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Early childhood developmental screening differs in the U.S., Scandinavia
Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.
Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.
High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.
Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).
Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.
Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.
In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.
Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.
One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.
According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.
According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices.
America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.
Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.
Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].
Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.
Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.
High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.
Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).
Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.
Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.
In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.
Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.
One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.
According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.
According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices.
America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.
Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.
Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].
Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.
Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.
High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.
Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).
Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.
Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.
In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.
Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.
One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.
According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.
According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices.
America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.
Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.
Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].
Fixing the ACA: 11 practical solutions
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
The Affordable Care Act – Obamacare – is not a disaster. It is not a long-term solution, but it is fixable. Now that repeal and/or replace efforts have failed, Congress should intelligently debate which solutions make the most sense and move forward with legislation to fix the health care system.
Before that can happen, Democrats and Republicans need to make certain acknowledgments.
Democrats should acknowledge that the ACA is flawed. Whereas many experts believe a single-payer system is ultimately going to be the best long-term answer, for our country, we’re just not there yet.
On the other side of the political aisle, Republicans should acknowledge that the ACA is not “a total disaster,” as purported by the president. That’s just not true. The ACA has dramatically reduced the U.S. uninsured population – from 49.9 million in 2010 to 29 million in 2015 (the latest figures), according to the Census Bureau. It cost much less than initially forecast after providing subsidies, assembling accountable care organizations, and providing copayment-free access to a core list of preventive services called the essential health benefits.
Nevertheless, Democrats should acknowledge that the ACA is not affordable. The cost of premiums, copayments, prescription drugs, medical procedures, and subspecialty visits are out of control. Furthermore, Democrats should admit that powerful lobbyists for plaintiffs’ lawyer associations are unwisely influencing their party’s position on tort reform.
So, how can the ACA be fixed? Earlier this year, Republican lawmakers proposed multiple versions of the Better Care Reconciliation Act (BCRA). Unlike the ACA, it really was “a total disaster.” Only 17% of Americans supported the BCRA, according to one poll from NPR/PBS NewsHour/Marist. Further, nearly every major medical organization adamantly opposed it, according to a report from NBC News.
Republicans who despise the ACA often fail to acknowledge what drove up premiums in the first place. Less competition led to higher costs. Republicans shot down the law’s original concept of a “public option.” Nineteen red states refused to expand Medicaid. All these decisions decreased competition in marketplaces.
Now Congress needs to take a deep breath, let go of their hyperpartisan expectations, and listen to these 11 suggestions. How about let’s:
1. Incentivize or persuade more states to expand Medicaid.
2. Create a public option or “public fallback plan” in every state that would compete alongside private plans in the marketplaces.
3. Possibly implement a Cadillac tax on high-cost private plans as recommended by economists.
4. Provide vigorous outreach to the millions of uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program.
5. Invest generously in parent-centered, equitable, high-quality early interventions such as Individuals with Disabilities and Education Act (IDEA) Part C, early childhood special education such as IDEA Part B, and early learning/preschool for young children. High-quality birth-to-5 programs yield $13 for every $1 invested and substantially lower health risks down the road of life.
6. Consider implementing a nationwide sugar tax. Evidence exists that taxing sugary drinks could improve the overall health of the U.S. population which could help to reduce the federal deficit over time.
7. Implement a six-point plan (as originally recommended by Sen. Bernie Sanders [I-Vt.]) to lower prescription drug prices. “Americans pay, by far, the highest prices for prescription drugs in the entire world,” Sen. Sanders notes on his website. He calls for negotiating better deals with drug manufacturers, reimporting prescriptions from Canada, restoring discounts for low-income seniors, prohibiting deals that block generic medications from entering the market, enacting stronger penalties for fraud, and requiring pricing and cost transparency.
8. Expand the role of nurses to filter out which patients need to be seen urgently, and which patients do not need an expensive trip to doctor’s office, urgent care, or emergency department. With appropriate training, nurses can manage behavior change and medication adjustment for chronic conditions; can lead care management teams for patients who are high utilizers of care; and manage transitions of care between the medical home, specialist outpatient, and hospital settings, according to primary care and nursing faculty leaders at the University of California, San Francisco.
