You are hereSkip Navigation Links > Home > Early childhood > Healthy Babies Healthy Children > Getting it right

Getting it Right at 18 Months ... Making it Right for a Lifetime

Download print version (PDF).

Report of the Expert Panel on the 18 Month Well Baby Visit

September 2005

Executive Summary

Our children are our future. The skills they need to achieve their full potential in life begin to form in the first months and years of life. Brain development in the first three years will affect learning, behaviour and health throughout life. Healthy child development is one of the key determinants of health.

We have the knowledge to enhance the development of all children in Ontario and help them achieve their potential. There are excellent parenting and family resource programs in the community that provide information and resources that parents can use to enhance their child's development. There are also specialized services to help children who are experiencing speech and language problems, vision problems or other developmental delays. The challenge is linking parents to these resources and services, and to other parents.

To help parents make the right connections, we must build stronger partnerships among parents, primary care providers and community services, and create a culture that enhances the developmental health and well-being of the youngest members of our society.

The primary care system provides an effective way to reach parents and children, and help build partnerships with community services. Most families with young children already have regular ongoing contact with the primary care system. They see their primary care provider at regular intervals during the first few months of their children's lives for well baby visits and immunizations (i.e., two months, four months, six months, nine months, 12 months, 15 months, 18 months). Many primary care providers (i.e., family physicians, community paediatricians and nurse practitioners) are already using these well baby visits as an opportunity to review the child's development, discuss with parents ways to provide warm, rich, responsive environments for their children, and connect them with services in the community. But this practice is not universal.

Desired Outcome

To create a culture focused on enhancing the developmental health and well-being of children.

The Expert Panel recommends that Ontario develop a system where every child in Ontario receives an enhanced 18 month well baby visit, which would include:

  • a developmental review and evaluation by parents and primary care providers, using the Nipissing District Developmental Screen (NDDS) and the Rourke Baby Record
  • a discussion between parents and primary care providers about healthy child development and behaviour
  • information about parenting and other community programs that promote healthy child development and early learning
  • when needed, timely referrals to specialized services
  • a measurement and evaluation component that tells us how our children are doing and that our programs are working.

From Plan to Action

The Expert Panel is recommending a number of strategies designed to ensure that every child in Ontario receives an enhanced 18-month well baby visit. These strategies will have a direct impact on the primary care system, and on community services for families and children. They may also result in increased demand for specialized services for children. Some of the recommendations can be implemented quickly; others will require more planning.

Achieving the desired outcome will require the support and commitment of the entire system.

The Expert Panel recommends that, to achieve the desired objective:

  • the Ministry of Children and Youth Services and the Ministry of Health and Long-Term Care dedicate appropriate resources and work collaboratively to implement an enhanced 18 month well baby visit
  • the two ministries establish an implementation group made up of people with expertise in primary care, healthy child development, professional education, and data, measurement and evaluation

Members of the Expert Panel are ready and willing to help implement an enhanced 18-month well baby visit. We are committed to working within our own organizations and in our communities to promote healthy child development.

The goal should be to have all elements of an enhanced 18 month well baby visit in place in Ontario within two years' time.

However, the Expert Panel would like to emphasize that the enhanced 18 month well baby visit is not an end in itself, but a means to enhance child development by creating more effective partnerships among parents, primary care providers and community services. Although the recommendations in this report are focused on a single event in time (i.e., the 18 month well baby visit), the Expert Panel believes that the process involved in that visit - such as using the NDDS and the Rourke, discussing healthy child development and linking families to services -- will help reinforce the importance of healthy child development and make both parents and primary care providers more aware of ways to support healthy child development throughout the early years.

The potential benefits to Ontario are measurable and real. Implementing an enhanced 18 month well baby visit and providing appropriate services will help all children in Ontario develop into healthy, educated, confident and productive adults . It is a critical investment in our human capital. It will also reduce the long-term costs associated with poor child development, including higher health and treatment costs later in life , higher welfare costs , and the social costs associated with juvenile delinquency and crime (Schweinhart et al, 2005).

Summary of Strategies to Achieve the Outcome

Creating a culture that is focused on enhancing child development will require tools, leadership , education, and other resources. The Expert Panel has identified a number of strategies (discussed in more detail in the full report) that must be implemented to support an enhanced well baby visit. Some of these strategies can be implemented immediately; others will require more planning and development.

1. Provide parents and providers with tools to support an enhanced 18 month well baby visit

1.1 Acquire province-wide rights to use the I8-month Nipissing District Developmental Screen (NDDS) and make it widely available to parents through their primary care providers, Ontario Early Years Centres, public health departments, libraries, recreation centres and other parenting and family services in the community.

1.2 Give all primary care providers free, easy access to the revised Rourke Baby Record, which includes an evaluation of the child's development, and encourage its use as a charting tool to promote and monitor healthy child development.

1.3 Fund the Ontario College of Family Physicians to work with the Guidelines Advisory Committee to develop a clinical practice guideline for primary care providers for an enhanced 18 month well baby visit.

1.4 Develop and promote the use of an 18 month visit flow chart to assist primary care providers.

2. Build effective partnerships among parents, primary care providers, and community resources

2.1 Ensure all information and education about the enhanced 18 month well baby visit is family-centred, reinforces parents' role in creating warm responsive environments where children can thrive, and encourages primary care providers to work with parents to enhance child development.

2.2 Provide primary care providers with information about healthy child development - including the effectiveness of the NDDS -- that they can share with parents.

2.3 Identify a core set of services to which all Ontario families should have access in their communities and regions.

2.4 Provide easy-to-use information to primary care providers about community services.

2.5 Establish consistent names for similar services across the province and a single branded local phone number that both primary care providers and parents can call for information, resources and referrals to community programs and services.

2.6 Ensure community services that see children referred by primary care providers are able to keep the primary care providers informed about the services provided and the children's progress.

3. Provide information, education and support for primary care providers

3.1 Develop an awareness/education program that will reinforce with primary care providers the importance of healthy child development and that builds on existing successful models .

3.2 Share and promote successful outreach strategies to involve primary care providers in healthy child development.

3.3 Identify and support peer leaders - family doctors, nurse practitioners, paediatricians, and child development specialists -- who can act as coaches and mentors, and help deliver education programs.

3.4 Provide incentives to compensate/remunerate primary care providers for providing an enhanced 18-month well baby visit.

3.5 Promote collaborative models for delivering the enhanced 18-month well baby visit.

4. Encourage timely access to services and manage wait times

4.1 Develop a standard system for collecting data on wait times for child development services across the province.

4.2 Develop a strategy to reduce and manage wait times.

4.3 Support families on wait lists by referring them to universal community services.

5. Describe the developmental health status of our children

5.1 Identify how to collect aggregate data from the 18-month well baby visit

5.2 Analyze and disseminate findings to strengthen services

5.3 Consider developing a secure system that can collect individual data and link with other early years information systems

6. Evaluate the impact of the enhanced I8-month well baby visit

6.1 Develop outcome measures for the enhanced 18-month well baby visit and evaluate the initiative's ability to achieve those outcomes.

6.2 Over time, establish at least one other point during the early years - likely age 5 -- when all children are evaluated for healthy child development.

6.3 Continue to evaluate the tools , resources and supports for the enhanced 18-month well baby visit, updating them as required to reflect new evidence and best practice.

Table of Contents

Preface

In the fall of 2004, the Minister of Children and Youth Services announced Best Start, a 10+ year plan designed to support parents in their efforts to raise healthy children and help them achieve their full potential. As part of the first phase of Best Start, the Minister convened an Expert Panel under the joint leadership of the Ontario College of Family Physicians and the Ontario Children's Health Network to provide advice on:

Members of the Expert Panel on the 18 Month Well Baby Visit were chosen for their knowledge and expertise in primary care, child health, public health, children' s services and research. They began meeting in February 2005. Over the next four months, the Panel worked intensively, gathering information from primary care providers and agencies that provide services for children through meetings and surveys, reviewing the literature and programs available in other jurisdictions, examining possible tools, and developing possible strategies to involve primary care providers in monitoring and promoting healthy child development. In June 2005, the Expert Panel held a consensus building workshop with experts in child health and development, where its proposals for tools, strategies and approaches were discussed. The Expert Panel used the feedback from the workshop to refine its work.

This is the final report of the Expert Panel to the Minister of Children and Youth Services.

