National Framework for Universal Child and Family Health Services

3.8.1 Developmental surveillance and health monitoring

Page last updated: 20 May 2013

A key function of universal child and family health services is to monitor child health, development and wellbeing, identify early disability and delay, or health issues (both physical and socioemotional) and support the developing parent and infant (young child) relationship. A schedule of contact visits with families (see Section 3.7) provides the opportunity to monitor child health, development and promote wellbeing through clinical observation, and assessment. The use of standardised, evidence-based assessment tools assists in the early identification of issues.

Developmental surveillance and health monitoring are fundamental components of the universal child and family health service. The National Health and Medical Research Council (NHMRC) review of evidence on child health screening and surveillance identified some of the difficulties surrounding the use of the term ‘surveillance’ [51, p.21]. The term can be misinterpreted by parents and families as representing health professional ‘checking up on’ parenting approaches or ‘judging’ their abilities [51, p.21].

Developmental surveillance is defined by the NHMRC as the process of:
‘eliciting and attending to parents’ concerns, making accurate and informative longitudinal observations on children, obtaining a relevant developmental history and promoting development’. [51 p, 22].

In this context, surveillance, whilst initiated by health professionals, is conducted in partnership with parents and families [51, p.21]. Surveillance occurs at two levels of the health system both in the form of individual (clinical and parental) surveillance and also population monitoring at the public health level [51, p.22].

Surveillance of child development allows for the early identification of children with developmental delay, and provision of early intervention services. There is strong evidence that early intervention for these children can significantly improve developmental outcomes [31, 52]. Developmental delay and disability may develop before identification, however, it may be possible in some cases, particularly high risk groups, to prevent the formation of, or decrease the extent of, the delay or disability. For children who may have increased needs due to poverty or other social disadvantage, there is the potential for preventing developmental delay and disability if effective intervention is provided [52].

Physical health

Physical health checks are included in the assessment of the child at varying frequencies to identify health issues and problems that would benefit from early intervention or treatment. A full physical assessment would include examination and assessment of the child, for example; head shape and size, eyes, mouth, skin colour and texture and body shape.

Physical examinations (including vision, hearing, and language assessment) also provide an opportunity for health professionals to observe the child’s behaviour, (assessing social and emotional development), observe parents’ interaction with the child, reassure parents by normalising behaviour, identify delays and provide anticipatory guidance. Physical examinations may also indicate signs and symptoms of child abuse or neglect. A secondary outcome of the physical examination is the opportunity provided by the examination for the health professional to model appropriate and responsive handling and interaction with the child.

Vision and hearing

Vision and hearing are vital for the optimal development and wellbeing of children. Vision and hearing loss affects both physical and psychosocial areas of development such as language, motor skills and parent/ infant interaction. Early identification of any vision or hearing deficit is therefore a priority for universal child and family health services. Targeted services are also required to provide support where an increased need or risk factor has been identified (for example, Aboriginal and Torres Strait Islander programs targeting ear health including otitis media). The ongoing review of risk factors and questions at key contact points prompt discussion with parents regarding any concerns they have about their child’s vision, hearing or other areas of development.
The National Children’s Vision Screening Project [53] recommended:
  • All Australian children be offered vision screening in the year prior to commencing formal school. The most appropriate age for visual acuity testing is when a child is four years old (with a range from 3.5 to 5 years of age).
  • The red reflex check be carried out on all newborns as part of a universal health- check.
  • An eye-health professional (optometrist, orthoptist, ophthalmologist) is responsible for further evaluation where indicated by the primary screen.
  • Children considered at increased risk (including those born prematurely, with disabilities or children living in remote Indigenous communities) require an in-depth assessment even if they have participated in the universal screening program.
The Sheridan-Gardiner vision screening tool is considered the gold standard tool for use with children aged four years and over, whilst the LEA symbols tool is appropriate for vision surveillance of younger children [53, p.28]. Identification of impaired colour vision is not currently recommended [51] (see Appendix 3 for description of vision screening tools).