9. Bring better accountability to health care by using bundled payments, global payments, and accountable care organizations, while simultaneously improving access and care coordination efforts for people with chronic conditions like mental health disorders and substance abuse, as recommended by the Commonwealth Fund.
10. Expand palliative care programs so far fewer people needlessly suffer and then die in very expensive intensive care units.
11. Enact common-sense tort reform. The overuse of tests and procedures because of fear of malpractice litigation, known as defensive medicine, is indirectly estimated to cost the United States $46 billion annually. According to a 2014 JAMA article, 28% of orders and 13% of costs were judged to be at least partially defensive, and 2.9% of total costs were completely defensive. Most costs were from potentially unnecessary hospitalizations. Survey studies show that greater than 90% of doctors practice defensive medicine, but what separates this perception from careful practice or patient expectations/demands remains controversial.
The main point is this – the Affordable Care Act is indeed fixable. We should not “let Obamacare implode, then deal” as the President tweeted. Whether politicians and other Americans can overcome their hyperpartisan beliefs and expectations remains to be seen.
Kevin P. Marks, MD, is a pediatrician in Eugene, Ore., and a clinical assistant professor at the Oregon Health and Science University, Portland.
New education law should improve services for children 0-5 years
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
One of the perceived failings of the No Child Left Behind Act was that it attempted to address disparities by increasing standardized testing throughout the K-12 period. Ironically, it left children under 5 years … well, behind. To more effectively prevent problems and reduce disparities, our nation should improve its early detection and intervention system.
This means increasing standardized screening for developmental-behavioral problems or at-risk conditions from 0 through 5 years – and then, swiftly connecting at-risk children/families to the most effective and appropriate community services. This strategy is analogous to quickly detecting and putting out small fires before they morph into raging forest fires.
On Dec. 10, The Every Child Achieves Act of 2015 was signed into law by President Obama with bipartisan support. One seemingly minor, but important new change is that federal funds can be allocated for states, school districts, and schools to improve early childhood learning services. However, the extent to which different states invest in early childhood programs remains to be seen.
A month earlier, a Pediatrics article entitled “Systemwide Solutions to Improve Early Intervention for Developmental-Behavioral Concerns” offered expert advice on how to frugally invest those dollars (Pediatrics 2015 Nov. doi: 10.1542/peds.2015-1723). For children aged 0- 5 years, my coauthors and I proposed that every state needs:
• Systemwide screening and care coordination.
• Comprehensive, equitable, and tiered assessments for at-risk or referred children.
• Universal access to high-quality early learning or preschool programs.
• Continuous accountability for the early detection and intervention process.
Systemwide screening
The American Academy of Pediatrics (AAP), along with a federal-level initiative, Birth to 5: Watch Me Thrive! recommends every infant, toddler, and preschooler be periodically screened for developmental-behavioral problems. The new mantra is, “Learn the Signs. Act Early.”
Parents should know that high-quality screening does not prematurely label children with a diagnosis. Instead, regular screenings help raise awareness of their child’s development, making it easier to expect and celebrate developmental milestones. Very importantly, screening has also been proven to substantially improve the percentage of children receiving early intervention (EI).
Connecting the dots, high-quality EI substantially lowers rates of academic remediation or failure, teenage pregnancy, antisocial or criminal behavior, substance abuse, suicidal ideation and attempts, unemployment, and welfare dependency. Just think how preventing all these problems relates to what has been in the news recently.
In reality, many health care clinics, day care centers, and preschools still don’t offer high-quality screening. Even pediatricians can struggle with implementing the AAP’s recommendations . In a busy office, proper implementation requires teamwork. At a statewide level, entire populations need to be accurately screened and tracked.
Systemwide care coordination
Unfortunately, only about 50% of referred children are promptly connected to EI services (Clin Pediatr [Phila]. 2011 Sep;50[9]:853-68). Many overwhelmed or anxious parents don’t follow up. This is problematic because these same “lost to follow-up” children typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, health care providers struggle with tracking at-risk children. And sometimes, pediatric offices don’t share referral information (including screening results) with EI agencies. However, if the child lives in a community with systemwide care coordination, then more than 80% of referred children will be linked to the EI intervention agency or an alternative resource like Early Head Start, a parenting program, or a home visitation program. Connecticut has more than double the EI enrollment rate (3.8%) of Georgia (1.5%), even though they share the exact same eligibility definition. The difference is Connecticut’s Help Me Grow program. Nevertheless, most states lack systemwide care coordination.
