ZZ’s Corner
It has been a while that “we are the world” was sung by children from around the world, it has been ringing in my ears and caused a lump in my throat. Plights of thousands of children orphaned and displaced because of the natural force of an earthquake in Bam last year, the recent earthquake and Tsunami, and on going wars in the continent of Asia, ravaging AIDS and on-going conflicts and wars in the African continent are major reasons for this melancholy. Reports from responsible journalists, human rights and non-for-profit service provider agencies give us a scan view of the enormity of pain and suffering of these children. In the face of the pain and suffering of all these children my contributions individually, or as an active member in coordination with some international agencies is minute.
News about trafficking of these children as forced-slave labor including prostitution and pornography, and as child-soldiers, is a warning bell that ought to be ringing in the ears of every concerned human being to prevent revictimization of the next generation of the world.
Ways of advocacy for these children in order to break the cycle of trauma and prevent revictimization of these children is as numerous as the number of children and their advocates. The key is to care, to think of a way, and to take action. We all know the power of cumulated efforts. Connect with a group or groups matching your belief and philosophy of life and reach out.
Your actions do count – at the least in the life of one of these children. As a sign said, â”we can save the world one child at a time”. After all, they are the world.
For more information you may contact UNICEF at www.unicefusa.org, Women’s Commission for Refugee Women and Children at www.womenscommission.org, Doctors Without Borders at www.doctorswithoutborders-usa.org, Oxfam America at www.oxfamamerica.org, Save the Children at www.savethechildren.org.
Brief Article
Developmental Checkups:
They’re Good, They’re Cheap and They’re Almost Never Done.
What is Wrong With This Picture?
By: Margaret Dunkle & Louis Vismara, MD
An important part of ensuring that every child enters school ready to learn is identifying problems early, and then addressing them before they become overwhelming. Our country’s track record of finding and helping young children with physical conditions such as leukemia, juvenile diabetes and asthma is improving. But all too often, mental health, learning and behavioral problems fester unattended, missing the critical womb-to-five window of opportunity when a child’s brain, body and behavior change at the most astonishing rate.
Late identification forces states, schools and taxpayers to foot the bill for expensive special education fixes to problems that could have been cured, or at least treated more effectively and more cheaply, during the preschool years. Consider these facts:
Five to eight percent of children under age five years have some sort of disability or chronic condition, such as autism, cerebral palsy, diabetes, epilepsy, mental retardation or orthopedic problems. The American Academy of Pediatrics cites much higher figures, saying that 12 to 16 percent of children have developmental or behavioral disorders.
The number of children with autism, in which cases early intervention is essential, is soaring. A 2003 editorial in the Journal of the American Medical Association estimates that, nationwide, one in every 170 children is affected by an autism spectrum disorder. The number of people with autism in California’s Developmental Services System doubled between 1998 and 2002.
Early detection and intervention work. As the National Academy of Sciences said in From Neurons to Neighborhoods, “Compensating for missed opportunities, such as the failure to detect early difficulties or the lack of environments rich in language, often requires extensive intervention, if not heroic efforts, later in life.” Although economists quibble about the exact numbers, study after study shows that intense preschool services produce huge academic, social and economic benefits–including savings to society of $30,000 to $100,000 per child. And dollars saved are surely not the only measure of value, especially to the one-in-25 households with a disabled preschooler.
White children with serious disabilities are often identified at much younger ages than ethnic”or language–minority children. A study of Pennsylvania children covered by Medicaid found that white children were diagnosed with autism more than a year earlier than their African-American or Latino counterparts: age 6.3 years for white children, 7.9 years for African-American children and 7.4 years for Latino children.
Many people think the problem is that we don’t know how to spot problems in young children. But they are wrong. Good screening instruments exist–tools that consistently detect children with problems and identify children without problems.
A 2001 American Academy of Pediatrics policy statement identifies high-quality parental-report tools that take only a few minutes to administer: the 10-question PEDS (Parents’ Evaluation of Developmental Status), the Ages and Stages Questionnaires and the Child Development Inventories.
These recommendations confirm what most of us already know: Parents are the best experts on their children. These tools provide an effective way to capture what parents know and to share it with doctors. In fact, these simple instruments identify 70 to 80 percent of children with problems. Repeated or “periodic” screenings increase these percentages. That’s the “good” news.
The bad news is that only 15 percent of pediatricians always use a screening tool. Seven out of 10 rely on their clinical judgments–even though this method identifies less than 30 percent of children with mental retardation, learning disabilities, language impairments and other developmental disabilities, and less than 50 percent of children with serious emotional and behavioral disturbances. Physicians who simply “eyeball” their youngest patients–as most do–miss half the problems that a two-minute screening tool would catch immediately.
