UBC Theses and Dissertations

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UBC Theses and Dissertations

Early identification of developmental impairments in infants from birth to nine months of age / |c by.. 1976

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EARLY I D E N T I F I C A T I O N OF DEVELOPMENTAL IMPAIRMENTS I N INFANTS FROM BIRTH TO NINE MONTHS OF AGE b y M. GRACE DOHERTY B.Sc.N . , U n i v e r s i t y o f A l b e r t a , 1969 A T H E S I S SUBMITTED I N P A R T I A L FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N NURSING i n THE FACULTY OF GRADUATE' STUDIES ( S c h o o l o f N u r s i n g ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE U N I V E R S I T Y OF B R I T I S H COLUMBIA J u l y , 197.6 (c) M u r i e l G r a c e D o h e r t y , 1976 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f f \ ) o & % i *OGr T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V6T 1W5 D a t e ^UkM 7Tjink i i ABSTRACT EARLY I D E N T I F I C A T I O N OF DEVELOPMENTAL IMPAIRMENTS I N INFANTS BIRTH TO NINE MONTHS OF AGE E a r l y r e c o g n i t i o n o f r e a l o r p o t e n t i a l d e v e l o p m e n t a l i m p a i r m e n t s i n i n f a n t s i s an i m p o r t a n t p u b l i c h e a l t h r o l e . C o m m u n i t y h e a l t h n u r s e s h a v e i n i t i a l a c c e s s t o t h e i n f a n t p o p u l a t i o n b y t h e m a n d a t e d n e w b o r n v i s i t a n d t h e n e c e s s a r y s k i l l s a n d t o o l s t o a s s e s s i n f a n t s f o r d e v e l o p m e n t a l i m p a i r - m e n t s . This experimental study was undertaken to determine t h e e f f e c t i v e n e s s o f s c h e d u l e d n u r s i n g a s s e s s m e n t s o f g r o w t h , d e v e l o p m e n t , v i s i o n , h e a r i n g and n u t r i t i o n f r o m b i r t h t o n i n e Q m o n t h s o f a g e . A s e c o n d a r y p u r p o s e was t o d e t e r m i n e t h e j p r e d i c t i v e v a l i d i t y o f c u r r e n t l y u s e d p r e g n a n c y a n d i n f a n t p r o f i l e s f o r s u b s e q u e n t d e v e l o p m e n t a l i m p a i r m e n t . The n u l l h y p o t h e s e s t e s t e d w e r e : I . T h a t t h e s c h e d u l e d , c o m m u n i t y h e a l t h n u r s i n g a s s e s s m e n t s b e t w e e n b i r t h a n d n i n e m o n t h s o f age w i l l n o t d e t e c t a n y d e v e l o p m e n t a l i m p a i r m e n t s w h i c h h a v e n o t a l r e a d y b e e n d e t e c t e d b y e x i s t i n g h e a l t h s e r v i c e s . I I . T h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f d e v e l o p m e n t a l i m p a i r m e n t s d e t e c t e d a t n i n e m o n t h s o f a g e , b e t w e e n a g r o u p o f i n f a n t s s c r e e n e d by t h e p r o p o s e d s c h e d u l e o f a s s e s s m e n t s a n d a g r o u p n o t s o s c r e e n e d . i i i I I I . T h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f c h i l d r e n e x h i b i t i n g d e v e l o p m e n t a l i m p a i r m e n t s by n i n e months o f age, between a g r o u p o f " a t r i s k " and a g r o u p o f