Universal Newborn Hearing Screening is now accepted as best practice and should be conducted in the early neonatal period before discharge from hospital to identify any significant sensorineural hearing loss. Distraction testing between seven and nine months is no longer recommended due to lack of evidence to support the practice [48]. All caregivers should be asked if they have any concerns regarding their infant’s hearing at each key contact visit.

In addition, for Aboriginal and Torres Strait Islander populations with a high prevalence of otitis media, surveillance and management for conductive hearing loss needs to expand beyond the neonatal period. Early identification is important because optimal speech and language development may result if intervention commences early. This can minimise the need for ongoing special education.
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Oral health

Good oral health throughout infancy and early childhood contributes to better health in adulthood. Studies have demonstrated an association between oral infections and conditions, such as diabetes, cardiovascular disease, stroke, and adverse pregnancy outcomes [54]. Early childhood caries (ECC) is a serious dental condition occurring during the preschool years of a child’s life when developing primary (baby) teeth are especially vulnerable. It can be a serious condition often requiring hospitalisation and dental treatment in an operating theatre under general anaesthesia. The pain, psychological trauma, health risks, and costs associated with restoration of carious teeth for children affected by ECC can be substantial, yet it is mostly preventable [55].

Assessment of oral health should be integrated into the general assessment of health at key periodic contact points and opportunistically. A visual check of the health of the mouth for dental disease by a child and family health professional raises parental awareness and provides the opportunity for anticipatory guidance, education and referral for further assessment and treatment. The ‘Lift the Lip’ campaign is an example of such a program.

There is good evidence to support water fluoridation in the reduction of dental caries [56].In communities where there is a lack of naturally occurring or artificially added fluoride in the water, parents should be encouraged to use fluoride toothpaste [57]. The use of oral fluoride supplements are no longer recommended [57].

Growth monitoring

Growth is considered to be the “most sensitive index of health’ including the “nutritional and emotional environment of a child” [58, p.230]. Growth monitoring (weight and height) is routine practice in all Australian jurisdictions. Monitoring and accurately identifying individual children who are not growing normally is important, as is having population data about rates of inadequate growth [59].

Weighing activities of infant and young child are valued by carers and are considered an incentive for the parent to bring the child to the child health centre and provide an opportunity for raising other concerns.

It is important that child and family health service professionals provide accurate information to parents regarding growth to limit anxiety and reduce the risk of obesity from overfeeding. The World Health Organization (WHO) growth charts [60] are the most contemporaneous growth charts available and provide an indication of growth of an infant exclusively breastfeeding for the first six months of life and after the introduction of solid foods. These growth charts will be considered as part of the implementation of the ‘National Breastfeeding Strategy’ [61] and the Australian Government’s review of the ‘Dietary Guidelines for Children and Adolescents in Australia’.

Aboriginal and Torres Strait children continue to be the most disadvantaged population group in Australia. Underweight and growth faltering is a problem in some Aboriginal families, particularly in rural and remote areas where high rates of growth faltering in the first few years of life are documented [59]. The accurate and early identification of overweight and obesity is also considered important because of the prevalence of obesity, early onset of type 2 diabetes and other chronic diseases.

Many Aboriginal and Torres Strait children also have difficulty accessing comprehensive universal child and family health services. Universal child and family health services must incorporate strategies that provide Aboriginal families with high quality, culturally safe care.

This care should include additional screening and assessment to Aboriginal and Torres Strait Islander families in communities that demonstrate higher prevalence rates of the following conditions:
  • Regular otoscopy: Aboriginal children have high rates of otitis media with resulting hearing loss and potential language and speech delays.
  • More frequent weight and length/height measurements if under or over nutrition is an issue.
  • Regular screening for anaemia from four months of age.
  • Deworming programs in communities where parasites are problematic.
  • Skin checks and prompt and low threshold for the treatment of skin sores [62].