Comprehensive, equitable, and tiered assessments
Nonsensically, there are 22 state-specific numerical definitions for EI eligibility, and the majority of states have inappropriately strict criteria (Pediatrics 2013 Jan:131[1]38-46). The proportion of children enrolled in EI ranges from a shameful 1.5% (Georgia) to a meager 7% (Massachusetts). On average, approximately 2.8% of children receive EI even though 25% of moderate- to high-income and 48% of low-income kindergarteners are “not ready to learn.”
Instead of a state-specific EI-eligible versus EI-ineligible process, comprehensive and equitable assessments should lead to a tiered spectrum of high-quality interventions for all at-risk children – most especially, disadvantaged children who are frequently missed. For example, the infant with a poor depressed mother is frequently deemed “ineligible,” but then is significantly behind by kindergarten age. To avoid squandering time-sensitive windows of opportunity, states need a national, research-driven definition of what constitutes a developmental–behavioral delay or at-risk condition. Families need EI or supports that are appropriately intensive, based on their continuum of need.
Universal access
Expanding early learning initiatives would yield benefits to society of roughly $8.60 for every $1 spent, about half of which comes from increased earnings for children when they grow up, according to a White House study by the President’s Council of Economic Advisers. Critics frequently ignore systematic reviews, which demonstrate beneficial outcomes for “high-quality” or “comprehensive” programs – and the younger the intervention, the better the outcomes.
Continuous accountability
This is needed to ensure children are being screened and swiftly linked to high-quality services. Accountability should include a low-cost metric of developmental-behavioral status at 5 years (that is, a school-based kindergarten-readiness intake assessment). If our ultimate goal is to improve outcomes and reduce disparities, then we need to make certain the system is working. That way, states can tweak their processes to optimize child outcomes over time.
Without a doubt, acting early builds better brains. The leadership question remains: Will politicians adequately invest in these systemwide solutions?
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore. He disclosed he is a coauthor of “Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services,” but has no other relevant disclosures. Email him at [email protected].
National inequities in early intervention services
Every day, we hear about people with developmental and/or mental health problems, antisocial/criminal behavior, gun violence, unemployment, poverty, subpar academic performance, high school drop outs, tobacco and substance abuse, or an unhealthy national debt to gross domestic product ratio. One overlooked barrier to preventing these problems is the absence of a federal-level, evidence-based definition for which children (0-3 years) possess a "developmental delay" (acquiring skills at a rate significantly slower than their peers) and which "at-risk" children are most deserving of publically funded early intervention (EI) services.
Imagine seeing a 12-month-old boy for his well-visit. He hasn’t said his first word yet and is frequently having temper tantrums. You appropriately refer him to an EI agency because of a positive/concerning, nationally standardized screening questionnaire. The parents follow up with the EI agency only to learn that their child "did not qualify" because his developmental-behavioral issues were not yet pronounced enough to meet your state’s eligibility criteria. Curiously, he "no-shows" for his 18-month well-visit, but you see him at again at 24 months and refer him to the EI agency for the second time. Then, the parents fail to promptly follow up. Eventually, at 39 months of age, he is diagnosed with autism and only then begins receiving intensive EI services. Think this is an uncommon story of a missed opportunity to prevent or ameliorate a developmental-behavioral problem? Well, it’s a true story.
If a child happens to live in Massachusetts, she might easily qualify for EI while another child with the exact same developmental-behavioral issues would not qualify if she lives in Missouri. Shockingly, 48 states have adopted no less than 22 unique numerical definitions of a developmental delay or EI eligibility and two states (Hawaii and Vermont) have not adopted any numerical criteria to determine EI eligibility.