not " a t r i s k " i n f a n t s , u s i n g t h e c r i t e r i a f r o m t h e V a n c o u v e r H e a l t h Department's P r e g n a n c y P r o f i l e and I n f a n t P r o f i l e A t R i s k C r i t e r i a . One hundred i n f a n t s f r o m one h e a l t h u n i t a r e a were s t u d i e d , a l t e r n a t e l y a s s i g n e d t o an e x p e r i m e n t a l and a c o n t r o l g r o u p . The e x p e r i m e n t a l group r e c e i v e d t h r e e v i s i t s i n a d d i t i o n t o t h e newborn v i s i t , a t 1 month, 3 months, and 6 months, f o r v a r i o u s c o m b i n a t i o n s o f f i v e t y p e s o f a s s e s s m e n t s . The c o n t r o l group r e c e i v e d o n l y t h e u s u a l newborn v i s i t , b u t no c o n t r o l was used t o p r e v e n t a c c e s s t o any o t h e r h e a l t h s e r v i c e s d u r i n g t h e s t u d y p e r i o d . P regnancy and i n f a n t p r o f i l e s were c o m p l e t e d f o r t h e s u b j e c t s i n b o t h g r o u p s a t t h e i n i t i a l v i s i t . 9 month a s s e s s m e n t s o f g r o w t h , d e v e l o p m e n t , v i s i o n , h e a r i n g and n u t r i t i o n were c o m p l e t e d f o r b o t h g r o u p s . The d a t a were s u b j e c t e d t o d e s c r i p t i v e a n a l y s i s and s t a t i s t i c a l a n a l y s i s by F i s h e r ' s e x a c t t e s t o f p r o b a b i l i t y , u s i n g 2 x 2 c o n t i n g e n c y t a b l e s . The f i n d i n g s s u p p o r t e d s c h e d u l e d community h e a l t h n u r s i n g a s s e s s m e n t s o f i n f a n t s from b i r t h t o n i n e months o f age. The p r e g n a n c y and i n f a n t p r o f i l e s were found t o be s e n s i t i v e b u t n o t s p e c i f i c t o o l s f o r p r e d i c t i o n o f s u b s e q u e n t d e v e l o p m e n t a l i m p a i r m e n t . The t h r e e n u l l h y p o t h e s e s were r e j e c t e d . iv I m p l i c a t i o n s f o r n u r s i n g p r a c t i s e a r e d i s c u s s e d a n d r e c o m m e n d a t i o n s f o r f u r t h e r r e s e a r c h s u g g e s t e d . V T A B L E OF C O N T E N T S C H A P T E R P A G E I . I N T R O D U C T I O N TO T H E S T U D Y . . . . . . . . . . . 1 I n t r o d u c t i o n 1 T h e P r o b l e m 2 S t a t e m e n t o f t h e p r o b l e m 2 S p e c i f i c q u e s t i o n s p o s e d f o r t h e s t u d y . . 3 S i g n i f i c a n c e o f t h e p r o b l e m . . . . . . . 3 A s s u m p t i o n s o f t h e S t u d y 5 D e f i n i t i o n s o f T e r m s U s e d 6 L i m i t a t i o n s o f t h e S t u d y . . . . . . . . . . 8 H y p o t h e s e s T e s t e d i n t h e S t u d y 8 O v e r v i e w o f t h e R e m a i n d e r o f t h e S t u d y . . . 9 I I . R E V I E W OF THE L I T E R A T U R E . 1 0 A t R i s k V e r s u s M a s s S c r e e n i n g . 1 0 Two E u r o p e a n P r o t e c t i o n P r o g r a m s 14 E d m o n t o n ' s " A t R i s k " P e d i a t r i c P r o g r a m . . . 