Are routine child health visits really necessary? The state of children’s development in BC

It is the last week of August. I am seeing Susan (a fictitious patient) in my office as a referral from her family doctor. Susan is about to start kindergarten and her mom is worried about her daughter’s asthma. 

I ask a few questions about Susan’s general health and development and examine her. She has not attended preschool and her mom reports that she is very shy and she cried when she went to her new school for a visit. Susan has not learned her numbers or letters and cannot yet print her name. When she does eventually speak, her words were soft and hard to understand. It is becoming clear that Susan is not ready for kindergarten.

Almost one-third of BC children eligible for kindergarten are not developmentally ready. Such children are described by Dr Clyde Hertzman as having “developmental vulnerability.” 

They exhibit significant delays in their physical, socio-emotional, or language-cognitive development. A child’s early development, of course, has a significant influence upon that child’s health, well-being, learning, and behavior, and the effect spans the child’s life course. Here are some facts about the state of children’s development in British Columbia:

• “Today only 71% of BC children arrive at kindergarten meeting all the developmental benchmarks they need to thrive both now and in the future.”1
• “29% are developmentally vul­nerable.”[1]
• “At three times what it could be, the current vulnerability rate signals that BC now tolerates an unnecessary brain drain that will dramatically deplete our future stock of human capital.”[1]
• Childhood vulnerability is rising. In 53 of 59 BC school districts, 30.35% of kindergarten children were vulnerable, up from 28.5% in 2008/9.[2]
• “Unnecessary early vulnerability in BC is costing the provincial economy a sum of money that is 10 times the total provincial debt load.”[1]
• Vulnerable children come from all walks of life. It is a middle-class problem, not just poverty related.[1]
• Most childhood vulnerabilities are avoidable and preventable.[3]

Helping children to be as healthy as they can be is hardly a new concept. The public health movement (1880–1920) brought in reforms that had an immediate and positive effect on the well-being of Canadian children and “came to regard youngsters as its most important clients.”[4] 
With prevention as the aim, the movement led to the establishment of two specialized services: one targeting infants and the other targeting school-age children. By the end of World War One, English Canadians came to recognize that intervention needed to occur prior to age six, and physicians, along with social workers, teachers, and psychologists, began to focus on the preschool years as well as the school-age years. Canada emerged as a nation characterized as having a “preoccupation with training its infants and preschoolers for proper citizenship.”[5]

A century later our own government acknowledges and has planned action to reduce childhood vulnerability. In the report, 15 by 15: A Comprehensive Policy Framework for Early Human Capital Investment in BC, it is recognized that supporting children in their early years is crucial. The report illustrates the importance of early human capital investments, and as a result the Government of British Columbia’s 2009 Strategic Plan committed to “lowering the provincial rate of early vulnerability to 15% by fiscal year 2015/16.”[1]

Healthy children are more likely to become healthy adults, thereby contributing to the future workforce and economy; as we so often hear, children are our future. Through routine health assessments, family physicians will, no doubt, encounter children with developmental issues that merit concern. 

By way of a systematic approach, family physicians are perfectly positioned to identify and assess children with developmental vulnerability and assist in providing interventions that will ultimately lead to a reduction in this vulnerability. The American Aca­demy of Pediatrics, for example, recommends children be seen routinely for “health supervision” visits. 

The timing and purpose of each visit is well detailed in the AAP Policy Statement and clearly organized in the AAP publication Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, third edition, which includes helpful screening questionnaires.[6] 

As a pediatrician in British Col­umbia, I only encounter those children who have been referred to me by my family physician colleagues. As such, I am limited in my ability to reduce childhood developmental vulnerability. I look to you to help in this regard. Children may be only 25% of the population, but are 100% of our future.
—Wilma Arruda, MD, FRCPC
Chair, Child and Youth Committee

This article has not been peer reviewed.

References

1. Kershaw P, Anderson L, Warburton B, et al. 15 by 15 A Comprehensive Policy Framework for Early Human Capital Investment in BC. Vancouver: Human Early Learning Partnership, University of British Columbia; 2009:1.
2. Human Early Learning Partnership (HELP). Early Development Instrument Fact Sheet. www.earlylearning.ubc.ca/wp-uploads/web.help.ubc.ca/2010/09/EDI-Fact-Sheet-PDF_2010-09-03.pdf (accessed 5 November 2010).
3. Human Early Learning Partnership (HELP). Nearly one in three BC children enter kindergarten vulnerable [news release]. 27 October 2009. www.earlylearning.ubc.ca/wp-uploads/web.help.ubc.ca/2010/01/News-Release-3rd-data-collection-Oct-27-09-2.pdf (accessed 5 Nov­ember 2010).
4. Sutherland N. Children in English-Canadian Society, Framing the Twentieth-Century Consensus. Toronto: University of Toronto Press; 1978:39. 
5. Strong-Boag V. Intruders in the nursery: Childcare professionals reshape the years one to five, 1920-1940. In: Parr J (ed). Childhood & Family in Canadian History. Toronto: McClelland and Stewart; 1982:160-178.
6. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. Pediatr 2000;105:645-646.