If every child had a high-quality developmental check-up–and communities followed up with services–thousands of children would have better lives. In the state of California, at least 124,000 children under age five years have or will develop a disability or mental or behavioral disorder, assuming a conservative five percent disability rate. If every child got a good screening, at least 75 percent (93,000 kids) could get needed help early, when it could do the most good. With repeat screenings, this number would go up even more. However, as things stand, less than half (56,000 children) will be identified as needing help; far fewer get it.
Our country’s pathetic record of identifying young children who need help could be quickly turned around if policymakers and communities took four practical steps:
1. Insist that pediatricians check every preschool child with a good screening instrument–not just once, but regularly. The best screening tools include the parent-based PEDS, the Ages and Stages Questionnaires and the Child Development Inventories. Parents need to know that they have the right to expect doctors to use a good tool and not just “eyeball”their child during a well-child visit. Pediatricians need to know that these tools exist, that they work, that they are inexpensive and that their receptionists can be trained to help parents fill out the forms.
2. Train parents, childcare workers and others to use the parent-based screening tools, rather than depending entirely on doctors and other professionals to flag problems. These common-sense tools help parents describe concerns about their child’s learning, development and behavior in ways that can enable doctors and other professionals to zero in quickly on problems and identify effective interventions.
3. Focus more on preschool special education. It is appalling that the US Congress puts so little of our tax money where research shows it would do the most good–on in the earliest years of life. Currently, the federal per-child contribution for the approximately 700,000 children ages three to five years old in special education is less than half that for school-age children, and the gap is widening. The federal contribution for infants and toddlers ages birth to two years has dropped by more than $150 per child since 1992. This “penny wise, pound foolish” approach costs families, schools, communities and taxpayers dearly over the long haul.
4. Integrate early identification and treatment of mental health, learning and behavior problems into core educational standards. Some states and communities are already taking concrete steps to emphasize that social and emotional well-being directly affects learning; it is much more than “plays well with others.” The Los Angeles County Children’s Planning Council and First 5 LA have identified the degree to which preschool children need special education and actually receive it as a core indicator of school readiness. And a new Illinois report on children’s mental health recommends that the legislature requires that the state board of education incorporate social and emotional standards into the Illinois Learning Standards.
Early identification is the essential first step to assuring that infants and preschoolers with problems get the help they need to grow and learn. Let’s get started by making it a priority to assure that every infant and preschooler gets screened–early and often–with a first-rate screening tool.
Some problems–like some disabilities–are not fixable, at least not yet. But the solution to our country’s poor record of identifying infants and preschoolers with problems is at our fingertips. We just need to do it.
For additional information, contact:
Margaret Dunkle
mcd729@aol.com, 818-952-6485
Margaret Dunkle is a Senior Fellow with the Department of Health Policy at George Washington University and lives primarily in Los Angeles. The California Endowment and Annie E. Casey Foundation support her work.
Louis Vismara, MD, is a parent of four children, one of whom has autism. A retired invasive cardiologist, he currently works as a consultant with the California State Legislature and is a Commissioner on the California First 5 Commission.
Editor’s Note: This article is adapted from a Commentary that first appeared in Education Week, September 24, 2003: http://www.edweek.org/ew/ewstory.cfm?slug=04dunkle.h23.
For a footnoted version, email requests to: mcd729@aol.com.
A list of studies consulted or referred to in this column may be obtained by e-mailing requests to: epedit@aol.com
This article is also available online from:
www.eparent.com/researchreflections/researchreflections_01_04.htm
News Briefs
Child Homicide
Editor’s Note: Death of children in the hands of their caregivers remains a major count in child fatality statistics due to abuse and neglect, and a challenge for service providing professionals and agencies.
Research statistics reveal that over 50-60% of child homicide is not reported (Crume, DiGuiseppi, Byers, Sirotnak, Garrett, 2002). The statistics also show that 1/3 of child homicide occurs before children reach their third birth date.
The Los Angeles County Interagency Council on Child Abuse and Neglect (ICAN) is the National Center on Child Fatality Review. For the past few years, I attended the ICAN Child Death Review monthly Team meetings as the Los Angeles County Department of Mental Health representative. The three-hour drive home was a welcome time-out after each of our meetings. These meetings continue and similar Teams have expanded across the country, and even beyond our borders.
The article below, is bringing the message home. With prior permission, the article below by Deanne Tilton Durfee, the Executive Director of ICAN is reprinted from UNIFIED RESPONSE, a publication by ICAN.
Global Issues and One Little Girl
By Deanne Tilton Durfee
September 2004, Brisbane Australia: – site of the International Society for the Prevention of Child Abuse and neglect (ISPCAN) Conference.
