I often characterize my career as the relentless pursuit of the answer to the question, “How do we strengthen child health services to promote children’s optimal healthy development?” I typically view this work in 3 stages: early efforts during the 1970s-1980s to enhance the efficacy of such traditional components of child health services as anticipatory guidance and developmental monitoring; concerted efforts in the 1990’s, the so-called “decade of the brain,” to apply the explosion in our knowledge of early brain development and early child development to build cross-sector collaboration among child health, early care and education, and family support, as exemplified by our Help Me Grow model; and, with the enhanced understanding in the new millennium of the “biology of adversity,” current activities to advance comprehensive system building with an “all sectors in” approach and cross-sector collaboration, as championed by our Connecticut Children’s Office for Community Child Health.

In our efforts to encourage interventions in response to critical contemporary issues (e.g., childhood obesity, violence prevention), we are mindful of the importance of identifying and supporting the diffusion of effective innovations that promote children’s optimal healthy development and well being.  As a result, I was particularly interested to read a study by Peacock-Chambers and colleagues in the December issue of the journal, Pediatrics, entitled, “Primary Care Interventions for Early Childhood Development: A Systemic Review.”  In this well-written manuscript, the authors summarize recent (i.e., the past 2 decades) evidence regarding the impact of primary care-based interventions on parenting behaviors and child development outcomes. They conducted a literature search to identify such interventions; categorized interventions as general developmental support, general behavioral development, or topic-specific interventions (e.g., reading, colic); and applied a clinically-relevant quality rating scheme to classify each intervention by level of evidence on a 4-point scale. 

The study is of interest with regard to both the specific findings for interventions and general implications for enhancing the efficacy of child health services. Consistent with similar reports over the past 5 decades, the article is remarkable for the relative paucity of research on interventions, the challenges in comparing the efficacy of diverse interventions due to striking differences in evaluation strategies and measures, the very modest impact of such interventions on long-term measures of child development and well-being, and the lack of available information to guide the scaling and sustainability of successful interventions. For example, the authors’ comprehensive literature review ultimately yielded only 48 articles in which 24 interventions were described that met all inclusion and exclusion criteria. While multiple interventions characterized as general developmental support demonstrated significant changes in parenting behaviors (e.g., parental sensitivity, higher quality parent-child interactions), only select interventions actually decreased rates of developmental delay (i.e., Healthy Steps and Video Interaction Project). Several interventions classified as general behavioral development resulted in decreased behavioral intensity for a period of time following the intervention, while a number of such interventions affected parenting behaviors (e.g., improved positive parenting behaviors, reductions in use of harsh discipline) and parental psychological outcomes (e.g., parental satisfaction, self-efficacy, and confidence; marital health). Interventions designed to address specific developmental topics such as colic resulted in short-term improvements, while others promoting literacy reported both positive parent behaviors (e.g., reading aloud as a favorite activity) and developmental gains (i.e., increased receptive and expressive vocabulary).

As noted, the heterogeneity of outcome measures precluded direct comparisons of different interventions and identified the need for consensus on important child outcomes, as well as the importance of longer follow-up periods to predict long-term health and academic success.  Despite such important limitations, this research is helpful in validating certain critical concepts that inform so much of our current work. For example, the methodology acknowledges the importance of a focus on both the long-term, elusive outcomes, such as academic success, that are so important to proving efficacy, as well as measures of more proximate factors that impact the process of intervention delivery, such as participant and provider attitudes and positive parenting practice. The authors emphasize the need to identify the common key components of interventions and their implications for the feasibility of their dissemination. This notion is consistent with our focus on articulating the core components and structural requirements of innovations to support diffusion. The authors also cite the gaps in the literature with respect to such crucial issues as considerations of cost and descriptions of training to enable replication of interventions. We are mindful of the importance of such issues in our activities to diffuse such innovations as Help Me Grow.

An accompanying commentary by our friend and colleague Dr. Jack Shonkoff, who directs Harvard University’s Center on the Developing Child, calls out crucial challenges facing the early childhood field: the need for new strategies that produce larger, scalable impacts on children’s development; and the need to re-consider our criteria for defining an intervention as “evidence-based.” He decries a focus on statistically significant differences between a treatment and comparison group for interventions that are not linked to specific impacts based on explicit causal hypotheses. He notes the perils of preferential attention to statistical significance over magnitude of impact, and the lack of attention to the latter in most research studies. In citing the remarkable advances in biomedical research that have produced dramatically improved outcomes for children with cancer, HIV/AIDS, cystic fibrosis, and other conditions, Shonkoff laments the limited population-level progress in reducing social class and racial disparities in developmental outcomes. He calls for the leveraging of new discoveries in such fields as neuroscience, molecular biology, and epigenetics, as well as applications of advances in biology that are driving “precision medicine” to address the social determinants of development. His recommendation that we have greater focus on mediating variables that are amenable to intervention (e.g., self-regulation in children, interactional skills of parents) are prime examples of meaningful and impactful proximate factors deserving of our attention.

How does this limited progress over 5 decades and the scientific insights of more recent years inform our approach to strengthening child health services to promote children’s optimal healthy development? We must continue to be thoughtful in selecting innovations for diffusion that are most likely to be scalable and impactful with respect to meaningful child outcomes. We must continue to focus on measuring both mediating variables that are amenable to intervention and lend themselves to measurement, as well as longer-term developmental outcomes. We must view interventions not in isolation, but rather in the context of their being embedded in comprehensive early childhood systems.  Family strengths and cultural values must inform the selection of interventions through meaningful parent engagement. We are excited to apply these criteria in our current efforts to strengthen child health services (e.g., Well Visit Planner diffusion), and as we embark on new opportunities afforded by our evolving partnerships with such organizations as Zero to Three (e.g., Healthy Steps).

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.

Articles cited:
1. Peacock-Chambers E, Ivy K, Bair-Merritt M.  Primary care interventions for early childhood development: A systematic review.  Pediatrics. 2017;140:e20171661
2. Shonkoff JP. Rethinking the definition of evidence-based interventions to promote early childhood development.  Pediatrics. 2017;140:e20173136