Even though 15%-17% of U.S. children have a developmental disability and 21% have a mental health disorder, the proportion of infants and toddlers enrolled in EI or Part C under the federal Individuals with Disabilities Education Act (IDEA) services ranges from a low of 1.5% (Georgia) to a high of 7% (Massachusetts). Four states (Massachusetts, New Hampshire, New Mexico, and West Virginia) automatically provide EI services to "developmental delayed" children and those "at risk" for emerging developmental-behavioral problems. However, if you have an "at-risk" child who is living in a state with strict eligibility criteria such as Georgia, Arizona, or Missouri, then the chances of your child receiving EI spirals downward. Millions of "at-risk" children are falling through the cracks.
The absence of a consensus-driven, defensible federal definition of what constitutes a developmental delay or "at-risk" condition in infants and toddlers, based on research rather than funding allocations, contributes to the inequitable, inefficient, and ineffective care that many U.S. children with developmental-behavioral problems receive. Wild variability across states is typically the result of short-sighted state budget decisions (strict eligibility standards reduce short-term EI costs to states and schools), but not the science of child development.
National inequities in EI services are not solely caused by differences in eligibility requirements. There are also big differences in statewide "early-detection systems" and care coordination efforts. Georgia has a substantially lower EI enrollment rate (1.5%) than Connecticut (3.8%) even though these two states share the exact same EI eligibility definition. This glaring difference is likely because of Connecticut’s Help Me Grow program, which fosters early detection, referral and care coordination services, but sadly, numerous other states lack this type of infrastructure altogether. Many referred children with positive/concerning developmental-behavioral screens who "do not qualify" for EI services will later be diagnosed as having a developmental-behavioral disorder with at least mild impairment. Importantly, children with milder delays often respond best to EI.
It’s frustrating for parents and providers – and tragically costly for our society – when infants and toddlers with red-flagged screenings do not receive EI services. For every dollar spent on early childhood development programs, there is a 7%-10% annual return rate in cost savings to society – and the younger the child served, the wiser the investment. Therefore, I’m urging the American Academy of Pediatrics (AAP), policy makers, and other early childhood advocates to help:
• Create a research- and/or consensus-driven "baseline" definition for EI eligibility. If certain states can afford to serve a greater proportion of "at-risk" children, then they should have the right to do so.
• Reform the federal IDEA Part C statute. Just as special education services for children 3-21 years (IDEA Part B) are mandated, Part C services should be required by the federal IDEA statute and not treated as discretionary. The timing is right, as IDEA – last revised in 2004 – is in the congressional pipeline to be reauthorized.
• Ensure that children universally receive developmental-behavioral screenings, as recommended by the AAP and as supported by a randomized controlled trial by Guevara et al. (Pediatrics 2013;131:30-7). Then speed children/families with suspected problems to the most appropriate and effective community resource(s) with the help of system-wide referral and care coordination programs.
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore., and coeditor of "Developmental Screening in Your Community: An Integrated Approach to Connecting Children with Services"and "Identifying and Addressing Developmental-Behavioral Problems."
Every day, we hear about people with developmental and/or mental health problems, antisocial/criminal behavior, gun violence, unemployment, poverty, subpar academic performance, high school drop outs, tobacco and substance abuse, or an unhealthy national debt to gross domestic product ratio. One overlooked barrier to preventing these problems is the absence of a federal-level, evidence-based definition for which children (0-3 years) possess a "developmental delay" (acquiring skills at a rate significantly slower than their peers) and which "at-risk" children are most deserving of publically funded early intervention (EI) services.
Imagine seeing a 12-month-old boy for his well-visit. He hasn’t said his first word yet and is frequently having temper tantrums. You appropriately refer him to an EI agency because of a positive/concerning, nationally standardized screening questionnaire. The parents follow up with the EI agency only to learn that their child "did not qualify" because his developmental-behavioral issues were not yet pronounced enough to meet your state’s eligibility criteria. Curiously, he "no-shows" for his 18-month well-visit, but you see him at again at 24 months and refer him to the EI agency for the second time. Then, the parents fail to promptly follow up. Eventually, at 39 months of age, he is diagnosed with autism and only then begins receiving intensive EI services. Think this is an uncommon story of a missed opportunity to prevent or ameliorate a developmental-behavioral problem? Well, it’s a true story.
