Cross-Sector Efforts to Support Optimal Developmental and Behavioral Health

Early identification of developmental delays and timely initiation of early intervention (EI) services can enhance outcomes for children and families.1 Pediatric professionals can play a critical role in this process given their near-universal access to young children, frequent contact with families, and opportunities to leverage caregiver-clinician relationships to connect families to other professionals.2 Yet, most children who are identified with developmental delays in pediatric primary care are not linked to EI services.3 The difference between the number of children identified with developmental delays in pediatric primary care and those who go on to receive services is a stark reminder that silos between sectors prevent systems from working for children and families.Previously, Nelson and colleagues provided randomized trial evidence that adding telephone-based early childhood care coordination delivered by 211LA, a health and human services call center that is based on a national model and serves Los Angeles County, to usual pediatric primary care enhances early identification of developmental delays and connection to services compared with usual pediatric primary care alone.4–6 The families randomized to the 211LA intervention reviewed developmental screening results with an early childhood care coordinator who made need-based referrals and conducted follow-up. More children in the intervention arm were referred to and received services, and these effects were sustained 2 years later. Despite the importance of these findings, the downstream effects of care coordination services on child developmental and behavioral outcomes remained unclear, leaving an important knowledge gap.In this issue of Pediatrics, Gulsrud et al continued this important line of research and examined language and behavioral outcomes 2 years post-enrollment among children randomized to the 211LA intervention compared with usual care.7 This study is important, in part, because there is a major need to go beyond examining the impact of early childhood care coordination interventions on referral and service enrollment toward assessing their impact on child outcomes. Such studies are needed to inform evidence-driven policy and systems building. There is also a critical need to follow children through key developmental stages that are marked by system transitions that can leave eligible children vulnerable to losing services. For example, Black and Latino children exiting Part C EI are somewhat less likely than white children to access early childhood special education on their third birthday.8 The fact that this team was able to achieve such high retention rates represents a major achievement.Notably, Gulsrud et al did not identify differences in language or behavior outcomes between the 2 arms. When interpreting these results and planning future work several critical issues arise.First, this study made the best possible effort to assess child outcomes in a follow-up to a study assessing impacts on service delivery. However, the sample size required to detect outcomes from a change in participation rates is much larger than that required to detect changes in those rates. Although larger effects might have been hoped for, direct estimates of Head Start and preschool effects (about 0.30 SD when compared with no services) suggest that the roughly 20 percentage point increase in participation found in this study would on average yield a 0.06 SD effect across the entire group.9 Detecting such an effect requires a sample size an order of magnitude larger than that required to detect the effect on services. The results of this study suggest much larger sample sizes are needed in future studies of developmental outcomes from interventions focused on improving service participation rates.Second, as acknowledged by the authors, it is important to consider limitations in how the outcomes were measured. Although recognizing the tradeoffs and practical requirements necessary to conduct a complex and relatively large study like this one, it is also important to note that the parent-report instrument used in this study was designed to identify children at risk for developmental delay, not changes in development over time. Furthermore, two-thirds of the families in the sample identified as Spanish speaking suggesting that the children were multilingual learners. Multilingual learners’ language abilities are best assessed across their languages,10 but skills were only assessed in 1 language, which likely underestimated the children’s language skills. Future work might yield different results if more sensitive and comprehensive measurement strategies are employed.Third, the analyses revealed imbalances between the arms that extended to the subgroups that enrolled in services and indicated that caregivers of children enrolled in services in the 211LA intervention arm were more likely to identify as immigrants to the United States and report speaking English less than very well. They were also more likely to report receiving virtual preschool/Head Start and fewer hours per week. These findings are noteworthy and represent an important consideration when planning future studies. Specifically, although beyond the scope of this intervention, supporting children and families particularly from historically marginalized backgrounds requires going beyond enrollment and reducing barriers to meaningful participation and attendance. Cross-sector data (ie, from the service providers), would go a long way in deepening insights into the receipt and dose of services. Such data could also offer a wider range of assessments on children and perspectives of different professionals, which would offer greater insight into their effects.Last, when interpreting the study findings, challenges related to the COVID-19 pandemic must be considered. Recruitment occurred from January 2020 to April 2021, which puts treatment from January 2020 to January 2022 and April 2021 to April 2023. Services fluctuated during this period because of COVID-19.11–14 By mid-March 2020, every school district and the Catholic school system in Los Angeles County had closed in-person education, including early education centers and preschool programs. Head Start programs also closed in-person services. Although some limited childcare services were offered, in-person early childhood programs remained closed or severely restricted until phased reopenings began in spring of 2021.15–17 Around this time, there were also intensive efforts to connect electronically with parents of young children in Los Angeles, which could have affected both treatment and controls resulting in reduced contrast between the arms. Additionally, for a substantial period of the time, services would have been remote and the number of children not receiving full special education services would have been much higher during this period, diluting services for those receiving treatment.8 In this context, it is unclear how different the results may have looked if the study had not been conducted during the pandemic.Importantly, as noted by the authors, the results cannot be interpreted as a test of effectiveness of early childhood services because the study was not designed to do so; nor can the results be interpreted simply as early childhood care coordination does not have downstream effects on child development and behavior because the interpretation requires more nuance. The key contributions of this study are in breaking new ground by overcoming existing silos between health care and other sectors and going beyond past studies that have not attempted to assess child outcomes and follow children through important developmental transition stages. The study also highlights that the challenges to conducting this kind of work are real, resource intensive, and require similarly highly skilled teams to overcome. Now the question is whether funders and policymakers will make the necessary investments to foster similar cross-sector collaborations, which are desperately needed, and afford the resources necessary to further advance research in this field.