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Healthy Babies Healthy Children Policy Statement on Universal Screening and Assessment for Healthy Child Development
Prenatal to School-Age

Purpose of this Statement

The intent of the current policy statement is to clarify and update the 2000 Healthy Babies, Healthy Children Prenatal and Early Identification Guidelines; clarify and update the Ministry requirement for Boards of Health from those Guidelines; and, clarify and strengthen the Ministry's commitment to the implementation of universal screening and assessment, prenatal to school age, by addressing the increased involvement of primary health care providers and parents.

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Objectives of Policy on Screening and Assessment

The objectives of this universal screening and assessment policy are :

  • to support comprehensive monitoring of healthy child development and early risk identification during the time between pregnancy and school entry;
  • to increase awareness of the value of healthy child development and the range of child and family support services that support family well-being; and,
  • to provide alternate access to Healthy Babies Healthy Children services, and to support children potentially at risk, who are not identified at the postpartum with referrals to the appropriate intervention services in a timely and effective manner.

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The Government introduced Healthy Babies Healthy Children on January 1, 1998, as a way to ensure that every child in Ontario has the opportunity to achieve his/her potential through healthy development in childhood. To reach every child to identify risk of poor development, Healthy Babies Healthy Children introduced a postpartum screening tool (Parkyn), a universal tool that successfully screens (with family consent) all newborns for risk, and which is administered in hospitals and by midwives. The results of the postpartum screen are forwarded to the Public Health Unit for follow-up with the family, including, when indicated, the introduction of early and appropriate interventions and other services to reduce risk.

While the postpartum screening tool is an effective way to identify newborns at risk, it does not identify children at risk prenatally or as they become toddlers and preschoolers. Families need access to alternate screening and assessment tools at different points in their children's early years so the health and social service system can provide appropriate interventions, when required, until the child reaches school age.

For this reason, Public Health Units and the Ministry of Community and Social Services Regional Offices jointly planned and conducted provincial consultations on processes to introduce universal screening and assessment at critical developmental points for children after birth to school age. The consultations were held concurrently across 37 Public Health Unit communities between May and July 1999. On June 29, 1999, the then Office of Integrated Services for Children (now the Integrated Services for Children Division) held a parallel consultation for stakeholders from 35 provincial associations. The total number of participants consulted was 1,820.

Participants reached consensus on the following :
  • Screening must occur early for successful interventions and should include universal prenatal screening.
  • The approach should be designed using universal, population health strategies.
  • The immunization record should be replaced with a more comprehensive document.
  • Families should be empowered in the assessment of healthy child development.

In the summer of 2000, Healthy Babies Healthy Children issued Early Identification Guidelines which included the six components listed below and, in January 2001, introduced the first three as Phase 1 of implementing the Early Identification Guidelines :

  • Cross-sectoral Community Planning;
  • Public Awareness Campaigns;
  • Parent Screening of Healthy Child Development and Learning;
  • Universal Well-Baby Screening at 18 Months;
  • Community Collaborative Screening for toddlers to preschoolers;
  • Transition Plan Between Preschool and School Systems.

In the Fall of 2000, the Ministry also introduced its Prenatal Guidelines, which required Boards of Health to implement a prenatal screen, the Larson Screen, as part of Healthy Babies Healthy Children.

Both the Early Identification Guidelines and the Prenatal Guidelines are designed to support the Healthy Babies Healthy Children goal of universal screening and assessment for healthy child development from prenatal to school age.

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The Strategies

A comprehensive system of universal screening and assessment for healthy child development, prenatal to school age, will require the ongoing support and involvement of primary health care providers, educators, social service providers and of parents during the early years. To identify children who are at risk prenatally and to identify those who are not identified in the postnatal period or whose situation changes after that early screen, Healthy Babies Healthy Children will use the following strategies :

  1. A)   Involvement of Primary Healthcare Providers
    The first strategy aims to increase the involvement of family physicians, nurses, midwives, nurse practitioners and paediatricians and others in local planning and monitoring of ongoing healthy child development, including professional assessment and screening. This strategy will also maximize interdisciplinary collaboration among health and social service providers, and encourage effective referrals. An example of the critical involvement of primary healthcare providers is support for an enhanced 18-month immunization and well-baby visit.
  2. B)   Support for an Enhanced 18-month immunization and well-baby visit
    The Periodic Health Exam (CTFPHC ) recommends cost-effective screening for appropriate populations. The opportunity for universal screening to coincide with the 18-month immunization schedule is a critical checkpoint for primary care providers to monitor achievement of developmental milestones.

