accessible Rahman et al., 2004a, 2008; Turmusani, Vreedeto the majority of the population. Home-visiting & Wirz, 2002; Walker et al., 2005; WHO, 1999,by health providers – an important vehicle for 2001a, 2006). WHO and UNICEF have developedintegrating child development concepts into a number of resources to help train clinicians inhealth care delivery – was also routinely practised LAMI countries to address child many of the LAMI countries. Accessibility is Community-based rehabilitation (CBR) interven- 11