Members of the Expert Panel on the 18 Month Well Baby Visit


Dr. Robin C. Williams (Chair)
Clinical Professor, Dept. of Paediatrics, McMaster University
Medical Officer of Health, Niagara Regional Health Department

Theresa Agnew
Nurse Practitioners Association of Ontario

Dr. Sheela Basrur
Chief Medical Officer of Health and Assistant
Deputy Minister, Public Health Division,
Ministry of Health and Long-Term Care

Marilyn Booth
Executive Director, Ontario Children's Health
Network

Ellen Boychyn
Board of Directors, Ontario Association for
Infant Development
Manager, Durham Infant Development

Dr. Ray Buncic
Paediatric Ophthalmologist, Hospital for Sick
Children

Dr. Jean Clinton
Assistant Clinical Professor, Dept. of
Psychiatry and Behavioural Neurosciences,
McMaster University
Consulting Child and Adolescent Psychiatrist

Dr. Linda Comley
Family Physician

Dr. Dave Davis
Associate Dean/Educational Consultant
Office of Continuing Education, Faculty of
Medicine, University of Toronto

Susan Fitzpatrick
Executive Director, Health Services Division,
Ministry of Health and Long-Term Care

Dr. Robin Gaines
Speech and Language Pathologist, Preschool
Speech and Language Program of Ottawa
Children's Hospital of Eastern Ontario
Infant Hearing Screening Program

Pat Hanly
Public Health Manager, Community Health
Department, Perth District Health Unit

Dr. Alan Hudak
Paediatrician
Clinical Lecturer, University of Toronto
Ontario Medical Association (Board of
Directors)

Janet Kasperski
Executive Director and CEO, Ontario College
of Family Physicians

Lynne Livingstone
Executive Director, Strategic Initiatives
Branch, Ministry of Children and Youth
Services

Lidia Monaco
Director of Children, Youth and Family
Services, St. Christopher House
Co-Chair, Ontario Early Years Centres
Provincial Network

Lorna Montgomery
Board of Directors, Ontario Association for
Infant Development
Clinical Director, Peel Infant Development

Dr. Wendy Roberts
Developmental Paediatrician
Child Development Program, Bloorview
MacMillan Children's Centre
Director, Autism Research Unit, Hospital for
Sick Children
Professor of Paediatrics, University of Toronto

Kathleen Gallagher Ross
Strategic Initiatives, Ministry of Children and
Youth Services

Dr. Garry Salisbury
Provider Services Branch
Ministry of Health and Long-Term Care

Dr. Peter Steer
President, McMaster Children's Hospital
Chief of Paediatrics, Hamilton Health
Sciences and St. Joseph's Healthcare,
Hamilton
Chair, Dept. of Paediatrics, McMaster
University

The members of the Expert Panel gratefully acknowledge the advice and expertise provided by the individuals who served on its subcommittees:


Roxane Belanger
First Words Preschool Speech and Language
Program, Ottawa

Sandy Bennett
Chronic Disease and Health Promotion
Branch, Public Health Division, MOHLTC

Jane Bertrand
Atkinson Centre, Ontario Institute for
Studies in Education, University of Toronto

Helen Brown
Chronic Disease and Health Promotion
Branch, Public Health Division, MOHLTC

Ian Brunskill
Public Health Division, MOHLTC

Paul Cano
Family physician

Bill Coleman
Ministry of Education

Susan Dahinten
School of Nursing, University of British
Columbia

Tara Kennedy
Department of Paediatrics, University of
Toronto and Bloorview MacMillan
Children's Centre

Jack Lee
Chronic Disease and Health Promotion
Branch, Public Health Division, MOHLTC


Vicki Leger
Ministry of Children and Youth Services

Catherine Lumsden
Ontario College of Family Physicians

Linda McLay
President, Nipissing District Developmental
Screen Canada

Elizabeth Rael
Chronic Disease and Health Promotion
Branch, Public Health Division, MOHLTC

Brenda Ross
Ministry of Children and Youth Services

Leslie Rourke
Discipline of Family Medicine, Memorial
University of Newfoundland, The Health
Sciences Centre

Ruth Schofield
Faculty of Health Sciences, McMaster
University

Susan Snelling
PHRED Program, Sudbury & District
Health Unit

Jean Victor Wittenberg
Infant Psychiatry Program/Psychotherapies
Programs, Hospital for Sick Children

Jeff Wright
Ministry of Children and Youth Services

Many other people actively contributed to our work, including the staff in public health units, Ontario Early Years Centres, Infant Development Programs, and Preschool Speech and Language Programs who took time from their busy schedules to complete our surveys, and the individuals who attended our consensus building workshop.

The Expert Panel would also like to thank the following people for their assistance:

I. Background

The link between healthy child development and life-long health and well-being

Our children are our future. Children born today are the students and workforce of tomorrow. They are our human capital: the community leaders and innovators who will shape our society. Throughout their lifetimes, they will live in a demanding world marked by rapid social, technological and economic change. The skills they need to cope in that future world -- language and literacy skills, the capacity to learn, problem solving skills, the ability to regulate their emotions and the ability to make healthy choices begin to form in the first months and years of life. In fact, brain development in the first three years sets the base of competence, and will affect learning, behaviour and health throughout life (McCain & Mustard, 1999). Child development is one of the determinants of health.

There are critical periods when young children need appropriate nutrition and stimulation to establish the neural pathways in the brain required for optimal development - that is, for them to be all they can be and achieve their full potential. Many of these critical periods are over or waning by the time a child is six years old. Children who do not receive the supports needed for healthy child development early in life may have difficulty overcoming problems later. They will be more likely to develop learning, behaviour or emotional problems, higher health and treatment costs later in life, higher welfare costs, and be more involved in juvenile delinquency and crime (Schweinhart et al, 2005) .. They may also be at higher risk for health problems, such as high blood pressure, Type II diabetes and mental health problems, than children who receive the kind of stimulation that supports healthy child development (McCain & Mustard, 1999).

The opportunity to enhance development for all Ontario's children

As a result of research, we now know the factors that put children at risk for poor development, such as poverty, stress, neglect or abuse. Although socioeconomic status is a risk factor for poor child development, there are children in all socioeconomic groups who are not reaching their optimal development.

We also know the types of activities that can enhance child development and improve behaviour, learning and health in later life (McCain & Mustard, 1999) - regardless of socioeconomic status, including:

Armed with this knowledge, it is possible for Ontario to develop programs and initiatives - such as an enhanced IS-month well baby visit -- that will support and assist all parents in their efforts to encourage their children's development.

The benefits of investing in young children

When we, as a society, support our youngest children, we reap the benefits over many years. Those children develop into healthy, educated, confident and productive adults. As Figure I illustrates, investing in our youngest children in the first years of their lives leads to the greatest return on our investment in human capital.

Ontario's healthy child development initiatives

Ontario supports a number of programs and services designed to promote healthy child development, from conception to age 6 (see Figure 2). The services listed above the heavy line, such as primary care services, parenting resource programs, child care services and kindergarten, are "universal" programs that all families in Ontario can access and use (depending on their availability in their communities). The services listed below the heavy line, such as the Infant Development Program and children's treatment services are "targeted" programs designed to help and support the approximately 8% of families who have been identified as being at high risk for poor child development and/or who have children with special needs.

Ontario is now starting to implement Best Start, a 10+year plan whose goals is to:

Best Start will fill gaps in the universal services for young children currently available by providing more child care places, developing an early learning program for all children between the ages of 2 and 4, and improving the quality of early learning and child care programs in the province. Best Start will also enhance certain targeted services, such as Healthy Babies Healthy Children and Preschool Speech and Language, so they are better able to serve the families and children who will benefit from their programs.

Challenge: linking parents to services

While Ontario funds a wide range of programs that support early child development, all families and children are not necessarily accessing or using these services. Barriers that keep families from connecting with services include language, culture, education and beliefs or attitudes about child raising. In some cases, parents are not aware of the importance of early child development or of the programs available to them. In other cases, parents may have a sense that they could be doing more to provide a safe rich environment for their young children, or they worry their child is lagging behind other children the same age in language or motor skills, but they do not know where to turn for help. Working parents may not have the time to seek out or attend community programs. More affluent families may assume that they do not need these services or that the programs are only available to families who are socially or economically disadvantaged.

Because it is not easy for parents to connect with community services, many families do not benefit from the opportunities to enhance their children's development. Some families whose children are experiencing some delays in their development are not assessed or linked with more specialized services, such as speech and language therapy, until the children start school- when it is much more difficult for them to catch up with their peers.

Opportunity: building on existing contacts with parents

The most effective way to help link all parents with young children (i.e., from conception to the age of 6) to services and to other parents is to integrate child development information, developmental reviews, and evaluations into the routine (universal) contacts that families already have with the health, social service and education systems. For example:

II. The 18 Month Well Baby Visit: An Opportunity to Enhance Child Development

School-based programs are an effective way to reach families with preschoolers and children starting school but, by ages 4, 5 and 6, critical learning periods have already been missed, and overcoming delays becomes more difficult and costly. For example, a speech/language delay identified between the ages of 2 and 3 can often be overcome when the child/family receive help while a similar problem identified at age 5 may take more time to correct and will already have cost the child significantly in confidence, self esteem, and other language and communication skills, and caused frustration that can lead to behaviour problems. Identifying and treating a vision problem within the first two years of life will help children achieve other developmental milestones.

To help parents create the warm, rich environment young children need, the Expert Panel recommends that primary care providers take a more systematic approach to supporting healthy child development, focusing particularly on the 18 month visit.

The age of 18 months is a key stage in healthy child development. It is the age when children are starting to speak so it is possible to detect early signs of speech and language or other communication problems. It is the age when children are becoming more independent and assertive, and parents may start to experience difficulties managing their children's behaviour. It is the age when early detection can make a difference for many children with specific disorders such as autism. It is also the last point in time when primary care providers will see almost all young children in their practice. After that age - when the child has received the required early immunizations many parents will only bring their child back to the primary care provider when the child is ill. Primary care providers may not see many children again until age 5 when they need immunizations required for school.

About the "Well Baby" Visit

"Well Baby Visits" are part of comprehensive primary health care for infants and their families, particularly in the first two years of life. This comprehensive health and development surveillance program focuses on promoting healthy development for all children. The timing of the well baby visits tends to follow the immunization schedule so there are 4 to 6 visits in the first year and a couple in the second. This ongoing monitoring provides regular opportunities for primary care providers to revisit the infant's growth and development within the family and community setting, provide support and education for parents, and connect families to community resources As an infant grows, it is important to review specific aspects of development, safety, nutrition and health.

The goals of the well baby visit are to:

  • address parental concerns
  • monitor physical growth and development
  • assess parent-child interactions and family health
  • counsel about development, safety, nutrition and community resources
  • encourage parents
  • provide immunization and other preventive care
  • identify risks/problems for action.