If a child happens to live in Massachusetts, she might easily qualify for EI while another child with the exact same developmental-behavioral issues would not qualify if she lives in Missouri. Shockingly, 48 states have adopted no less than 22 unique numerical definitions of a developmental delay or EI eligibility and two states (Hawaii and Vermont) have not adopted any numerical criteria to determine EI eligibility.
Even though 15%-17% of U.S. children have a developmental disability and 21% have a mental health disorder, the proportion of infants and toddlers enrolled in EI or Part C under the federal Individuals with Disabilities Education Act (IDEA) services ranges from a low of 1.5% (Georgia) to a high of 7% (Massachusetts). Four states (Massachusetts, New Hampshire, New Mexico, and West Virginia) automatically provide EI services to "developmental delayed" children and those "at risk" for emerging developmental-behavioral problems. However, if you have an "at-risk" child who is living in a state with strict eligibility criteria such as Georgia, Arizona, or Missouri, then the chances of your child receiving EI spirals downward. Millions of "at-risk" children are falling through the cracks.
The absence of a consensus-driven, defensible federal definition of what constitutes a developmental delay or "at-risk" condition in infants and toddlers, based on research rather than funding allocations, contributes to the inequitable, inefficient, and ineffective care that many U.S. children with developmental-behavioral problems receive. Wild variability across states is typically the result of short-sighted state budget decisions (strict eligibility standards reduce short-term EI costs to states and schools), but not the science of child development.
National inequities in EI services are not solely caused by differences in eligibility requirements. There are also big differences in statewide "early-detection systems" and care coordination efforts. Georgia has a substantially lower EI enrollment rate (1.5%) than Connecticut (3.8%) even though these two states share the exact same EI eligibility definition. This glaring difference is likely because of Connecticut’s Help Me Grow program, which fosters early detection, referral and care coordination services, but sadly, numerous other states lack this type of infrastructure altogether. Many referred children with positive/concerning developmental-behavioral screens who "do not qualify" for EI services will later be diagnosed as having a developmental-behavioral disorder with at least mild impairment. Importantly, children with milder delays often respond best to EI.
It’s frustrating for parents and providers – and tragically costly for our society – when infants and toddlers with red-flagged screenings do not receive EI services. For every dollar spent on early childhood development programs, there is a 7%-10% annual return rate in cost savings to society – and the younger the child served, the wiser the investment. Therefore, I’m urging the American Academy of Pediatrics (AAP), policy makers, and other early childhood advocates to help:
• Create a research- and/or consensus-driven "baseline" definition for EI eligibility. If certain states can afford to serve a greater proportion of "at-risk" children, then they should have the right to do so.
• Reform the federal IDEA Part C statute. Just as special education services for children 3-21 years (IDEA Part B) are mandated, Part C services should be required by the federal IDEA statute and not treated as discretionary. The timing is right, as IDEA – last revised in 2004 – is in the congressional pipeline to be reauthorized.
• Ensure that children universally receive developmental-behavioral screenings, as recommended by the AAP and as supported by a randomized controlled trial by Guevara et al. (Pediatrics 2013;131:30-7). Then speed children/families with suspected problems to the most appropriate and effective community resource(s) with the help of system-wide referral and care coordination programs.
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore., and coeditor of "Developmental Screening in Your Community: An Integrated Approach to Connecting Children with Services"and "Identifying and Addressing Developmental-Behavioral Problems."
Every day, we hear about people with developmental and/or mental health problems, antisocial/criminal behavior, gun violence, unemployment, poverty, subpar academic performance, high school drop outs, tobacco and substance abuse, or an unhealthy national debt to gross domestic product ratio. One overlooked barrier to preventing these problems is the absence of a federal-level, evidence-based definition for which children (0-3 years) possess a "developmental delay" (acquiring skills at a rate significantly slower than their peers) and which "at-risk" children are most deserving of publically funded early intervention (EI) services.