    The Rourke Baby Record : Evidence-Based Infant/Child Health Maintenance Guide was developed for physicians and other primary healthcare providers, to support screening and preventive health care and to provide a guide for identifying at-risk infants and children. Use of this record, or a comparable one, enables universal screening at the 18-month immunization and well-baby visit and supports ongoing healthy child development monitoring through other well-baby visits with primary health care providers.

    Support for an enhanced 18-month immunization well-baby visit assumes a multidisciplinary collaboration amongst professionals in health, education and social services across the geographic catchment areas so all children and families have access.

    An interdisciplinary training project using a Continuing Medical Education (MAINPRO-CME) accreditation process will be used to educate physicians, nurses, midwives and other primary care and social service providers in ongoing developmental assessment and to increase their knowledge of healthy child development monitoring from birth, using tools like the Rourke.

    The Ontario College of Family Physicians (OCFP) will lead the collaborative development of this MAINPRO-CME with representation from other profession the Registered Nurses Association of Ontario (RNAO), Ontario Association of Midwives (AOM), Canadian Paediatric Society (CPS) Ontario and representatives from the developing Ontario Early Years Centres. There will be a small bursary fund attached to this initiative. In addition, local Healthy Babies Healthy Children programs will identify champions/opinion leaders who will help increase primary care providers' participation in the interdisciplinary learning/training program.

  3. Strengthening/Supporting Involvement of Parents and Families
    The second strategy aims to strengthen/support parents and families in monitoring healthy child development by providing appropriate screening tools that can be administered by parents, and by linking/referring parents to community parent-serving sites such as Community Health Centres, Family Practice Networks, and the Ontario Early Years Centres.

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The Tools for Comprehensive Screening and Assessment

The Prenatal Screen

The period between conception and birth lays the foundation for a child's well-being. During this time, children begin to develop basic neural structures, which have a direct impact on their development. For mothers at risk, the prenatal period is a critical time and the optimal starting point for Healthy Babies Healthy Children services. In fact, from a healthy child development perspective, it is crucial that Healthy Babies Healthy Children seek ways to ensure that, if services are required, they begin prenatally. The relationship that develops after the baby's birth is often enhanced if the home visitor gets to know the mother in the prenatal period.

Prenatal screening targets all pregnant women in Ontario and provides an opportunity for early detection of families who may need support to help their children achieve their potential. The strategies/interventions used in prenatal home visiting recognize that : pregnant women are ready to learn and modify health behaviors, psychological stress can affect pregnancy outcome, and the development of attachment begins prenatally.

The prenatal screening tool is the Larson* Screen, which consists of three questions designed to identify factors that are predictors of difficulty with parenting, including :

  1. the mother's education level;
  2. her attendance at prenatal classes;
  3. if she is a smoker, how much she smokes.

The Larson, a relatively non-intrusive tool that is fast and easy to administer, has been shown to predict families at risk for difficulties in the postpartum period. Some health units administer only the three required questions; others integrate the three questions into a longer, more detailed pre-natal assessment.

The Larson may be completed at prenatal clinics, physicians' offices or other community sites, or by phone by nurses, physicians, midwives, and other service providers skilled in maternal/ newborn care. Women who score "at risk" are referred to the Public Health Unit for a brief assessment and appropriate supports.

Some primary care providers are currently using other widely accepted screening/assessment tools. The Public Health Branch of the Ministry of Health and Long Term Care (MOHLTC) and the Integrated Services for Children Division (ISCD) will continue to support the use of the Antenatal Record by primary health care providers and the use of the Antenatal Psychosocial Health Assessment (ALPHA form) by primary health care providers and other health professionals.

Parent Screening/Monitoring of Healthy Child Development

Parents possess in-depth developmental information and are in a unique position to conduct ongoing observations of their children. This makes them valuable partners in the screening process. According to the research, parents' participation in monitoring their children's development through screening tools/parent questionnaires strengthens families' sense of responsibility and empowerment, and promotes primary prevention. A parent completed questionnaire or checklist is an important strategy in the Healthy Babies Healthy Children universal screening and assessment healthy child development monitoring system.