Brazil – a multi-year project was presented that engages children in creating poster art for child abuse prevention. The pictures were divided between artwork created by children who had frequently been hit (“smacked”) by their caretakers, and those who had not. Children who had been hit drew sad faces in gloomy surroundings. The others drew happy faces, sunshine and flowers. The result was proof positive to the Brazilian delegates that hitting children causes depression and hopelessness. And so, they are spreading the word through the reproduction and marketing of this artwork.
The Southern Asian countries spoke up about the need for DATA. They stated their belief that keeping better track of the extent of child abuse and neglect would help all nations make their cause to the powers that be. Quite insightful, and quite a surprise to hear!
A representative from India made a compelling case for child suicide prevention. In Delhi, where the value of education is primary, the child suicide rate is almost twice that of Los Angeles County.
A Lebanese physician spoke of his inroads in diagnosing shaken baby syndrome. Our hearts stopped when he pulled out his “palm pilot” and showed a tiny patient of his on life support, thrashing with seizures. He carefully documented the history of shaking by the father.
Uganda, the Congo and Botswana spoke of children’s rights balanced with children’s responsibilities. The Philippines and Malaysia are actively pursuing formalized child death review, and Kenya is implementing child abuse protocols developed by Great Britain.
The hopeful stories were many, told by optimistic and committed people who had traveled far to learn how to better protect the most vulnerable members of their homelands.
As the main conference began, Michael [Durfee] and I [Deanne Tilton Durfee] were gratified with the intense interest in child fatality review. Our workshop was overflowing, after which we were invited to address Brisbane’s Commission on Children about their newly forming team. The conference closed with a touching keynote from Dr. Astrid Heppenstall Heger.
Upon returning home, I noted our NCFR Website, www.ican-ncfr.org, had been visited by 112 countries.
December 1, 2004, Coroner’s Office, Los Angeles, California:
site of the monthly Child Death Review Team meeting.
Approximately 25 professionals from social services, law enforcement, health, mental health, schools and forensics met to review deaths of children in Los Angeles County. As happens every month, the Team rolled through introductions, follow up, and case review.
Every child death is tragic, but somehow the case of one three-year old little girl stopped the hearts of the Team. Perhaps it was the colorful picture of her standing under a Christmas tree, beaming trustfully at the camera… then, the post mortem photos. More likely it was the accounts of the two officers who responded to the call, describing the “beautiful” child they found with bruises and abrasions from her head to her feet. The officers assured us that they handled this case dispassionately, but their eyes betrayed their words. For two hours the Team examined the details of the case, a boyfriend left to baby-sit while the mother worked. The child had multiple old and new injuries, but a hard blow to her stomach ended her life.
The officers had handled the case heroically and effectively. The boyfriend confessed when one of the officers asked him to apologize to the deceased child. From the death to the prosecution, the case was managed exceptionally well. So, justice had been done. The police officers, who were both fathers, had not received critical incident debriefing or grief counseling. It was of some comfort that they told us they felt better after meeting with the Team.
But questions lingered. Why couldn’t we have reached this tiny person sooner? I could only imagine what she felt each day as her mother left her in the care of this brutal man. How could her mother leave her with him? Didn’t the neighbors hear her cry or see her bruises? No third world three-year-old could have suffered more than this child.
The follow up for next meeting: how could this senseless death have been prevented?
Just for Your Information
Training & Continuing Education
AMERICAN FAMILY PHYSICIAN
Autism: A Medical Primer
http://www.aafp.org/afp/20021101/1667.html
Autism is a wide-spectrum, pervasive developmental disorder of uncertain etiology.
CONTEMPORARY PEDIATRICS
Is It Autism?
http://www.athealth.com/apps/redirect.cfm?linkid=171
This review covers diagnostic criteria, conditions to consider in the differential, the evaluation, and treatment options.
BRIGHT FUTURES
Pervasive Developmental Disorders (PDD)
http://www.brightfutures.org/mentalhealth/pdf/bridges/pdd.pdf
Early identification and intensive intervention can improve outcomes for most children with PDDs.
NATIONAL INSTITUTE OF MENTAL HEALTH
Autism Spectrum Disorders
http://www.athealth.com/consumer/disorders/autismpdd.html
ASD is defined by a certain set of behaviors that can range from the very mild to the severe.
MEDSCAPE
Treatment of Comorbid Disorders in Autism: Which Regimens Are Effective and for Whom?
http://www.medscape.com/viewarticle/430507_print
The development of new classes of medications is broadening the options for treating
individuals with autism and comorbid psychiatric illness.
CNS SPECTRUMS
Social Cognition and Its Neural Correlates in Schizophrenia and Autism
http://www.cnsspectrums.com/pdf/art_508.pdf
This article reviews research into two of the processes thought to underlie social cognition in schizophrenia and autism.