Because families are already bringing their children to primary care providers at 18 months to be assessed, it would be highly efficient to expand the current well baby visit to include: a more extensive discussion with parents about enhancing healthy child development, a more in-depth review and evaluation of the child's current stage of development, and information and referrals that will help parents connect with community programs and services.

Building on the 18 month well baby visit would:

Parents' health has a direct impact on child health and well-being. Because of their relationship with the family and their training, primary care providers are also able to evaluate the parents and identify any issues, such as depression, stress or family violence, that could adversely affect the child's development.

An enhanced 18 month well baby visit would also be consistent with Ontario's vision for children and its focus on health promotion and preventive care. Children who have the opportunity to develop to their full potential are more likely to be successful in school and in life, and more likely to enjoy life-long health and well-being. In addition, the few children who are experiencing developmental delays can be identified early and receive appropriate services and support.

Ontario's Vision for Children

An Ontario where all children and youth have the best opportunity to succeed and reach their full potential.

An enhanced 18 month well baby visit in action

An enhanced 18-month well baby visit involves both parents and primary care providers doing a thoughtful review and evaluation of a child's development. The following is a description of an enhanced 18 month well baby visit with suggested points for further inquiry based on the revised Rourke Baby Record and the parent-administered NDDS, and informed by materials developed for Bright Futures, a program developed by the US Department of Health and Human Services.

Before the visit, parents complete the 18 month Nipissing District Developmental Screen (NDDS): a one-page checklist of "yes/no" questions about all aspects of their child's development. The visit begins with the provider talking to the parents about their answers to the NDDS. Did they answer "no" to any questions? Do they have any concerns about their child's development? Any issues identified by parents, such as behaviour issues, sleeping or eating problems, are discussed briefly and recorded on the provider's chart or record. They also provide a focus for the rest of the examination and visit.

The primary care provider then does a review and evaluation with the parents, asking about:

  • the family situation (how are you? how are things going in your family? have there been any changes in the family? any previous issues that should be reviewed? are there any parental issues that could affect the child, such as stress, fatigue or depression? what is the child's place in the family")
  • nutrition (is the toddler still breast-feeding? if not, how much and what type of milk does the child drink? how much juice? what types or varieties of food does the child eat? is the child still using a bottle? does the child go to sleep with a bottle? are there any family or cultural dietary issues? is the family vegetarian")
  • parent/child interactions (what are some of the things you enjoy most about your child? what seems most difficult? what kinds of things do you find yourself saying "no" about? how are you managing her behaviour? do you set limits? have you established a schedule for eating and sleeping") In addition to asking the parent questions, the primary care provider will observe the interaction between parent and child (e.g., how do they communicate? what words do they use? what is the tone of the interaction and the feeling conveyed? when the primary care provider speaks to the child directly, does the parent intervene? does the parent seem positive when speaking about the child?)
  • the child's social/emotional development or temperament (does the child have opportunities to play with other children? how does he relate to other children? how does he assert himself? does he come for comfort when distressed")
  • the child's communication skills (can the child point to three body parts? does he or she imitate sounds? does he or she participate in pretend play?)
  • the child's motor skills (can the child walk backward 5 steps without support? has he or she recently mastered a new fine motor task?)
  • the child's adaptive skills (can the child remove socks or gloves without help?)

Any problems or issues identified by either the parent or the provider are discussed and kept in mind throughout the visit.

The primary care provider then weighs and measures the child (including measuring the head circumference) and graphs the results on the child's growth chart, looking for any changes in growth patterns. A physical examination at 18 months includes observing the child's gait, assessing the eyes and vision, asking about and assessing the child's hearing, and asking about dental care. It also includes a general physical examination that, depending on the developmental assessment, may also include a neurological examination.

The primary care provider then discusses safety issues with parents, focusing particularly on bath safety and the choking risk associated with small toys. He or she also reviews the immunizations the child will receive at that visit, and the boosters required in the future.

At the end of the visit, the primary care provider reinforces the positive things that the parents are doing to enhance their child's development, and encourages parents to use the age-appropriate activities listed on the NDDS (e.g., reading and talking to the child, joining parent and play groups). The provider also provides information on community resources for parents and children - such as the Ontario Early Years Centres -- and reinforces the importance of giving the child opportunities to play and to interact with other children.

If, in the course of the visit, the provider identifies a problem or issue that requires more specialized services or follow-up, he or she will discuss this with the parents and make the appropriate referral/s, (See Appendix 4.)

The provider administers the immunizations (two needles: Pentacel and MMR) and observes the parent/child interaction during that stressful event.

The provider completes his or her chart or records, and notes any issues in the child's file.

The benefits of an enhanced 18 month well baby visit: Experience in one practice

Because a standard enhanced 18-month well baby visit is not yet in widespread use, there has been no systematic evaluation of its impact. However, a retrospective review/audit in a six-physician family practice1 that provides an enhanced 18-month well baby visit, revealed the following:

These findings demonstrate that an enhanced 18-month well baby visit can be delivered effectively by providers in primary care settings. The results reinforce that most children are achieving their potential. They also indicate that the process does help identify issues that require further action.

The Expert Panel recommends the following plan to implement an enhanced 18 month well baby visit within Ontario 's primary care system.

III Implementing an Enhanced 18 Month Well Baby Visit

Goal

To promote and enhance the healthy development of all children in Ontario through a focus on the I 8-month primary care well baby visit.

Objectives

  1. To develop effective partnerships among parents, primary care providers and community services to promote healthy child development.
  2. To make the consistent promotion and monitoring of healthy child development, focusing particularly on the 18 month well baby visit, a standard of care for all primary care providers, including family health teams , primary care physicians and nurse practitioners.
  3. To make parents aware of community resources that will support them in raising their children, help improve their parenting skills and give their children an opportunity to learn and grow in safe, responsive environments.
  4. To link families with children who are experiencing developmental delays with appropriate community resources.
  5. To describe the developmental status of Ontario's children at age 18 months.

Desired outcome

To create a culture focused on enhancing the developmental health and well being of children.

The Expert Panel recommends that Ontario develop a system where every child in Ontario receives an enhanced 18 month well baby visit which would include:

  • a developmental review and evaluation by parents and primary care providers, using the Nipissing District Developmental Screen (NDDS) and the Rourke Baby Record
  • a discussion between parents and primary care providers about healthy child development and behaviour
  • information about parenting and other community programs that promote healthy child development and early learning
  • when needed, timely referrals to specialized services
  • a measurement and evaluation component that tells us how our children are doing and that our programs are working.

Principles and assumptions

The Expert Panel's recommendation for an enhanced 18 month well baby visit is based on principles/assumptions taken from current practice and the scientific literature.

Challenges and opportunities

The enhanced 18 month visit just described is already occurring in many primary care settings across the province. Many primary care providers have embraced their role in monitoring child development, and integrating an ongoing developmental evaluation into the routine care they provide for families and children.

The challenges that many primary care providers will face in implementing this strategy to enhance healthy child development include:

Changes that are occurring in the primary care system - in particular, the establishment of primary care group practices such as family health networks, groups and teams, the increase in community health centres (CCHCs), and the strengthening of public health services - may provide the means to overcome some of the challenges and an opportunity for primary care to play a stronger role in promoting healthy child development For example, family health networks, groups and teams will focus more on preventive care and enhancing health, and on providing comprehensive care for families across all ages and stages of life, As part of their contract with the Ministry of Health and Long-Term Care, they are provided with incentives to meet certain targets for childhood immunizations and other preventive services, These teams of family physicians have the skills and expertise required to evaluate child development As other providers such as nurse practitioners, nurses and others are added to the teams, the physicians will have better supports and an enhanced 18 month well baby visit could become part of the services that all teams offer.

The enhanced well baby visit would also be a natural "fit" for community health centres, which focus on promoting health and providing comprehensive health and social services for the populations they serve.

The strengthening of public health services across the province may also provide a means to support an enhanced 18 month well baby visit, either by providing information for primary care providers or by working collaboratively with them to ensure that all families have access to information about child development, a developmental evaluation at 18 months, and appropriate referrals to community services,

Strategies

To achieve the desired outcome and successfully implement an enhanced 18 month well baby visit across the province, Ontario will need the right tools, leadership, partnerships, education and other resources. The Expert Panel recommends the following strategies to implement an enhanced 18 month well baby visit

1. Provide parents and providers with tools to support an enhanced 18 month well baby visit

The purpose of monitoring child development, focusing on the 18 month well baby visit, is to make primary care providers and parents more aware of the importance of healthy child development and how to enhance it. Much has been learned from primary care practices and community programs about the tools and processes to make this work.

For some primary care providers, the process of working with parents to monitor and promote child development may be a change in practice. Having access to standard tools and resources will make it easier for them to make that change and incorporate the developmental review and evaluation into their 18 month well baby visit. Providers who are already routinely assessing the children they see will also benefit from standard tools which can help: streamline their practice, ensure all children are assessed consistently, and ensure families are referred or directed to appropriate community programs and/or specialized services.

While having access to standard resources and tools will ensure greater consistency across the province, the tools are not an end in themselves: they are the means to ensure that both parents and primary care providers are looking for ways to enhance child development throughout the early years. The Expert Panel recommends that Ontario:

1.1 Acquire province-wide rights to use the IS-month Nipissing District Developmental Screen (NDDS) and make it widely available to parents through their primary care providers, Ontario Early Years Centres, public health departments, libraries, recreation centres and other parenting and family services in the community

The Nipissing District Developmental Screen (NDDS) is a parent-completed surveillance tool designed to help parents understand healthy child development and review whether their children are achieving developmental milestones. The NDDS consists of a checklist of questions about a child's communication, gross motor skills , cognitive skills, social-emotional skills and self-help skills at different ages from one month to six years, as well as a list of age-appropriate activities that parents can use to enrich their child's development. See Appendix 1 for a copy of the 18-month NDDS.)

