A home visit program designed to identify early childhood language delays not only failed to spot most delayed children, but also failed to refer the vast majority of identified children for further evaluation or intervention.
The results suggest that the home visitors didn't get enough training to properly screen children and that the visitors lacked the skills necessary to communicate concerns about developmental delays to parents, according to Tracy M. King, M.D., and colleagues (J. Dev. Behav. Pediatr.2005;26:293–303).
“This study argues for prudence in the ongoing proliferation of home visiting programs and for caution in setting expectations regarding child development outcomes,” said Dr. King of Johns Hopkins University School of Medicine, Baltimore, and her coinvestigators.
The researchers compared language delay identification rates for children enrolled in the Hawaii Healthy Start Program (304) with rates in a group of control children (209). All of the children were at high risk of developmental delay, child abuse, or neglect.
The Hawaii Healthy Start Program (HHSP) provides a regular home visitor, who teaches parents about child development, models good parental behavior, and links parents to a medical provider. The visitor also performs childhood developmental testing–including language testing–when the child is 3 years old. The control group did not receive any home visitation services.
The home visitors identified only 24% of children with severe language delay. Parents and primary care providers in the HHSP group each identified 31% of such children, while parents in the control group identified almost twice as many (56%).
The fact that parents in the control group had an increased identification rate raises the concern that the home visitors actually interfered with identification. This could be because they lack sufficient training and are giving parents false reassurance of the child's language development.
Among children with any language delay, home visits identified 17%. Parents and primary care providers also did poorly in this group, identifying 26% and 24%, respectively. Parents in the control group identified 20% of children with any language delay and primary care providers, 25%.
Particularly concerning were the low referral rates after children were identified, the investigators said. Among the 72 children identified as having delays, only 2 were referred to their primary care provider, and none were referred to local early intervention programs.
Poor parental identification rates could be related to the high-risk communities in which the families lived, the investigators said. “It may be that language delays have become so prevalent in certain at-risk communities that it is no longer possible for parents to make accurate assessments of their child's development based on comparisons with the child's peers.”
Poor home visitor and medical provider identification rates are probably due to inadequate training in child development.
In an accompanying editorial, Shirley Russ, M.D., and Neal Halfon, M.D., said identification rates could be improved by using trained nurses as home visitors. Similar programs employing nurses have higher family retention rates and much better identification and referral rates (J. Dev. Behav. Pediatr. 2005;26:304–5).
“Professional nurses would be more likely to have knowledge of early childhood systems and resources in the community and would also have had more training in communicating about health and development issues to parents,” said Dr. Russ and Dr. Halfon of the University of California, Los Angeles.
Dr. King and colleagues replied in a second commentary that unfortunately visiting nurse programs are costly and difficult to staff in areas such as Hawaii (J. Dev. Behav. Pediatr. 2005;26:307).