This article provides a unique look at development—the lessons highly industrialized nations can learn from the rest of the world. Thailand, for example, created a comprehensive child development program through integration of health, education, economic development, social welfare, and community involvement. The program was proven to improve developmental outcomes that included IQ and nutritional status.
The World Health Organization's definition of health as the optimal state of physical, emotional, and social well-being clearly involves early emotional development. The field of early emotional development grows more important daily because of both the changes in the prevalence of childhood illness and the influx of new information on early childhood development (Tables 1, 2). In addition, it is clear that one cannot separate physical, emotional, and social well-being; children present a seamless whole of interaction among these various factors. The goal of child health care remains to provide technically competent and empathic care for the child and her/his family to ensure optimal well-being.
THE INTERNATIONAL PERSPECTIVE
The needs of children differ in each country and so too will the services they require. The global view of health generally has been limited to concern about exotic diseases coming into the United States and the treatment of these diseases in patients overseas. However, there is another significant aspect of a global view: We can learn from other cultures.
In the past decade, at least two important innovations from the developing world are being practiced in the developed world: oral rehydration for children with diarrhea and the presence of a doula during childbirth. The impact of a doula on reducing the duration and complications of labor was recognized first by Drs Kennell and Klaus in Guatemala—their findings have been confirmed since in nearly 1 dozen controlled trials.
THE CHILD DEVELOPMENT PROGRAM IN THAILAND
An extremely interesting program in early child development that may benefit children all over the world is being implemented in Thailand. The Thai Community-based Child Development Program is predicated on the same neurodevelopmental research indicating that early infant stimulation is crucial in helping children achieve their full potential. In this integrated, multidisciplinary, family-based child health program, child developmental elements have been incorporated into the backbone of the service. The elements (Table 3) emphasize intersectorial collaboration and bring together health, education, community economic development, social welfare, and nongovernmental organizations with community volunteers to empower families to provide better care for their children (Fig 1).
The center of the service program is a community volunteer, usually a woman who has raised children and who, after short introductory training, is assigned 5 families who are expecting new infants. She makes a home visit shortly after the birth of the infant, assesses the home using an adaptation of the Home Observation for Measurement of the Environment (HOME) assessment instrument3 and evaluates the mother's capacity to care for and to stimulate her infant adequately. The volunteer then instructs the mother in a variety of early infant-stimulation techniques, including talking, touching, holding, playing, and using appropriate toys. The program has been supported by UNICEF, Save The Children, and the Royal Thai Government. From 1990 to 1996, the program was implemented in 16 provinces in Thailand. The program evaluation (Table 4) demonstrates that in villages where the program has been implemented, developmental characteristics (such as IQ) were better than in comparison villages. In addition to these IQ scores, children in the program villages weighed more and had a reduction in second-degree malnutrition. This success motivated the Thai government to fund and implement the program in all 75 provinces and to increase the age from preschool up to and through 18 years.
In the fall of 1997, an International Pediatric Association workshop was held in Thailand. The participants went to program villages, made home visits, studied the data, and made a series of recommendations that are important for early child-development programs (Table 5).
First, there is a need for a simple but comprehensive well-child service package, including developmental assessment, to help instruct care providers. This is needed because one of the limiting factors in early child-development programs is lack of protocols or service packages to guide nonprofessional workers.
Second, a referral system is necessary for those with developmental and behavioral problems, with effective feedback to community-level workers.
Third, students of medicine and other health- related fields should be involved in these programs. In particular, health profession students should learn to work collaboratively with other sectors, such as education and economic development.
Fourth, perhaps most important, the concept of child development should be expanded to include family function. All too often, child development is viewed as an assessment of physical milestones. This approach, characteristic of the developmental disabilities field, has serious limitations in terms of optimizing the broad development of children.
Fifth, all personnel must realize that parents are the first line of child-development assessment and intervention. Health workers need to teach parents the developmental and interactional skills necessary for healthy infants.
UNITED STATES PROGRAMS
Two programs in the United States have incorporated some of these principles into an effective early intervention. These are the Nurse Home Visiting Program of David Olds and the Healthy Steps Program, now being implemented through the Commonwealth Fund. Neither of these programs is as broad as the Thailand Community-based Child Development Program; they do not involve multiple sectors in the community, and the Healthy Steps Program does not begin during pregnancy. A concept more akin to the Thailand program is the proposal by Robert Chamberlin to “put it all together,” which means involving multiple sectors to address the entire family and community, as well as the individual child, and carrying out rigorous evaluation. The Thailand Community-based Child Development Program offers much for those of us in the developed world to emulate.
- HOME =
- Home Observation for Measurement of the Environment
- ↵Palfrey JS. Community Child Health: An Action Plan for Today. Westport, CT: Prager Press; 1994
- Noggerty RJ
- ↵Caldwell B, Bradley R. Home Observation for Measurement of the Environment. Little Rock, AR: University of Arkansas; 1979
- Copyright © 1998 American Academy of Pediatrics