Ideally, parents would obtain a copy of the 18-month NDDS - from the primary care provider, from a public health nurse, or from a parenting service or library in the community -- and would complete it and bring the results to the visit. If parents did not have access to the NDDS before the visit, they should be given a copy at the time of the visit and asked to complete it before seeing the primary care provider. The provider and parents would then discuss the results. If parents answered "no" to any question, that would be discussed with the provider. If parents answered "no" to two or more questions on the NDDS, that would be a trigger for the primary care provider to consider referring the child for a more in-depth developmental assessment.

The Nipissing is available in five languages - English, French, Spanish, Chinese and Vietnamese - and is already in widespread use in the Healthy Babies Healthy Children program, the Ontario Early Years Centres and other developmental services, It is an effective way to educate parents about healthy child development, involve them in monitoring their child's development, and encourage appropriate developmental activities, It has also been shown to be effective in identifying children at risk of developmental delays, Because of the cost of the Nipissing, it is not as widely accessible or consistently used as it could be. The Expert Panel believes that making the NDDS more widely available in primary care practices and in community settings will benefit the children of Ontario. The Ministry of Children and Youth Services should also determine whether the Nipissing should be available in other languages.

Primary care providers should be informed about the NDDS and its use. Experience in the Ontario College of Family Physician's Healthy Child Development program indicates that physician education about the tool and its usefulness results in greater uptake and use of the tool by parents.

The goal is to make the enhanced 18 month visit a standard of care based on current evidence. The process of developing the guideline should be multidisciplinary, and result in information that can be used by all primary care providers. It should also include and promote specific resources for parents on healthy child development and parenting.

1.2 Give all primary care providers free, easy access to the revised Rourke Baby Record, which includes a developmental evaluation, and promote its use as a charting tool to monitor child development.

Many primary care providers in Ontario are already using the Rourke Baby Record as a charting tool as part of their well baby care. It is a Canadian tool first developed in 1977 and endorsed by the College of Family Physicians of Canada and the Canadian Paediatric Society, which can be used at key ages and stages in the early years: 2 months, 4 months, 6 months, 12 months, 18 months, 2-3 years and 4-5 years.

The authors have worked closely with the Expert Panel to integrate a developmental checklist into the Rourke Baby Record. At 18 months, that evaluation consists of a checklist of 13 items that can be used to evaluate a child's attainment of milestones in social/emotional development, communication/play, motor skills and adaptive skills. (See Appendix 2 for a copy of the revised one-page Rourke Baby Record.)

Primary care providers should have a copy of the Rourke Baby Record - either electronically or in hard copy -- for every child in their practice. Providers would use the form with parents to complete a systematic in-depth review and evaluation of the child's development.

1.3 Fund the Ontario College of Family Physicians to work with the Guidelines Advisory Committee to develop a clinical practice guideline for primary care providers for an enhanced 18 month well baby visit

The Guidelines Advisory Committee (GAC), a joint initiative of the Ministry of Health and Long-Term Care and the Ontario Medical Association, promotes evidence-based health care and the consistent use of best available clinical practice guidelines. When developing a guideline, the GAC conducts an in depth, rigorous review of existing clinical practice and current evidence, and makes recommendations about the best approach.

1.4 Develop and promote the use of an "18 month visit flow sheet" to assist primary care providers

An 18 month visit flow sheet will help ensure that the enhanced IS-month well baby visit is delivered consistently and efficiently, and in a standard way across the province. The flow sheet should set out the route that most families will take and identify the critical points where information provided by parents or identified by providers may require more discussion or a referral to services. (See Appendix 3.)

2. Build effective partnerships among parents, primary care providers, and community resources

The enhanced 18 month well baby visit is not an end in itself, but the means to enhance child development by creating more effective partnerships among parents, primary care providers and community resources. Although the 18-month visit is focused on a single event in time, the process of doing the review and evaluation helps to reinforce the importance of healthy child development and to make both parents and providers more aware of other ways - including tools -- to support healthy child development throughout the early years.

Effective parenting is critical to healthy child development. Parents should play an active part in monitoring their children's development and helping children develop and master key skills.

For the enhanced IS-month well baby visit to achieve its goal and objectives, it must be an effective way to link families and children to community resources, parenting resources, play programs and, for those children with developmental delays, more specialized services. Primary care providers in Ontario are usually well connected and have established referral networks with the specialized health services in their area, such as community-based paediatricians, developmental paediatricians, dentists, infant development programs, children's treatment centres , ophthalmologists, and child and adult mental health services. They may be less aware of the other resources for families in their communities, such as Early Years Centres, parent resource centres, parenting programs and play groups. To enhance development for all children, they will need to develop links with these services. Children 's services, in turn, will have to develop better techniques for communicating with primary care providers.

To encourage a strong partnership among parents, primary care providers and community services designed to encourage healthy child development:

2.1 Ensure all information and education about the enhanced 18 month well baby visit is family-centred, reinforces parents' role in nurturing healthy children, and encourages primary care providers to work with parents to enhance child development.

2.2 Provide primary care providers with information about healthy child development - including the effectiveness of the NDDS -- that they can share with parents

Excellent parent resources have been developed and are available.2 Primary care providers should be supplied with free copies of these resources that they can give to parents. This will make it easier and faster for primary care providers to explain the importance of child development, and give parents information they can refer to at home. In addition, primary care providers will actively encourage parents to use the NDDS (see 1.1) at all stages of their child's growth and development, and not just at 18 months.

Every effort should be made to promote the use of credible existing materials, such as the Let's Grow resources available through many public health units, and to provide consistent information for parents. Information should be age appropriate. It should also be accessible to people from different cultures. The goal is ensure that the public understand what an 18-month old child can and should do.

2.3 Identify a core set of services to which all Ontario families should have access in their communities, regions and provincially

All families with young children in Ontario should have access to a core or minimum set of services in their communities or regions so primary care providers can make appropriate referrals, regardless of where they are working in the province. The Ministry of Children and Youth Services should work with the Ministry of Health and Long-Term Care and the recently established Local Health Integration Networks (LHINs) to identify the core services families need, and the most effective way to provide those services (e.g., locally, regionally using technology).

2.4 Provide easy-to-use information to primary care providers about community services

To link families to the right resources, primary care providers need consistent information about the services available in their communities and regions. Most communities have identified one program -- often Healthy Babies Healthy Children -- responsible for maintaining an up-to-date inventory of services for children. Funding should be provided to allow that organization to develop and distribute a one-page template, illustrating the local early child development and parenting resource system, to all primary care providers. (See Appendix 4.)

2.5 Establish consistent names for similar services across the province and a single branded local phone number that both primary care providers and parents can call for information, resources and referrals to community programs and services

Ideally, all primary care providers and other child service providers should have a complete, up-to-date listing of community resources and developmental programs, and a description of the services they provide. But community services can change, which makes it difficult to keep a hard copy resource up to date. To help primary care providers connect with local programs, the same services across the province should be referred to in a consistent way that describes the services offered (e.g., the Preschool Speech and Language program of[name of community]). In addition, local communities should have a single branded phone number that both primary care providers and parents can use to access local community programs. This phone line should be staffed to coincide with hours offered in family practices. In communities that have already established a community resources number (e.g., 211 or parent talk lines), information about children's services should be incorporated into that program to avoid duplication.

Local communities should also explore other strategies to help link primary care providers and children's services, such as holding information/education sessions that bring both groups together to discuss common issues, and building on existing relationships (e.g., primary care providers and public health).

2.6 Ensure community services that see children referred by primary care providers are able to keep the primary care providers informed about the services provided and the children's progress

When primary care providers refer a family or child to another service, they expect to be kept informed of the child's progress. They use that information to provide more comprehensive family-centred care to the child and family, and to support the family's participation and use of the community service.

Many community services are not accustomed to communicating with primary care providers, and will have to develop the forms and systems to be able to keep primary care providers informed about the family's and child's progress (e.g., a one-page form that can be completed and faxed to a physician's office). Some organizations have already taken this step (see Appendix 5). Some, because of the volume of referrals they handle, may need additional funding to develop and maintain a feedback loop to primary care providers.

3. Provide information, education and support for primary care providers

Any change in practice must be supported with ongoing education and incentives. To provide that support:

3.1 Develop an awareness/education program that will reinforce with primary care providers the importance of healthy child development and that builds on existing successful models.

A comprehensive awareness/education program for primary care providers
should include:
- the importance of early childhood development
- the key role that parents and primary care providers play
- the knowledge and skills required to assess child development
- the tools and how to use them
- the services available in the community to enhance healthy child development and how to link with them
- the supports available to primary care providers (e.g., public health units, developmental services).

Effective ways to deliver this education include: integrating into existing CME and other primary care continuing education programs, providing small group, problem-based learning opportunities, developing a video of an enhanced 18-month visit accessible online, developing an on-line education module, making presentations at hospital rounds, academic detailing by public health nurses, and encouraging closer ongoing collaboration between primary care providers and public health. Whenever possible, education efforts should build on the delivery systems already in place, such as those provided through the Ontario College of Family Physicians.

In addition to formal educational programs, primary care providers should have access to user-friendly, self-explanatory, on-line education materials that they can use when they choose. They should also have access to educational materials that can be shared with front-line or entry staff, including receptionists, who may be responsible for explaining the well baby visits, asking parents to complete the NDDS, following up with parents on missed visits, and helping families make appointments with community services. All educational materials should clearly explain the benefits to children, families, and clinicians of monitoring child development, linking parents to community resources and intervening at the first sign of a developmental delay.