Imagine seeing a 12-month-old boy for his well-visit. He hasn’t said his first word yet and is frequently having temper tantrums. You appropriately refer him to an EI agency because of a positive/concerning, nationally standardized screening questionnaire. The parents follow up with the EI agency only to learn that their child "did not qualify" because his developmental-behavioral issues were not yet pronounced enough to meet your state’s eligibility criteria. Curiously, he "no-shows" for his 18-month well-visit, but you see him at again at 24 months and refer him to the EI agency for the second time. Then, the parents fail to promptly follow up. Eventually, at 39 months of age, he is diagnosed with autism and only then begins receiving intensive EI services. Think this is an uncommon story of a missed opportunity to prevent or ameliorate a developmental-behavioral problem? Well, it’s a true story.
If a child happens to live in Massachusetts, she might easily qualify for EI while another child with the exact same developmental-behavioral issues would not qualify if she lives in Missouri. Shockingly, 48 states have adopted no less than 22 unique numerical definitions of a developmental delay or EI eligibility and two states (Hawaii and Vermont) have not adopted any numerical criteria to determine EI eligibility.
Even though 15%-17% of U.S. children have a developmental disability and 21% have a mental health disorder, the proportion of infants and toddlers enrolled in EI or Part C under the federal Individuals with Disabilities Education Act (IDEA) services ranges from a low of 1.5% (Georgia) to a high of 7% (Massachusetts). Four states (Massachusetts, New Hampshire, New Mexico, and West Virginia) automatically provide EI services to "developmental delayed" children and those "at risk" for emerging developmental-behavioral problems. However, if you have an "at-risk" child who is living in a state with strict eligibility criteria such as Georgia, Arizona, or Missouri, then the chances of your child receiving EI spirals downward. Millions of "at-risk" children are falling through the cracks.
The absence of a consensus-driven, defensible federal definition of what constitutes a developmental delay or "at-risk" condition in infants and toddlers, based on research rather than funding allocations, contributes to the inequitable, inefficient, and ineffective care that many U.S. children with developmental-behavioral problems receive. Wild variability across states is typically the result of short-sighted state budget decisions (strict eligibility standards reduce short-term EI costs to states and schools), but not the science of child development.
National inequities in EI services are not solely caused by differences in eligibility requirements. There are also big differences in statewide "early-detection systems" and care coordination efforts. Georgia has a substantially lower EI enrollment rate (1.5%) than Connecticut (3.8%) even though these two states share the exact same EI eligibility definition. This glaring difference is likely because of Connecticut’s Help Me Grow program, which fosters early detection, referral and care coordination services, but sadly, numerous other states lack this type of infrastructure altogether. Many referred children with positive/concerning developmental-behavioral screens who "do not qualify" for EI services will later be diagnosed as having a developmental-behavioral disorder with at least mild impairment. Importantly, children with milder delays often respond best to EI.
It’s frustrating for parents and providers – and tragically costly for our society – when infants and toddlers with red-flagged screenings do not receive EI services. For every dollar spent on early childhood development programs, there is a 7%-10% annual return rate in cost savings to society – and the younger the child served, the wiser the investment. Therefore, I’m urging the American Academy of Pediatrics (AAP), policy makers, and other early childhood advocates to help:
• Create a research- and/or consensus-driven "baseline" definition for EI eligibility. If certain states can afford to serve a greater proportion of "at-risk" children, then they should have the right to do so.
• Reform the federal IDEA Part C statute. Just as special education services for children 3-21 years (IDEA Part B) are mandated, Part C services should be required by the federal IDEA statute and not treated as discretionary. The timing is right, as IDEA – last revised in 2004 – is in the congressional pipeline to be reauthorized.
• Ensure that children universally receive developmental-behavioral screenings, as recommended by the AAP and as supported by a randomized controlled trial by Guevara et al. (Pediatrics 2013;131:30-7). Then speed children/families with suspected problems to the most appropriate and effective community resource(s) with the help of system-wide referral and care coordination programs.
Dr. Marks is a general pediatrician at PeaceHealth Medical Group in Eugene, Ore., and coeditor of "Developmental Screening in Your Community: An Integrated Approach to Connecting Children with Services"and "Identifying and Addressing Developmental-Behavioral Problems."