16 A t R i s k C r i t e r i a P r o p o s e d • 1 7 C h o i c e o f M e a s u r e m e n t P r o c e d u r e s 1 9 S u m m a r y 1 9 I I I . D E S I G N AND METHODOLOGY 2 1 T h e P r e l i m i n a r y S t u d y 2 1 D e s i g n o f t h e S t u d y 2 3 E x p e r i m e n t a l d e s i g n . 2 3 T h e s e t t i n g . 2 4 v i C H A P T E R PAGE T h e s u b j e c t s 2 4 M e t h o d o l o g y o f t h e S t u d y 2 5 S t a f f i n s t r u c t i o n 2 5 M e a s u r e m e n t p r o c e d u r e s 26 D a t a c o l l e c t i o n 3 1 D a t a a n a l y s i s . . . 3 3 S u m m a r y 3 4 I V . A N A L Y S I S OF THE D A T A 3 5 A n a l y s i s R e l a t e d t o t h e H y p o t h e s e s 35 A n a l y s i s r e l a t e d t o H y p o t h e s i s I 3 5 A n a l y s i s r e l a t e d t o H y p o t h e s i s I I . . . . 3 7 A n a l y s i s r e l a t e d t o H y p o t h e s i s I I I . . . . 3 8 A d d i t i o n a l D a t a 4 1 C h i l d h e a l t h c e n t r e a t t e n d a n c e f o r i m m u n i z a t i o n 4 1 P h y s i c a l e x a m i n a t i o n b y p h y s i c i a n . . . . 4 2 N u t r i t i o n a l d a t a 4 2 P a r e n t i n i t i a t i o n o f c o m m u n i t y h e a l t h n u r s e c o n t a c t 4 3 S u m m a r y 4 4 V . SUMMARY, F I N D I N G S , C O N C L U S I O N S , I M P L I C A T I O N S FOR N U R S I N G P R A C T I C E , AND RECOMMENDATIONS FOR" F U R T H E R R E S E A R C H . . . . . . . . . 4 5 S u m m a r y 4 5 F i n d i n g s F i n d i n g s r e l a t e d , t o H y p o t h e s i s I . . . . . 4 8 v i i PAGE F i n d i n g s r e l a t e d t o H y p o t h e s i s I I . . . . 4 9 F i n d i n g s r e l a t e d t o H y p o t h e s i s I I I . . . 4 9 C o n c l u s i o n s 5 0 I m p l i c a t i o n s f o r n u r s i n g p r a c t i c e 5 1 R e c o m m e n d a t i o n s f o r f u r t h e r r e s e a r c h . . . 5 3 B I B L I O G R A P H Y 5 4 A P P E N D I X E S A . T h e P r e g n a n c y a n d I n f a n t P r o f i l e s . . . . . . 6 4 B. T h e M e a s u r e m e n t P r o c e d u r e s . . . . . . . . . 6 9 C. T h e S t a f f I n s t r u c t i o n s a n d E x p l a n a t i o n t o P a r e n t s 8 0 D. T a b l e s o f D e s c r i p t i v e A n a l y s i s . . . . . . . 8 4 v i i i L I S T OF T A B L E S T A B L E P A G E 1 . T h e P r o p o s e d A s s e s s m e n t S c h e d u l e f o r I n f a n t s i n t h e E x p e r i m e n t a l G r o u p , 32 2 . I n f a n t D e v e l o p m e n t o f I m p a i r m e n t s D e t e c t e d b y S c h e d u l e d A s s e s s m e n t s W h i c h h a d n o t A l r e a d y B e e n D e t e c t e d B y E x i s t i n g H e a l t h S e r v i c e s • • • 36 3. C o m p a r i s o n o f Two G r o u p s o f I n f a n t s b y N u m b e r o f D e v e l o p m e n t a l I m p a i r m e n t s D e t e c t e d a t N i n e M o n t h s o f A g e • 3 7 4 . C o m p a r i s o n o f I n f a n t s C o n s i d e r e d A t R i s k o r N o t A t R i s k B y t h e P r e g n a n c y P r o f i l e w i t h T h o s e C o n s i d e r e d A t R i s k o r N o t A t R i s k b y t h e I n f a n t P r o f i l e 3 8 5. C o m p a r i s o n o f I n f a n t s C o n s i d e r e d A t R i s k o r N o t A t R i s k B y t h e C o m b i n e d P r e g n a n c y a n d I n f a n t P r o f i l e s B y P r e s e n c e o r L a c k o f S u b - s e q u e n t D e v e l o p m e n t a l I m p a i r m e n t 3 9 6. C o m p a r i s o n o f I n f a n t s C o n s i d e r e d A t R i s k o r N o t A t R i s k b y t h e P r e g n a n c y P r o f i l e B y P r e s e n c e o r L a c k o f S u b s e q u e n t D e v e l o p m e n t a l I m p a i r m e n t . . . . . . . . 