3.2 Share and promote the use of successful outreach strategies to involve primary care providers in healthy child development

Some organizations, such as public health units, the Ontario College of Family Physicians, and the Ontario Medical Association, have a long history of working with primary care physicians on population health issues. This experience can be used to identify successful outreach strategies and build partnerships with primary care providers focused on healthy child development.

3.3 Identify and support peer leaders -- paediatricians, primary care providers and child development specialists -- who can act as coaches and mentors, and help deliver education programs

Based on the Ontario College of Family Physicians' (OCFP) highly successful Collaborative Mental Health Care Network, local champions and leaders with appropriate support -- can create a culture of practice that enhances child development. Their passion, commitment and expertise can help overcome the barriers to providing a universal 18 month assessment. Local organizations, including the Best Start network, local health units, local medical societies, academic centres, the OCFP and the Nurse Practitioner Association of Ontario should work together to identify and support local champions and leaders.

3.4 Provide incentives to compensate/remunerate primary care providers for providing the enhanced 18 month well baby visit

A developmental review and evaluation will add time to the 18 month well baby visit. Because many primary care physicians are still compensated on a fee for service basis and are extremely busy with the patient demands on their time, it may be necessary to provide specific incentives to make it feasible for them to incorporate an enhanced 18 month well baby visit into their busy practices. The level of remuneration should be significant enough to reinforce the importance of the primary care provider's role in monitoring and enhancing healthy child development.

The Expert Panel recommends that:

3.5 Promote collaborative models for delivering the enhanced 18-month well baby visit

At the current time, well baby visits are provided by physicians and nurse practitioners. Physicians and Nurse Practitioners are qualified to provide all aspects of the 18 month check-up [or well baby care] and currently provide this service in a variety of practice models (or settings) including Community Health Centres, Family Health Networks, community-based clinics and hospital-based clinics. Because of the current shortage of family doctors, community-based paediatricians and nurse practitioners in parts of the province, some families may not have a primary care provider. The Ministry of Health and Long Term Care is currently implementing a number of strategies to enhance primary care, including introducing Family Health Teams. In this collaborative model of care, physicians, nurse practitioners, nurses and other professionals will work together to provide primary care. Within Family Health Teams, components of the enhanced l8-month visit could be conducted by a family practice nurse or by a public health nurse linked to the practice, who have the knowledge and skills to do a developmental evaluation; other components would be done by the nurse practitioner or physician.

Some family physicians work collaborative1y with public health nurses or child development experts in the community to help deliver the developmental portion of the 18 month well baby visit. Some communities have also made effective use of community clinics to provide developmental reviews and/or assessments and immunizations, and to link families to services. Communities that provide the enhanced 18-month visit this way should ensure that the clinics: are collaborative and represent all early intervention and parenting services in the community; and are promoted effectively to parents and actively engage parents in supporting child development.

4. Encourage timely access to services and manage wait times

Many of the strategies already described - such as building closer partnerships between primary care providers and community services, establishing a single branded local phone number, and providing referral tools for primary care providers - will lead to more timely referrals for families to parenting and play programs as well as to more specialized child development services.

A more systematic assessment of all children at 18 months may also result in more referrals for services. Some providers have expressed concern about the ethics of identifying children who need services, when those services may not be available. According to a survey done by the Expert Panel and feedback from community services, wait times for Infant Development Programs can range from one to 18 months, depending on the needs of the child and family, the area of the province and availability of resources. Most families wait more than six months for preschool speech and language assessments and for other specialized assessment services. To manage wait times and ensure families receive timely referrals:

4.1 Develop a standard system for collecting data on wait times for child development services across the province

An enhanced 18-month well baby visit will likely increase the demand for/use of parenting programs and resources. It will also lead to primary care providers identifying more children who need specialized children's services. This may lead to or exacerbate wait times for some services.

For Ontario to provide an effective system of services for children, it needs accurate, comparable information on wait times for services. The Ontario Children's Health Network (OCHN) has started an initiative to assess wait times for some clinical services. OCHN should expand this initiative to include monitoring wait times for developmental assessments and treatments in communities across the province.

Information about wait times should be shared with parents, so they know how long they will likely wait before receiving services.

4.2 Develop a strategy to reduce and manage wait times

Information on wait times for children's services should be used by the LHINs, the Ministry of Health and Long-Term Care, and the Ministry of Children and Youth Services to plan services, and to reduce and manage wait times.

4.3 Support families on wait lists by referring them to universal community services.

While families are waiting for specialized services, they should receive other services that can make a difference in their children's lives. For example, the Ontario Early Years Centres, library programs, and other parenting resource programs in the community can provide services that will support families and enhance child development. In fact, all families should be linked to these services for children. Primary care providers may also be able to provide services that will help families while they wait for further developmental assessment and intervention.

All programs with wait lists should identify other services in the community that can provide support during wait times.

5. Describe the developmental health status of our children

The implementation of a standard enhanced 18-month well baby visit for all Ontario children will provide an opportunity to collect valuable information on the developmental health of our children. A certain amount can be learned from non-nominal aggregate data, which is easier to collect. However, the Expert Panel strongly supports moving over the longer term to a system that can track individual children throughout the early years, and assess the impact of different interventions and services on their health and well-being (see 5.3).

To ensure Ontario is able to describe the developmental health status of our children:

5.1 Identify how to collect aggregate data from the 18-month well baby visit

One of the Expert Panel subcommittees identified the type of data that should be collected, including:

In addition, the Expert Panel suggests that the government (e.g., MCYS, MOHLTC) consider collecting data on sensory impairment (i.e., any problems with vision or hearing) and the need for additional assessment due to more than one developmental area being affected.

To support data collection, the revised Rourke Baby Record has been designed with a tear off section that records the recommended data elements. However, the group identified significant challenges to collecting the data -- including privacy issues, data security, data quality- which must be resolved. The Expert Panel recommends that the Ministry of Children and Youth Services and the Ministry of Health and Long-Term Care work with the Privacy Commissioner to resolve privacy issues, and consult with other provinces (i.e., Manitoba, B.C.) that are already collecting this type of data. There may be an opportunity to use the Best Start demonstration communities to assess approaches to collecting data.

5.2 Analyze and disseminate findings to strengthen services

Once data collection issues are resolved, the government (e.g., MCYS, MOHLTC) should use the aggregate data to develop a series of regular reports, targeted to different audiences, that describe the developmental status of Ontario's 18-month olds. These reports will be important to ensure the ongoing commitment of the physicians providing the data.

The reports should also be used to plan and refine programs and services. They should be disseminated to government ministries - including Children and Youth Services, Health and Long-Term Care and Education - to help shape policies and programs. Findings should also be shared with parents, primary care providers and child development services to help reinforce the importance of healthy child development and improve practice.

5.3 Consider developing a secure system that can collect individual data and link with other early years information systems

Although it is possible to analyze some trends using aggregate data, the Expert Panel believes that there are benefits in collecting individual data that can be used to follow specific children (e.g., children who receive speech and language services in the early years) and assess outcomes. Other provinces, such as Manitoba and B.C., are currently maintaining information systems that allow them to link the results of a child's 5-year assessment with his or her 18 month assessment. They can use this data to follow children through the system, assess the impact of the services they receive, and identify service gaps.

The collection of individual data is a sensitive issue that adds significantly to the complexity of the information system required for this project. Should the government (e.g., MCYS, MOHLTC) opt to move, over time, to the collection of individual data, it will be critical to develop specific measures to ensure security and confidentiality, including obtaining parental consent, establishing secure systems for primary care providers to submit data and using a unique identifier that will allow analysts to link data (while still protecting children's identities). The government (e.g., MCYS, MOHLTC) should ensure that any system developed complies with health information privacy and consent legislation. It should also explore the possibility of obtaining from parents a single consent at the time of postnatal screening (i.e., through Healthy Babies Healthy Children) to collect assessment information throughout the early years. Obtaining parental consent and protecting their privacy will also require the understanding and support of primary care providers and their office staff.

In addition, every effort should be made to build on systems already in place, such as the system used to collect assessment data from Healthy Babies Healthy Children (i.e., ISCIS). The data system should also be able to link data from the l8-month assessment with information that will be collected on children as they enter school.

6. Evaluate the impact of the enhanced 18-month well baby visit

Resources for children's health and developmental services are limited and must be used wisely. The Expert Panel believes that an enhanced l8-month well baby visit will have a positive impact on healthy child development. It will increase awareness of the critical importance of early child development. It will lead to more families being connected to community services, more parents providing rich environments for their children, and more children with developmental delays being identified early and linked to services that can help them overcome the delays. We believe this investment will payoff in terms of improved child outcomes and less need for services for children later in life. "Getting it right at 18 months" can, indeed, mean "making it right for a lifetime". To determine whether an enhanced l8-month well baby visit and other early years services lead to positive health outcomes:

6.1 Develop outcome measures for the enhanced 18-month well baby visit and evaluate the initiative's ability to achieve those outcomes

The outcomes should focus on parent/child access to the enhanced visit, its impact on the use of parenting and developmental services in the community, the number of children referred to specialized services, the effectiveness of strategies to support families on wait lists for services, and the overall impact on child development. The Best Start demonstration sites may provide an opportunity to test proposed outcome measures and evaluation tools.

