Hogg Foundation for Mental Health

Healthy Steps for Young Children

Developmental Specialists in Pediatric Practices Improve Child Well-Being, Parental Involvement say Johns Hopkins Researchers in JAMA study

January 1, 2004

Researchers evaluating the Healthy Steps for Young Children project–a national pilot to expand pediatric care to include mental and developmental well-being as much as physical health–have found that families experienced significant improvements in the quality and access to appropriate services, according to the Dec. 17 issue of the Journal of the American Medical Association. Healthy steps

Healthy Steps is an unique intervention model that uses the medical setting (i.e., pediatric and family medicine practices, hospital and community clinics, HMOs, and residency training programs) to promote a universal, team-based approach to addressing families’ needs and delivering patient care. Participating pediatric practices hired two childhood development specialists to monitor behavioral development, promote good health practices, make home visits, and respond to parental concerns about infant and toddler development.

In addition, participating families receive a variety of program components, including in-home visits with Healthy Steps specialists trained in child development and the psychosocial aspects of care, a telephone hotline to address parents’ developmental concerns, developmental assessments, educational materials, parental support groups, and referral to community resources.

Researchers with the Johns Hopkins Bloomberg School of Public Health in Baltimore conducted a controlled clinical trial of the project between September 1996 and November 1998 at 15 random Healthy Steps sites nationwide. The study followed 3,737 (67.2 percent) of enrolled families of children from birth up through age 3, conducting follow-up interviews with those families at 33 months.

The researchers found that improved delivery of developmental and behavioral services to young children in the pediatric practice setting led to enhanced quality of care, broadened communications between pediatricians and parents, and helped children receive appropriate preventive services. Specifically, participating families were far more likely to:

Discuss concerns with someone in the practice about a variety of issues such as the importance of routines, discipline, reading to children, language development, child’s temperament, and sleeping patterns;
Be highly satisfied with care because someone in the practice went out of their way for them;
Receive timely well-child visits and vaccinations;
Remain at the practice for at least 20 months; children who received Healthy Steps also had increased odds of having a visit after 20 months.

In addition, evaluators found that parents who participated in the intervention were less likely to use severe discipline on their child, such as spanking with an object, yelling, or slapping in the face; and, mothers considered at high-risk for depression who participated in the Healthy Steps program were more likely to discuss their feelings of sadness with someone in the practice.

"For all children, not just those at high-risk, the quality of pediatric care in the first three years of life was dramatically improved because of this intervention," says lead evaluator Cynthia Minkovitz, MD, MPP, associate professor in the Department of Population and Family Health Sciences at Johns Hopkins. "In addition, it has produced more favorable disciplinary practices and helped parents better understand children’s behavior and development."

Initiated in 1996 with a $4.5 million grant from The Commonwealth Fund of New York, Healthy Steps is being conducted at 36 sites nationwide. The Hogg Foundation for Mental Health joined the project in 1997 and helped secure other local funders in order to locate four Healthy Steps sites in Texas: the Fort Bend Family Health Center in Richmond, Healthcare Professional Associates in Amarillo, Texas Children’s Hospital in Houston, and the private practice of Dr. Daniel Trevino in San Antonio. The Hogg Foundation committed more than $700,000 in funding and technical assistance to the sites. In the end, Texas accounted for roughly 600 of the 3,700 families participating in the project nationally.

From the start, the Healthy Steps for Young Children Program was designed to meet two interrelated needs: those of families regarding their young children’s early development and behavior and those of pediatric clinicians who are frustrated that they lack the time required to help parents better understand how to care for their young children.

The project was conceptually based upon extensive scientific research indicating that children’s physical and cognitive development is most important during the first three years, when they mature from wholly dependent infants into walking, talking, reasoning toddlers. Healthy Steps argues that if parents can be educated about their child’s development–on everything from well-baby checkups to early learning–and can foster a closer relationship with their pediatrician, then the health and well-being of their child can be improved.

Given the growing evidence of deficiencies in the quality of health care for children (e.g., low rates of preventive services, persistent disparities in health status, and lack of a usual source of care among ethnic and racial minorities and children in low-income families), it is hoped that the data will help convince practitioners, funders, and other stakeholders of the benefits of the Healthy Steps approach in improving the health and development of their young patients and reduce long-term health costs.

"Healthy Steps was developed in response to the needs and expectations of parents, who say they want information on their children’s development," said Karen Davis, president of The Commonwealth Fund, which is based in New York. "Pediatric practices provide unique opportunities to favorably influence health care for young children, increase parents’ satisfaction, and influence parental practices to improve child development and behavior."

"Having a developmental specialist as a team member should be a standard way of practice for pediatricians," says Barry Zuckerman, MD, chief of the Pediatrics Department at Boston Medical Center and the architect of the Healthy Steps concept. "Physicians say they are more effective when they have a colleague with the necessary skills in behavior and development who can take the time to address parent’s concerns."