4 0 7. C o m p a r i s o n o f I n f a n t s C o n s i d e r e d A t R i s k o r N o t A t R i s k b y t h e I n f a n t P r o f i l e b y P r e s e n c e o r L a c k o f S u b s e q u e n t D e v e l o p - m e n t a l I m p a i r m e n t • 4 0 i x T A B L E P A G E 8. C o m p a r i s o n o f Two G r o u p s o f I n f a n t s by A t t e n d a n c e a t C h i l d H e a l t h C e n t r e s o r P h y s i c i a n s ' O f f i c e s F o r I m m u n i z a t i o n - 4 1 9. C o m p a r i s o n B e t w e e n Two G r o u p s of. I n f a n t s b y E a r l y I n t r o d u c t i o n o f S o l i d F o o d s a n d b y N i n e M o n t h A s s e s s m e n t a s B e i n g O v e r w e i g h t . . . . . . . . . . '. . . . . . . . . 4 2 1 0 . C o m p a r i s o n B e t w e e n T w o G r o u p s o f B r e a s t f e d I n f a n t s b y A g e o f W e a n i n g F r o m t h e B r e a s t . . . 4 3 1 1 . D e s c r i p t i o n s o f t h e I m p a i r m e n t s D e t e c t e d i n t h e E x p e r i m e n t a l G r o u p I n f a n t s F r o m B i r t h t o N i n e M o n t h s o f A g e . 8 5 12.,. D e s c r i p t i o n s o f t h e I m p a i r m e n t s D e t e c t e d i n t h e C o n t r o l G r o u p I n f a n t s a t N i n e M o n t h s o f A g e 8 7 1 3 . C o m p a r i s o n B e t w e e n M o t h e r s o f T w o G r o u p s o f I n f a n t s B y N u m b e r s C o n s i d e r e d A t R i s k B y I n d i v i d u a l C r i t e r i a o n t h e P r e g n a n c y P r o f i l e 8 8 1 4 . C o m p a r i s o n B e t w e e n M o t h e r s o f Two G r o u p s o f I n f a n t s B y N u m b e r s C o n s i d e r e d A t R i s k B y I n d i v i d u a l C r i t e r i a o n t h e I n f a n t P r o f i l e 8 9 X ACKNOWLEDGEMENTS I w i s h t o e x p r e s s my g r a t i t u d e t o a l l t h o s e who made t h i s s t u d y p o s s i b l e : t o H e l e n E l f e r t a n d B e t t y C a w s t o n f o r t h e i r p r o f e s s i o n a l g u i d a n c e a n d p e r s o n a l i n t e r e s t ; t o t h e V a n c o u v e r H e a l t h D e p a r t m e n t f o r s u p p o r t o f t h e s t u d y ; t o t h e s t a f f o f W e s t H e a l t h U n i t , e s p e c i a l l y t h e c o m m u n i t y h e a l t h n u r s e s , t h e n u r s e c o - o r d i n a t o r , R u t h S c o t t , a n d s e n i o r c l e r k , J e a n P o w e l l , f o r t h e i r c o n t i n u e d e n c o u r a g e m e n t a n d c o - o p e r a t i o n ; t o Guy C o s t a n z o f o r h i s a s s i s t a n c e i n t h e d a t a a n a l y s i s ; a n d t o t h e f a m i l i e s who p a r t i c i p a t e d i n t h e s t u d y f o r t h e i r e n t h u s i a s m a n d warm r e s p o n s e . 