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Child Development at Two to Two and a half years

Introduction

The child development check at 2-2.5 years is the final developmental check undertaken by the health visiting (HV) service before a child enters school at either 2-3 years (if they are eligible for an early school place) or at the age of 4-5 years. This is part of the mandated checks that health visitors provide to all children and gives an ideal opportunity for the health visiting service to assess the child in the context of the whole family and identify any needs or risks.

The 2-2.5 year development check is assessed through the Ages and Stages Questionnaire 3 (ASQ-3). This is an assessment tool that helps parents and provides information about the developmental status of their child across five areas:

  • communication
  • gross motor skills
  • fine motor skills
  • problem solving
  • personal-social

The total scores from the ASQ-3 are used to shape further referrals and access to early help partners if required.

What do we know?

The results of the Ages and Stages Questionnaire (ASQ-3) (DoH, 2015) are not yet available at a local level, and cannot be generalised until full coverage is achieved. This has recently been achieved in the Berkshire area.

From October 2015 the results of the Ages and Stages questionnaire will be reported within the Public Health Outcomes Framework (PHOF). This will indicate the percentage of 2-2.5 year olds who take up the offer of an assessment and the percentage of those that have a valid ASQ-3 completed. This information will be published at a national and local level. The increased ability to offer a universal screening programme will enable the mapping of needs and risks of poorer outcomes, which will provide a baseline for the development of targeted services in future.

The PHOF also includes a measure of the next age specific assessment at 4-5 years old when a child enters school. The requirement to offer increased access to high quality early years schooling, means that there is a potential overlap between the two measures. Joint training is therefore required to ensure that there is a consistent interpretation of the 'good communication' score and the personal social and emotional development scores in each.

Facts, Figures, Trends

In the absence of locality level outcomes for the 2-2.5 year check it is important to note what they are used for.

The results of the check should inform work with eligible children's parents to improve their child's readiness for school. School readiness is measured by the Early Year's Foundation Stage (EYFS) attainment profile.

PHOF profiles based on 2014/15 data showed that the Reading average (67.1%) for the percentage of children achieving a good level of development at the end of reception was better than other local authorities matched on levels of deprivation. Reading's average was also higher when compared to the England average of 66.3%. The chart below shows that school readiness levels has consistently been improving over recent years.

Figure 1: School readiness; achieving a good level of development (Reading and England 2012/13 to 2014/15)

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Source: Public Health Outcomes Framework

National & Local Strategies (Current best practices)

The evidence base for the Healthy Child programme 0-5 (DH 2009) can be found at https://www.gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life and a rapid review to update the evidence contained within it can be found at https://www.gov.uk/government/publications/healthy-child-programme-rapid-review-to-update-evidence.

The Wave Trust (2012) published an evidence based framework for commissioning prevention programmes to optimise child development at the age of two years. The areas of impact are; assessing maternal mental health in pregnancy, developing secure attachment, offering specialist parent- infant psychotherapy support, identifying risk factors during pregnancy, assessing social and emotional development and offering early help and support, reducing domestic violence, improving parenting capability, improving multi agency working and workforce capacity.

NHS England have commissioned an increased health visiting workforce and has published the 2015-16 national service specification for health visiting. This contains the full evidence base for the 0-5 healthy child programme.

Public Health England (PHE) promotes integrated two year reviews where the children is in an early years setting which aim to bring together the Early Years Foundation Stage (EYFS) Progress Check at age two with the Healthy Child Programme (HCP) 2-2½ year health and development review. PHE has published the six high impact areas for commissioning public health programmes for children aged 0-5. These can be found at https://www.gov.uk/government/publications/commissioning-of-public-health-services-for-children. The high impact areas include the integrated two year review alongside; the transition to parenthood and the early weeks, maternal mental health, breastfeeding, healthy weight and healthy nutrition, and managing minor illnesses and reducing accidents.

A review of the pilot into integrated reviews can be found here https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/376698/DFE-RR350_Integrated_review_at_age_two_implementation_study.pdf

What is this telling us?

If a child does not receive a good start in life then it can impact on their health and wellbeing for life. Brain development at the age of three is enhanced by sensitive attuned parenting and promoting secure attachment. Parental skills and confidence can be affected by a range of risk factors which also affect the child's social and emotional and behavioural outcomes.

Early detection of physical development delays is as important as the assessment of child emotional and social development.

Speech and language delays are the biggest contributor to poor school readiness in Reading and joint training is recommended to identify commonalities between the ASQ-3 and EYFS communication criteria.

Promotion of on line checking of child development is essential. Parents concerned about their child's communication can go to the local Berkshire Healthcare Foundation Trust integrated therapies website and self assess their child's progress using the early years toolkit. This can be found at: http://www.berkshirehealthcare.nhs.uk/page_sa.asp?fldKey=305.

A focus on avoiding child maltreatment (whether by neglect, physical or emotional abuse) and wider safeguarding is essential. Referrals to the early help team are supported by programmes that aim to reduce the risk of a child being taken into care. The early help process offers self help programmes to parents coping with the impact of domestic abuse, alcohol or drug misuse or low levels of parental mental health that do not meet the criteria for referral to adult mental health services.

Brain development is increased through parent/carer and child interaction and the health visiting teams are trained to promote attachment but as yet do not have a commissioned perinatal mental health service that meets national best practice into which they can refer women who are anxious and depressed. About 50% of women who are assessed as in need of emotional support and physical help who are referred to Psychological Therapies (IAPT) services ante or postnatally do not attend these services unless supported by the voluntary sector. This is a gap that is echoed across Berkshire. There is a gap too in perinatal mental health training for other early year's staff and volunteers who work with families. This requires multi agency action and has been set as an outcome within the voluntary sector strategy.

Strategies for reducing barriers to uptake of the 2-2.5 year assessment include offering improved drop in and bookable sessions for working parents through commercial settings and evening and weekend access. This is now a quality indicator in the health visiting service contract.

Regarding the six high impact areas all require better data sharing and specifically there is a gap in new birth notification which is impacting on the ability to track progress in the early years.

The other key gap is in comprehensive training for early year's staff in attachment and the measures used to assess attachment.

Parents can be assured that the health visiting services have been trained in Motivational interviewing and in the optimum way to assess child development.

This section links to the following sections in the JSNA:

Early Years Foundation Stage Attainment

Perinatal Mental Health

References

Department of Health, 2015. Factsheet: Developing a public health outcome measure for children aged 2 - 2½ using ASQ-3™. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/467602/ASQ-3_acc.pdf

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