Tools for Physical Development Monitoring

Development monitoring and assessment should comprise a combination of techniques — practitioners are expected to be able to recognise the full range of normal development, but the use of tools to guide clinical judgement is also recommended for universal application. Several studies have found developmental monitoring without the use of tools to be inadequate and ineffective in detecting lower range developmental delay [63]. The use of validated screening and assessment tools is therefore recommended.

The following tools have been validated and are currently available and appropriate for use in Australia for general developmental monitoring.

Table : Validated tools for general developmental monitoring

Validated Screening ToolAgeElicitation
Parents’ Evaluation of
Developmental Status (PEDS)
[51, 64]
0 to 8 years Parent report
Ages and Stages Questionnaire
(ASQ) [51]
3 to 60 monthsParent report
Brigance Screens [51]21 to 90 monthsParent report or direct elicitation
Child Development Inventory
(CDI) [65]
3 to 72 monthsParent report

Further information about these tools can be found in Appendix 3.
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Socioemotional and cognitive developmentAccording to National Scientific Council on the Developing Child [66 p, 2]

The core features of emotional development [in children] include the ability to identify and understand one’s own feelings, to accurately read and comprehend emotional states in others, to manage strong emotions and their expression in a constructive manner, to regulate one’s own behaviour, to develop empathy for others and to establish and sustain relationships.

Monitoring a child’s socioemotional development, supporting the parent/child developing relationship and promoting welfare and readiness to learn through play are a key function of the child and family health service. This involves promoting and monitoring:
  • infant/child–parent/carer interaction;
  • parent/child relationships–physical availability, emotional warmth, responsiveness and stability;
  • child behaviour, social and emotional health; and
  • normalising behaviours and assisting parents to have realistic expectations and understanding of their child’s behaviour.
By normalising childhood behaviour and giving information on the social and emotional needs of children, parents are better prepared to support their child’s development in a way that is meaningful. Furthermore, by identifying those children who are having problems with emotional or social behaviours, early intervention can have significant and long-term effects not only for the child and his or her family but in some cases for the wider community and society.

Observation and parent questions are widely used techniques for monitoring socioemotional wellbeing and are most effective when relationships of trust are developed between the parent and the health professional. Use of parent evaluation tools can provide a useful basis to provide anticipatory guidance with parents’ to reflect a partnership approach.

There are evidence-based tools available for assessment of parenting interactions and child behaviour that are appropriate for use in a universal child and family health setting (see Appendix 3). Services are encouraged to consider these tools as part of a suite of strategies to monitor child socioemotional wellbeing.

Language and literacy

Most children develop language skills to communicate in their first language naturally. However, the ability to understand their language in a written form requires assistance that begins long before commencement of school at five years of age. Literacy is dependent on the home environment and the opportunity to develop emergent literary skills in the first years of life is critical [67]. Universal child and family health services are well placed to promote literacy development activities and education with parents, caregivers and communities.

Table : Validated tools for monitoring child socioemotional wellbeing

ToolAgeDomain
Ages and Stages: Social Emotional
Questionnaire [51]
1 month to 5 yearsChild behaviour and emotional
health
Parents’ Evaluation of
Developmental Status (PEDS)
[51, 64]
0 to 8 yearsSocioemotional developmental
concerns
Neonatal Behavioural Assessment
Scale [68]
0 to 2 monthsParent/child attachment
Strengths and Difficulties
Questionnaire [69]
4 to 12 yearsChild behaviour and emotional
health
Paediatric Symptom Checklist4 to 18 yearsChild behaviour and emotional
health
NCAST Parent Child Interaction
Assessment Scales (Feeding and
Teaching) [70]
Feeding 0 to 12 months
Teaching 0 to 36 months
Carer-child interaction (sensitivity
to cues; response to infant
distress; provision of social
emotion and cognitive growth
fostering activities; clarity of infant
cues; responsiveness to caregiver).
Brigance Screens [51]0 to 7 yearsSocial and emotional disorders
Modified Checklist for Autism in
Toddlers (M-CHAT)
16 to 30 monthsAutism

Further information about these tools can be found in Appendix 3.
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