As part of the requirements for Early Identification, Boards of Health will provide parents with a developmental screen that parents can use to monitor their children at different developmental stages/milestones. Health units have the choice of using parental screens such as the Nipissing** Developmental Screen or the Ages and Stages Questionnaires (ASQ). Parents who have questions after completing the screen are advised to call their local Public Health Unit, Community Health Centre or Ontario Early Years Centre, or speak to their health practitioner.

Professional Monitoring/Assessment of Healthy Child Development

To achieve universal screening and assessment, prenatal to school age, along with social service providers and educators, primary health care providers - the physicians, nurses, nurse practitioners and midwives who have regular contact with families and children - must play a more significant role. They have opportunities to observe the child during routine office or clinic appointments, like the 18-month immunization and all well-baby visits/clinics. Screening by health professionals is an important strategy in helping families at risk access Healthy Babies Healthy Children.

The Rourke Well-Baby Record : Evidence-Based Infant/Child Health Maintenance Guide is an assessment tool presently used as the record for all well-baby visits by many family physicians and community paediatricians in Ontario. It is ideally suited to multi-disciplinary care by physicians, nurses, and nurse practitioners. Various sections of the tool can be completed by one person or shared among staff who have contact with the family. The use of this tool helps to ensure that child development is monitored continually (at regular stages) as the child grows, and that families are referred to Healthy Babies Healthy Children if required. In addition, use of the Rourke Well-Baby Record strengthens the links between primary healthcare providers, particularly physicians, and Healthy Babies Healthy Children and the community.

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Impact of the Strategies and Tools

The use of these tools and strategies will strengthen universal screening and screening through Healthy Babies Healthy Children and community sites, like, Schools, Family Practice Networks, Community Health Centres, Community Clinics, Ontario Early Years Centres. They will also support collaboration and partnership with families through Community Health Centres, primary health care providers, Healthy Babies Healthy Children, and other community parenting sites, like the Ontario Early Years Centres, through outreach to physicians and other primary care providers.

Transition to School

For example, a key area where increased participation and involvement of parents and a broad network of professionals (from education, social services and health care) is important is where the need for smooth transition between the preschool years to the education system so that support services and programs for children who require them are not disrupted. Such liaison work requires reciprocal sharing of information that will identify students needs, and support families in becoming familiar with school requirements. Communities are encouraged to support and build on such strategies with local school boards.

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Integrated Information System

The Information Services for Children Information System (ISCIS) System will be used to monitor increased referrals to Healthy Babies Healthy Children and increased utilization of screening and assessment.

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Expected Outcomes
  • increased knowledge of healthy child development amongst primary health care providers who complete the MAIN-PRO, CME,
  • an increase in the number of referrals to Healthy Babies Healthy Children from primary health care providers and other community services/programs; and,
  • an increase in the percentage of women/families identified and referred to services in the prenatal period through to school age that are experiencing psychosocial risk factors and/or other health and developmental risk factors.

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Update of Ministry Requirements

The Ministry requirements from the 2000 Prenatal and Early Identification Guidelines for Phase 1 are updated as follows :

  • Boards of Health are required to implement a parent developmental screening tool like the Nipissing or Ages and Stages Questionnaires and to provide access to a professional to assist parents in completing and/or interpreting the screen, and with any follow-up needs.
  • Boards of Health are required to implement the Larson Screen during the prenatal period and to provide simplified access to prenatal services.
  • Boards of Health are required to support broad community participation in planning for Healthy Babies Healthy Children screening and assessment. Communities were already required to have an implementation working group/committee for Healthy Babies Healthy Children. Some communities have moved to establish broader children's service committees. Regardless of the structure in place, broad community participation is expected in planning for the implementation of Healthy Babies Healthy Children Universal Screening and Assessment for Healthy Child Development from Prenatal to School-Age.

For more information

Early Years and Healthy Child Development Branch
Integrated Services for Children Division
15th Floor, 56 Wellesley Street West
Toronto, Ontario
M7A 2B7

Call the ministry INFOline at 1-800-268-1154
(Toll-free in Ontario only)
In Toronto, call 416-314-5518
TTY 1-800-387-5559
Hours of operation : 8:30am - 5:00pm
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