1 C H A P T E R I I N T R O D U C T I O N TO THE ST U D Y I N T R O D U C T I O N I t i s now u n i v e r s a l l y a c c e p t e d t h a t t h e e a r l i e s t p o s s i b l e d i a g n o s i s a n d t r e a t m e n t a r e e s s e n t i a l t o p r e v e n t , o r a t l e a s t t o m i n i m i z e t h e h a n d i c a p p i n g e f f e c t s o f a d i s - a b i l i t y a n d t o m a k e t h e m o s t o f t h e a s s e t s a c h i l d p o s s e s s e s . I t i s a l s o g e n e r a l l y a g r e e d t h a t i t s h o u l d b e t h e r e s p o n s i b i l i t y o f t h e l o c a l h e a l t h a u t h o r i t y t o s e e k o u t y o u n g c h i l d r e n w i t h h a n d i c a p s o r p o t e n t i a l h a n d i c a p s , a n d i t i s i m p o r t a n t t h a t t h i s t a s k i s p e r f o r m e d a s e f f i c i e n t l y a s p o s s i b l e . ^ T h e p r e s e n t d a y i n t e r e s t i n i n f a n t r i s k c a n b e t r a c e d b a c k t o L i l i e n f e l d a n d P a s a m a n i c k a n d t h e i r i n t r o d u c t i o n o f 2 t h e p h r a s e " a c o n t i n u u m o f r e p r o d u c t i v e c a s u a l t y " a s a d e p a r t u r e f r o m t h e i n t e r e s t i n p e r i n a t a l d e a t h , o n l y , p r e v a - 3 l e n t i n t h e 1 9 4 0 s a n d e a r l y 1 9 5 0 s . A s i n f a n t m o r t a l i t y r a t e s h a v e d e c r e a s e d , t h e t h r u s t o f o b s t e t r i c a n d p e d i a t r i c c a r e h a s b e e n i n c r e a s i n g l y t o w a r d i m p r o v e m e n t o f t h e q u a l i t y o f l i f e f o r s u r v i v i n g i n f a n t s b y t h e p r e v e n t i o n o r e a r l y r e c o g n i t i o n a n d t r e a t m e n t o f d i s a b i l i t y . T h i s i n t e r e s t i s s h a r e d b y t h e p u b l i c a s w e l l a s p r i v a t e s e c t o r s o f h e a l t h c a r e s e r v i c e s . A s c o m m u n i t y h e a l t h n u r s e s p r o v i d e t h e b u l k o f t h e f o r m e r , t h e m a t t e r o f s e r v i n g t h i s i n f a n t p o p u l a t i o n 1 J . M e i e r , S c r e e n i n g a n d A s s e s s m e n t o f Y o u n g C h i l d r e n a t D e v e l o p m e n t a l R i s k ( W a s h i n g t o n : PHEW P u b l i c a t i o n s , 1 9 7 3 ) , 17, 2 A.M. L i l i e n f i e l d a n d B. P a s a m a n i c k , " A s s o c i a t i o n o f M a t e r n a l a n d F e t a l F a c t o r s w i t h C e r e b r a l P a l s y a n d E p i l e p s y , " A m e r i c a n J o u r n a l o f O b s t e t r i c s a n d G y n e c o l o g y , L X X ( J a n u a r y , 1 9 5 5 ) , 9 3 . : 3 R.G. M i t c h e l l , " C h a n g i n g C o n c e p t s o f Risk," D e v e l o p . M e d . C h i l d N e u r o l . , X V I I (1975), 277. 2 most e f f i c i e n t l y i s a c o n t i n u i n g n u r s i n g c o n c e r n . THE PROBLEM S t a t e m e n t o f t h e P r o b l e m The p r o b l e m i d e n t i f i e d was t h e p o s s i b l e l a c k o f e a r l y d e t e c t i o n o f d e v e l o p m e n t a l i m p a i r m e n t s i n t h e f i r s t s e v e r a l months o f l i f e , o f V a n c o u v e r i n f a n t s , d e s p i t e t h e a c c e s s i b i - l i t y t o h e a l t h c a r e f a c i l i t i e s and t h e a v a i l a b i l i t y o f p r e - p a i d m e d i c a l