6.2 Over time establish at least one other point during the early years - likely age 5 -- when all children are assessed for healthy child development

Ideally, all children in Ontario would be assessed again around age 3 but, because children do not necessarily have contact with primary care, community or school services at that age, it is probably not possible at the current time. Instead, the Expert Panel recommends that Ontario target age 5, when all children are preparing to enter school. The Panel suggests that the Ministry of Children and Youth Services initiate a similar process to that used to develop the recommendations for an enhanced l8-month well baby visit to: identify the data to be collected at age 5, when and where it would be collected, and the tools to be used. The assessment at age 5 would include data from the EDI that is currently conducted on children in kindergarten or entering grade 1 and would provide information on social-emotional competency. It should also include the use of other tools, including parent completed tools, that would provide as assessment of family-based domains.

6.3 Continue to evaluate the tools, resources and supports for the enhanced 18-month well baby visit, updating them as required to reflect new evidence and best practice.

In addition to evaluating the impact of the enhanced visit, every effort should be made to continue to evaluate and refine the tools, resources, education programs, incentives and other supports for the enhanced 18 month well baby visit.

From plan to action

The Expert Panel has set a series of strategies to support an enhanced 18-month well baby visit. The proposed strategies will have a direct impact on the primary care system, and on community services for families and children. They may also result in increased demand for specialized services for children.

Some of these strategies - such as providing access to the NDDS, the Rourke Baby Record and other tools, educating primary care providers, and building partnerships - can be implemented quickly. Others, such as the wait time strategy, a system to collect data and an evaluation plan, will require more planning. (See Appendix 6 for a list of strategies that can be implemented immediately and those that will require more planning.)

Achieving the desired outcome - an enhanced 18 month well baby visit for every child in Ontario -- will require the support and commitment of the entire system.

Members of the Expert Panel are ready and willing to help. We are committed to working within our own organizations and in our communities to promote healthy child development. We have developed a implementation/communication plan, which is based on using our organizations and associations to provide education about the enhanced 18-month well baby visit and promote its use. (See Appendix 7) The goal should be to have all elements of an enhanced 18 month well baby visit in place in Ontario within two years' time.

The Expert Panel recommends that:

  • the Ministry of Children and Youth Services and the Ministry of Health and Long-Term Care dedicate appropriate resources and work collaboratively to implement an enhanced 18 month well baby visit.
  • the two ministries establish an implementation group made up of people with expertise in primary care, healthy child development, professional education, and data, measurement and evaluation.

Members of the Expert Panel are ready and willing to help. We are committed to working within our own organizations and in our communities to promote healthy child development. We have developed a implementation/communication plan, which is based on using our organizations and associations to provide education about the enhanced 18-month well baby visit and promote its use. (See Appendix 7)

The goal should be to have all elements of an enhanced 18 month well baby visit in place in Ontario within two years' time.

IV. Conclusion

Primary care providers have an opportunity to make a significant difference in the lives of young children and families - not only for the traditionally "deprived" child but for all young children. As noted earlier, an enhanced 18 month well baby visit is not an end in itself, but the means to enhance child development by building a shared understanding and more effective partnerships among parents, primary care providers and community resources. These partnerships can help create the kind of culture and environments that will support our children during the early years, help them achieve their optimal development, and create the foundation for a lifetime of health and well-being.

The potential benefits to Ontario are measurable and real. Implementing an enhanced 18 month well baby visit and providing appropriate services will help all children in Ontario develop into healthy, educated, confident and productive adults. It will also reduce the long-term costs associated with poor child development, including higher health and treatment costs later in life, higher welfare costs, and the social costs associated with juvenile delinquency and crime (Schweinhart el al, 2005).

An enhanced 18 month well baby visit, combined with the post-natal screening now done by Healthy Babies Healthy Children and the proposed assessment of children when they enter grade one, provides a starting point for monitoring and promoting healthy child development in the early years. Over the long-term, Ontario should develop the capacity to understand and support healthy child development from birth to age 18.

References

Carneiro P, Heckman J. Human Capital Policy. National Bureau of Economic Research. Working Paper 9495. February 2003.

Goldfarb C., Roberts, W. Developmental monitoring in primary care. Can Fam Physician 42: 1527-1536. 1996

McCain M., Mustard F. Reversing the Real Brain Drain. The Early Years Study. Final Report 1999. Toronto. Publications Ontario, 1999:31.

US Department of Health and Human Services. Bright Futures. Guidelines for Health Supervision of Infants, Children and Adolescents. Second Edition, Revised.

Schweinhart LJ, Montie J, Xizng Z, Barnett WS, Belfield CR, Nores M. Lifetime Effects: The High/Scope Perty Preschool Study Through Age 40. High/Scope Educational Research Foundation. 2005.

Williams RC. The 'deprived preschooler' and the paediatrician. Paediat Child Health. Vol 4. No.8 November/December 1999.

Appendix 1: 18 Month Nipissing District Developmental Screen

Nipissing District Developmental Screen™

The Nipissing District Developmental Screen is a trademark of Nipissing District Developmental Screen Inc. © first published in 1993 and in 2002 Nipissing District Developmental Screen Inc. All rights reserved

Child's Name

 

Birth Date

 

Today's Date

 
Yes No By Eighteen Months, does your child...
Checkmark Checkmark  
    1. Identify pictures in a book (e.g . "Show me the baby")?
    2. Use familiar gestures (e.g. waving, pushing away)?
    3. Follow directions when given without gestures (e.g. "Throw me the ball ", "Bring me your shoes")?
    4. Use common expressions (e.g. "all gone" or "oh-oh")?
    5. Point to at least three different body parts when asked (e.g. "Where is your nose?")?
    6. Say five or more words? (Words do not have to be clear.)
    7. Hold a cup to drink?*
    8. Pick up and eat finger food?
    9. Help with dressing by putting out arms and legs?*
    10. Crawl or walk up stairs/steps?
    11. Walk alone?
    12. Squat to pick up a toy without falling?
    13. Push and pull toys or other objects while walking? (Picture A)
    14. Stack three or more blocks?
    15. Show affection towards people, pets or toys?
    16. Point to show you something?
    17. Look at you when you are talking or playing together?

* item may not be common to all cultures

Activities for your child...

Type The following activities will help you play your part in your child's development.
Learning/Thinking Help me to notice familiar sounds, such as birds chirping, car or truck motors, airplanes, dogs barking, sirens , or splashing water. Imitate the noise you hear and see if I will imitate you. Encourage me by smiling and clapping.
Speech/Language I am learning new words every day. Play games to help me learn the names of things. Put pictures of familiar things such as toy animals, people or objects in a bag and say "One, two, three, what do we see?" and pull a picture from the bag.
Speech/Language Pretend to talk to me on the phone or encourage me to call someone.
Social icon Don't be afraid to let me see what I can do with my body. I need to practise climbing, swinging, jumping, running, going up and down stairs, and going down slides. Stay close to me so I don't get hurt.
Social icon Play some of my favorite music. Encourage me to move to the music by swaying my arms, moving slowly, marching to the music, hopping, clapping my hands, tapping my legs, etc. Let's have fun doing actions while listening to the music.
Social Let me play with balls of different sizes. Take some of the air out of a beach ball. Watch me kick, throw, and try to catch it.
Fine muscle I like toys that I can pull apart and put back together: large "LEGO", containers with lids , or plastic links. Talk to me about what I am doing using words like "push " and "pull".
Fine muscle I'm not too little to play with large crayons. Let's scribble and talk about our art work.
Learning/Thinking I like simple puzzles with two to four pieces and shape-sorters with simple shapes. Encourage me to match the pieces by taking turns with me.
Social I want to do things just like you. Let me have toys so I can pretend to dress up, have tea parties, and play mommy or daddy.
Emotional I feel safe and secure when I know what is expected of me. You can help me with this by following routines and setting limits. Praise my good behaviour.
Social I like new toys so find the local toy lending library or play groups in our community.

I enjoy exploring the world but I need to know that you are close by. I may cry when you leave me with others, so give me a hug and tell me you will be back.

Always talk to your health care or child care professional if you have any questions about your child's development or well being.

Appendix 2: Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance Guide

Rourke Baby Record : Evidence-based infant/child health maintenance guide

Drs. Leslie Rourke, Denis Leduc and James Rourke
Revised May 2006
© Copyright Canadian Family Physician

Birth Date (d/m/yr ):

 

M [ ] F [ ]

Name:

 

Past problems/Risk factors :

Family history :

Rourke Baby Record : Evidence-based infant/child health maintenance guide - 18 Months
Date of Visit 18 months
Growth* Height Weight Head circ.
Parental Concerns  

Nutrition*

( ) Breastfeeding*
( ) Homogenized milk
( ) No bottles

Education and Advice

Injury Prevention

Behaviour

Family

Other

Check if discussed and no concerns

Cross of concerns

( ) Car seat (child)*
( ) Both safety*
( ) Choking/safe toys*

( ) Parent/child interaction
( ) Discipline/Limit setting**

( ) Parental fatigue/stress/depression **
( ) High-risk children**

( ) Socializing/peer play opportunities
( ) Dental CarelDentist**
( ) Toilet learning**

Development**
(Inquiry and observation of milestones)

Tasks are set after the time of normal milestone acquisition.

Absence of any item Suggests the need for further assessment of development.

NB-Correct for age if < 36 weeks gestation

Check if attained

Cross if not attained

Enhanced inquiry after Nipissing Developmental Screen (NDDS)**

Number of "NO" flags on NDDS:

( ) Social/Emotional
( ) Child's behaviour is usually manageable
( ) Usually easy to soothe
( ) Comes for comfort when distressed

Communication Skills
( ) Points to 3 different body parts
( ) Tries to get your attention to see something of interest
( ) Pretend play with toys and figures (e.g. feeds stuffed animal)
( ) Turns when name is called
( ) Imitates speech sounds regularly
( ) Produces 3 consonants, e.g. P M B W H N

Motor Skills
( ) Walks backward 2 steps without support
( ) Feeds self with spoon with little spilling

Adaptive Skills
( ) Removes hat/socks without help
( ) No parent concerns

Physical examination

Evidence-based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit.

