The importance of early childhood experiences in setting the foundation for long-term health and behavioral outcomes has been well established. It has been maintained that the science of child development and the core capabilities of adults highlight several principles that can be used to improve outcomes for children and families. To assure optimal outcomes, we must support responsive relationships for children and adults, strengthen core life skills, and reduce sources of stress in the lives of children and families.1
In this issue of Pediatrics, Brown et al2 report their findings in “Preventive Behavioral Health Programs in Primary Care: A Systematic Review.” They focus on studies of preventive behavioral health for children 0 to 5 years old. The authors use the guidelines from the Society for Prevention Research3 to examine the efficacy, effectiveness, and readiness for scale-up of preventive interventions considered applicable in pediatric primary care, with the aim of assessing the rigor of studies and delineating further research needs. In the review they identify gaps that limit understanding of whether and where programs are ready for real-world implementation and argue for more methodologically sound studies. Recommended areas for future research include testing for mechanisms of action, determining the specific benefits of different types of primary care settings, and completing long-term or observational studies to establish long-term outcomes, thus defining the populations most likely to engage and to benefit from an intervention. The authors conclude that integrated behavioral health programs in primary care are promising but that further research is needed to inform successful scale-up.
The benefit and cost-effectiveness of community-based early intervention through home visiting and preschool services are well established.4 With growing emphasis on population health outcomes, it is appropriate to extend the concept of the pediatric medical home to the medical neighborhood.5 This framework promotes enhanced collaboration with community partners, including home visiting programs and population-based parenting management programs. Such programs may be physically housed in a variety of settings, including the primary care setting.
With this in mind, several examples of efforts that can be tied to the primary care setting warrant consideration for scale-up. The United Nations Office on Drugs and Crime has published a compilation of evidence-based family skills training programs that have the strongest scientific evidence based on randomized controlled trials.6
Several of the United Nations programs are potentially ready for scale-up in the pediatric medical neighborhood. The Triple P – Positive Parenting Program and The Incredible Years offer universal, selective, indicated treatment and early intervention components for families of infants and youth. According to the United Nations report, Triple P has the most scientific evidence of the 150 programs that were evaluated, including 4 meta-analyses, 10 independent randomized controlled trials, 47 randomized controlled trials, and 28 quasi-experimental studies. The Incredible Years follows close behind with 8 independent randomized controlled trials and 10 randomized controlled trials. Both programs are based in cognitive social learning theory, recognizing the essential role of relationships in fostering healthy growth and development. The Nurse-Family Partnership, one of the federally approved home visiting programs supported by the Health Resources and Services Administration’s Maternal, Infant, and Early Childhood Home Visiting Program,7 has 3 randomized controlled trials and supports pregnant and first-time, low-income mothers by focusing on the development of therapeutic relationships with families.
Brown et al2 effectively summarize the extensive challenges pediatric professionals face in children’s mental health. Although their systematic review identifies important gaps in the existing research on preventive behavioral health programs in pediatric early childhood primary care, the urgency of the current challenges support forging ahead with community partnerships in the medical neighborhood and exploring implementation of programs such as Triple P, The Incredible Years, and the Nurse-Family Partnership. These programs have the potential to achieve the desired outcomes of supporting responsive relationships, strengthening core life skills, and reducing sources of stress in the lives of children and families.
- Accepted January 17, 2018.
- Address correspondence to John C. Duby, MD, CPE, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children’s Hospital, 1 Children’s Plaza, Dayton, OH 45404. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-0611.
- Center on the Developing Child at Harvard University
- Brown C,
- Raglin Bignall WJ,
- Ammerman RT
- Center on the Developing Child at Harvard University
- United Nations Office on Drugs and Crime
- Sama-Miller E,
- Akers L,
- Mraz-Esposito A, et al
- Copyright © 2018 by the American Academy of Pediatrics