( ) Eyes (red reflex)*
( ) Corneal light reflex/Cover-uncover test and inquiry*
( ) Hearing inquiry
( ) Tonsil size/Teeth*
Problems and Plans  
Immunization
Provincial guidelines vary
Sienature
Record on Guide V: Immunization Record

Rourke Baby Record : Evidence-based infant/child health maintenance guide - 2-3 Years and 4-5 Years
Date of Visit 2-3 years 4-5 years
Growth* Height Weight Head circ.
-if prior abnormal
Height Weight
Parental Concerns    

Nutrition*

( ) Homogenized or 2% milk
( ) Gradual transition to lower fat diet*
( ) Canada's Food Guide*
( ) 2% milk
( ) Canada's Food Guide*

Education and Advice

Injury Prevention

Behaviour

Family

Other

Check if discussed and no concerns

Cross of concerns

( ) Car seat (child/booster)*
( ) Carbon monoxide/Smoke detectors
( ) Bike Helmets*
( ) Matches
( ) Firearm safety/removal*
( ) Water safety

( ) Parent/child interaction
( ) Parental fatigue/depression**
( ) Discipline/Limit setting**
( ) Family conflict/stress
( ) High-risk children**
( ) Siblings

Second-hand smoke*
( ) Complementary/alternative medicine*
( ) Active healthy living/media use*

( ) Dental cleaning/Fluoride/Dentist*
( ) Toilet learning**
( ) Socializing opportunities
( ) Encourage reading**

( ) Assess day care/preschool needs/school readiness**

Environmental health including:
( ) Sun exposure/sunscreens/insect repellent*
( ) Pesticide exposure*
( ) Check serum lead ifat risk*


 

Development**
(Inquiry and observation of milestones)

Tasks are set after the time of normal milestone acquisition.

Absence of any item Suggests the need for further assessment of development.

NB-Correct for age if < 36 weeks gestation

Check if attained

Cross if not attained

2 years
( ) At least 1 new word/week
( ) 2-word sentences
( ) Tries to run
( ) Puts objects into small container
( ) Copies adult's actions
( ) Continues to develop new skills
( ) No parent concerns

4 years
( ) Understands related 3-part directions
( ) Asks lots of questions
( ) Stands on 1 foot for 1-3 seconds
( ) Toilet trained during the day
( ) Tries to comfort someone who is upset
( ) No parent concerns
3 years
( ) Understands 2 step direction
( ) Twists lids off jars or turns knobs
( ) Turns pages one at a time
( ) Shares some of the time
( ) Listens to music or stories for 5-10 minutes with adults
( ) No parent concerns
5 years
( ) Counts to 10 and knows common colours and shapes
( ) Speaks clearly in sentences
( ) Throws and catches a ball
( ) Hops on 1 foot
( ) Shares willingly
( ) Works alone at an activity for 20-30 minutes
( ) Separates easily from parents
( ) No parent concerns

Physical examination

Evidence-based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit.

( ) Blood pressure
( ) Eyes (red reflex)/Visual acuity*
( ) Corneal light reflex/Cover-uncover test and inquiry*
( ) Hearing inquiry
( ) Tonsil size/Teeth*
( ) Blood pressure
( ) Eyes (red reflex)/Visual acuity*
( ) Corneal light reflex/Cover-uncover test and inquiry*
( ) Hearing inquiry
( ) Tonsil size/Teeth*
Problems and Plans  
Immunization
Provincial guidelines vary
Sienature
Record on Guide V: Immunization Record

Grades of evidence: (A) Bold type - Good evidence (B) ltalic -- Fair evidence (C) Plain - Consensus With no definitive evidence
(*) see Infant/Child Health Maintenance (**) see Healthy Child Development Selected Guidelines

Disclaimer: Given the constantly evolving nature of evidence and changing recommendations, the Rourke Baby Record: EB is meant to be used as a guide only.
Financial support for this revision is from the Strategic Initiatives Division of the Ontario Ministry of Children and Youth Services, with funds administered by the Ontario College of Family Physicians.

This form is reproduced by McNeil Consumer Healthcare, Printable versions are available on The College of Family Physicians Canada and Canadian Paediatric Society websites Or by calling McNeil Consumer Healthcare at 1-800-265-7323.

Development

Maneuvers are based on the Nipissing District Development Screen and other developmental literature. They are not a developmental screen, but rather an aid to developmental surveillance. They are set after the time of normal milestone acquisition.

Thus, absence of anyone or more items is considered a high-risk marker and indicate s the need for further developmental assessment, as does parental concern about development at any stage.

- "Best Start" website contains resources for maternal, newborn, and early child development
- OCFP Healthy Child Development: Improving the Odds publication is a toolkit for primary healthcare providers

Behaviour

Night waking/crying:
Night waking/crying occurs in 20% of infants and toddlers who do not require night feeding. Counseling around positive bedtime routines (including training the child to fall asleep alone), removing nighttime positive reinforcers, keeping morning awakening time consistent, and rewarding good sleep behaviour has been shown to reduce the prevalence of night waking/crying, especially when this counseling begins in the first 3 weeks of life.
- The Medical Journal of Australia

Parenting/Discipline
Promote effective discipline through evaluation, anticipatory guidance and counseling using the following principles: respect for parents, cultural sensitivity, improving social supports, increasing parent al confidence, increasing parental pleasure in children, and supporting and improving parenting skills.

- Canadian Paediatric Society -Effective discipline for children
- OCFP Healthy Child Development

Toilet Learning

The process of toilet learning has changed significantly over the years and within different cultures. In Western culture, a child-centred approach, where the timing and methodology of toilet learning is individualized as much as possible, is recommended.

- Toilet learning: Anticipatory guidance with a child-oriented approach

Literacy
Physicians can promote literacy and early childhood reading by facilitating reading in the office. Encourage parents to watch less television and read more to their children.
Autism Spectrum Disorder

When developmental delay is suspected in an 18-month child, assess for autism spectrum disorder using the Checklist for Autism in Toddlers (CHAT) - Journal of Autism and Development al Disorders 2001;31(2).

OCFP Healthy Child Development

Parental Family Issues Affecting Development
  • Maternal depression - Physicians should have a high awareness of maternal depression, which is a risk factor for the socioemotional and cognitive development of children. Although less studied. paternal factors may compound the maternal-infant issues.
  • Shaken baby syndrome - A high index of suspicion is suggested.
  • Fetal alcohol syndrome/effects (FASIFAE) - Canadian Guidelines published in CMAJ supplement

High-risk infants/children

- Day Care:
Specialized day care or preschool is beneficial for children living in poverty (family income at or below Statistics Canada low-income cut-off). These disadvantaged children are at an increased risk of mortality and morbidity, including physical, emotional, social and education deficits.

- Home Visits:
There is good evidence for home visiting by nurses during the perinatal period through infancy for first-time mothers oflow socioeconomic status, single parents or teenaged parents to prevent physical abuse and/or neglect. Canadian Task Force on Preventative Health Care

Risk factors for physical abuse:

  • low SES
  • young maternal age (< 19 years)
  • single parent family
  • parental experiences of own physical abuse in childhood
  • spousal violence
  • lack of social support
  • unplanned pregnancy or negative parental attitude towards pregnancy

Riskfactors for sexual abuse:

  • living in a family without a natural parent
  • growing up in a family with poor marital relations between parents
  • presence of a stepfather
  • poor child-parent relationships
  • unhappy family life

Draft Data Collection Tear Off Sheet for Rourke Baby Record
Directions: Tear off sheet is to be placed on the front right half of the 18 month visit Rourke Baby Record, covering the patient's name and the 2-3 year and 4-5 year visit

Birth Date (d/m/yr ):

 

M [ ] F [ ]

1) # of "No" flags on completed Nipissing Developmental Screen __

2) # high risk markers noted on the 18 month Rourke Baby Record __

Parent /family issues (e.g. parent/child interaction, parental stress/depression, high risk markers) #__

Social/Emotional #__

Communication skills #__

Motor skills #__

Adaptive skills #__

Sensory impairment (problems with vision or hearing) #__

3) Need for additional assessment ( more than one developmental area affected) Yes__ No__

Appendix 3: 18 Month Visit Flow Chart

See PDF.

Appendix 4: Early Child Development and Parenting Resource System

Appendix 5: Community Service Referral Forms

Simplified Access Referral

Health Department1
605 Rossland Road E.
Whitby. ON L1N 6A3
905-668-7711
1-800-841-2729
Fax: 905-666-6232

Children's Services2
605 Rossland Road E.
Whitby ON L1N 6A3
905-668-7711
1-800-372-1102
Fax: 905-666-6226

230 Westney Road South
Ajax. ON L1S 7J5
905-686-6466
1-800-214-7163
Fax: 905-619-4578
Family & Community Action Program

Kinark Child & Family Services
1916 Dundas st., East. Unit 2
Whitby. ON L1N 2L6
905-433-0241
Fax: 905-432-0916

1 Hospital Court
Oshawa, ON L1G 2B9
905-576-8711

Resources for Exceptional Children
865 Westney Rd South
Ajax, ON L1S 3M4
905-427-8862
1-800-968-0066
Fax: 905-427-3107

by: Referred to:
 
Behaviour Management2
 
 
 
Children's Services2
 
 
Healthy Babies/Healthy Children1
 
Infant Development1
   
Family & Community Action Program
   
Kinark Child & Family Services
Central East Preschool Autisim Service
   
Feeding/Swallowing Clinic
Neonatal Follow up Clinic
N.LG.U.
   
Resources for Exceptional Children

SIMPLIFIED ACCESS REFERRAL

Consent for referral: Verbal ( ) Written ( )

Given by:

 

Referral Date:

 

Referral taken by:

 

Referred by: (Name and telephone, extension)

 

Child's Name:

 

Health Card No.:

 

D.O.B.:

 

Parent(s):

 

Guardian:

 

Siblings/D.O.B.:

 

Address:

 

Postal Code:

 

Telephone:

Home:

 

Business:

 

HBHC Telephone Assessment Done:

HBHC Family Assessment Done:

Infant Development to Complete:

PEDS Completed:

Nipissing Completed:

DISC Completed:

Family Visitor

Reason for referral: (concerns, risk factors, diagnosis)

 
 
 

Additional agencies referred to/Involved:

 

Service Coordination Required:

 

Preschool/Community Setting/other caregiver:

 

How did you know about service?

Nipissing ( ) Years before 5 ( ) Media ( ) Doctor Other

 
 

Parent's verbal consent to forward information to:

 

Family Doctor/Paediatrician:

 

Phone #

 

Information is collected under the authority of the Child and Family Services Act for the purpose of providing Infant Development

Physician Notification

Health Department
Healthy Babies/Healthy Children
Infant Development

605 Rossland Road E.
Whitby ON L1N 6A3
905-668-7711
1-800-841-2729
Fax: 905-666-6232

Children's Services
Behaviour Management

605 Rossland Road E.
Whitby ON L1N 6A3
905-668-7711
1-800-372-1102
Fax: 905-666-6226

Family & Community Action Program
230 Westney Road South
Ajax, ON L1S 7J5
905-686-6466
1-800-214-7163
Fax: 905-619-4578

Kinark Child & Family Services
1916 Dundas St., East, Unit 2
Whitby, ON L1N 2L6
905-433-0241
Fax: 905-432-0916

1 Hospital Court
Oshawa, ON L1G 289
905-576-8711

Resources for Exceptional Children
865 Westney Rd South
Ajax, ON L1S 3M4
905-427-8862
1-800-968-0066
Fax: 905-427-3107

SIMPLIFIED ACCESS REFERRAL

Child's Name:

 

D.O.B.:

 

The above named child has been referred to Simplified Access.

After discussion with the family, referrals have been made to:

 
 
 
 
 
 
 
 

In addition recommendations were made for parents to contact:

 
 
 
 

Signature of Staff

 

Date

 

Name of Organization

 

Information is collected under the authority of the Child and Family ServIces Act, for the purpose of providing Infant Development Services. If you have any questions concerning the collection of the information, please contact the Manager of Infant Development.
DRHD-ID~322 109/20051

Simplified Access Authorization for Release of Information

Health Department
Healthy Babies/Healthy Children
Infant Development

605 Rossland Road E.
Whitby ON L1N 6A3
905-668-7711
1-800-841-2729
Fax: 905-666-6232

Children's Services
Behaviour Management

605 Rossland Road E.
Whitby ON L1N 6A3
905-668-7711
1-800-372-1102
Fax: 905-666-6226

Family & Community Action Program
230 Westney Road South
Ajax, ON L1S 7J5
905-686-6466
1-800-214-7163
Fax: 905-619-4578

Kinark Child & Family Services
1916 Dundas St., East, Unit 2
Whitby, ON L1N 2L6
905-433-0241
Fax: 905-432-0916

1 Hospital Court
Oshawa, ON L1G 289
905-576-8711

Resources for Exceptional Children
865 Westney Rd South
Ajax, ON L1S 3M4
905-427-8862
1-800-968-0066
Fax: 905-427-3107

In order to develop a service plan that best supports my child and family,

I/We

 

(parent/guardlan)

Of:

 
 
 

(address)

hereby authorize verbal and/or written communication of referral and assessment information between authorized personnel of the Simplified Access Process.

Please check, initial and add appropriate agencies:

Checkmark Agency
 
Central East Preschool Autism Service
 
Durham Behaviour Management Services
 
Durham Regional Children's Services
Durham Infant Development Services
Durham Preschool Speech and Language Program
Family & Community Action Program
Healthy Babies, Healthy Children Durham
Kinark Child and Family Services
Lakeridge Health Corporation
Resources for Exceptional Children

Regarding

 

(Child's name)

D.O.B.

 

Unless otherwise noted, this authorization is valid for six months from the date of signature.

 

(Date)

 

(Signature of parent/guardian)

 

(Date)

 

(Signature of parent/guardian)

 

(Date)

 

(Signature of witness)

Information is collected under the authority of the Child and Family Services Act, for the purpose of providing Infant Development services. If you have any questions concernIng the collection of the Information, please contact the Manager of Infant Development.
DRHD-ID-305 (0912005)

Appendix 6: Proposal for Phased Implementation of Strategies

Strategy Implement immediately Refer to implementation group
1. Provide parents and providers with tools 1.1 Acquire rights to NDDS and distribute
1.2 Provide easy access to revised Rourke Baby Record
1.3 Develop clinical practice guideline
1.4 Develop clinical pathway
 
2. Build partnerships among parents, primary care providers and community resources 2.1 Ensure information about the 18-month well baby visit is family-centred
2.2 Provide primary care providers with information about healthy child development
2.4 Provide information to primary care providers about community services
2.5 Establish a single branded local number to call for children's services
2.3 Identify a core set of children's services
2.5 Establish consistent names for similar services
3. Provide education for primary care providers 3.1 Develop an awareness/education program that will reinforce with primary care providers the importance of healthy child development and that builds on existing successful models.
3.2 Share and promote successful outreach strategies to involve primary care providers in healthy child development.
3.3 Identify and support peer leaders - family doctors, paediatricians, nurse practitioners and chi ld development
specialists -- who can act as coaches
and mentors, and help deliver
education programs.
3.5 Promote collaborative models for
delivering the enhanced 18-month
well baby visit.
3.4 Provide incentives to compensate/remunerate primary care providers for providing an enhanced 18 month well baby visit.
4. Encourage timely access/manage wait times 4.3 Support families on wait lists by referring them to universal community services (e.g., OEYCs, libraries, recreation centres) 4.1 Develop a system to collect data on wait times
4.2 Develop a wait time strategy
5. Describe the developmental health status of Ontario's children   5. 1 Identify how to collect aggregate data from the 18-month well baby visit
5.2 Analyze and disseminate findings to strengthen services
5.3 Consider developing a secure system that can collect individual data and link with other early years information systems
6 Evaluate the impact of the enhanced 18-month well baby visit   6.1 Develop outcome measures for the enhanced I8-month well baby visit and evaluate the initiative's ability to achieve those outcomes.
6.2 Over time, establish at least one other point during the early years - likely age 5 -- when all children are assessed for healthy child development.
6.3 Continue to evaluate the tools, and supports for the enhanced I8-month well baby visit, updating them as required to reflect new evidence and best practice.

Appendix 7: Implementation/Communication Plan

Target Audience Leads Strategies
Parents and Families with Young Children

• Healthy Babies Healthy Children
• Preschool Speech & Language
• Infant Development
• Public Health Departments
• Childcare
• OEYC
• Family resource programs
• Best Start hubs
• Local Public Health dept's
• Libraries
• Recreation centres
• Expert Panel and sub committee members

• social marketing campaign
• TV/radio spots
• Parent handouts distributed through OEYCs, libraries and other parenting/family services
• Parent focused magazines (e.g. Today's Parent, Canadian Living, local publications)
• Newsletters distributed by specialized services (e.g., Infant Development)
Paediatricians
Family Doctors
Nurse Practitioners
Clinic/FP nurses
Clinic Staff (receptionist etc.)
OCHN
OCFP
• OMA
• NPAO
• M of C&YS
MOHLTC
• Public Health Department
• Local medical societies
• Public Health Branch MOHLTC
• Presentations
• Annual Meetings
• Symposiums
• Identification of opinion leaders amongst physicians, nurses, office staff (i.e. shared-care/mentor networks
• CME/CHE events
• Family practice rounds in hospitals
• Article in appropriate publications/newsletters etc.
• Local contacts/academic detailing by public health departments or others

Community Programs/Services
• Healthy Babies Healthy Children
• Preschool Speech & Language
• Infant Development
• Public Health Departments
• Childcare
• OEYC Provincial Network
• Ontario Association of Family Resource Programs
• Common Table - Ontario Coalition of Children's Services
• Best Start programming
• Children's Aid societies
• Children's mental health services
• Family counselling programs

• Local Public Health dept's
• Ministry of Children and Youth Services
• Expert Panel and subcommittee members
• Board of the Ontario Association for Infant Development and other professionals boards
• Best Start Networks
• OACASs
• Association of Early Childhood Educators of Ontario
•  L'Association francophone à l'éducation des services à I'enfance de I'Ontario (AFÉSEO)
• Counsil for Early Childhood Development
• Promote at annual meetings (e.g. CPHA, OPHA, Childcare, Infant Development)
• HBHC Network meetings, community presentations
• Venues for community outreach
• Articles in appropriate publications/newsletters
• web sites (e.g., www.oaid .ca)
• Local contacts through MOH/local public health dept's
• Family physician/paediatrician distance online learning modules
• Council for Early Childhood Development publications and presentations

1 The Smithville Family Health Centre: the sole clinic serving a small town/rural low to middle income population of 10,000 people.

2 Some of the web sites that have information on healthy child development are: Invest in Kids, Canadian Paediatric Society, Multiple Births Canada, Today's Parent, Safe Kids Canada, Canadian Institute of Child Health, Centre of Excellence for Early Childhood Development. and the web sites of local public health units.