c a r e p l a n s . The community h e a l t h n u r s i n g c o n t a c t f o r many i n f a n t s was l i m i t e d t o a s i n g l e m a n d a t e d newborn v i s i t f o l l o w i n g h o s p i t a l d i s c h a r g e . R o u t i n e e x a m i n a t i o n and w e i g h i n g o f i n f a n t s on t h e s e v i s i t s a nd a t C h i l d H e a l t h C e n t r e s h a s been d e e m p h a s i z e d i n r e c e n t y e a r s w i t h a f o c u s r a t h e r o n m a t e r n a l c o u n s e l l i n g a n d a n t i c i p a t o r y g u i d a n c e . The e x i s t i n g m e d i c a l c a r e p l a n s do p r o v i d e t h e a l t e r n a t i v e o f h a v i n g i m m u n i z a t i o n g i v e n b y t h e f a m i l y ' s p h y s i c i a n , b u t do n o t o f f e r r o u t i n e p r e v e n t i v e p h y s i c a l e x a m i n a t i o n s f o r h e a l t h y i n f a n t s b e y o n d t h e s i x week p o s t - d e l i v e r y c h e c k , i n c l u d e d i n o b s t e t r i c a l c a r e . I n t e r e s t i n e x p a n d i n g t h e i r n u r s e s ' a s s e s s m e n t s k i l l s h a s r e s u l t e d i n t h e V a n c o u v e r H e a l t h D e p a r t m e n t p r o v i d i n g i n s e r v i c e p r o g r a m s i n p h y s i c a l and d e v e l o p m e n t a l a p p r a i s a l o f c h i l d r e n . A g r o w i n g number o f community h e a l t h n u r s e s h a v e , o v e r t h e p a s t two y e a r s , s t a r t e d e x a m i n i n g and a s s e s s i n g i n f a n t s on i n i t i a l and r e p e a t v i s i t s , a s w e l l a s a t C h i l d H e a l t h C e n t r e s . As y e t , no e v a l u a t i o n h a s b e e n u n d e r t a k e n t o d e t e r m i n e t h e e f f e c t i v e n e s s o f t h i s i n v e s t m e n t o f n u r s i n g t i m e , b u t i n t e r e s t h a s b e e n e x p r e s s e d b y n u r s i n g s t a f f i n d e v e l o p m e n t o f a d e p a r t m e n t a l p r o g r a m . S p e c i f i c Q u e s t i o n s P o s e d f o r t h e S t u d y The q u e s t i o n s a s k e d f o r t h i s s t u d y w e r e : 1. W o u l d s c h e d u l e d p h y s i c a l a n d d e v e l o p m e n t a l a s s e s s m e n t s b y a c o m m u n i t y h e a l t h n u r s e d e t e c t a n y r e a l o r p o t e n t i a l d i s a b i l i t i e s i n i n f a n t s , o r w o u l d t h i s be a d u p l i c a t i o n o f p r e s e n t p h y s i c i a n s u r v e i l l a n c e ? 2. I s i n c r e a s e d c o m m u n i t y h e a l t h n u r s e s u r v e i l l a n c e o f a l l i n f a n t s i n d i c a t e d , o r s e l e c t i v e f o l l o w - u p o f t h o s e i n f a n t s deemed t o b e a t g r e a t e r r i s k o f s u b s e q u e n t d i s a b i l i t y o n l y ? 3. I f t h e l a t t e r , a r e c r i t e r i a o n t h e p r e s e n t l y u s e d V a n c o u v e r H e a l t h D e p a r t m e n t P r e g n a n c y P r o f i l e a n d 4 I n f a n t P r o f i l e A t R i s k C r i t e r i a f o r m s p r e d i c t i v e o f s u b s e q u e n t d i s a b i l i t y ? 4 . I f a n a s s e s s m e n t p r o g r a m were i m p l e m e n t e d , w o u l d t h o s e i n f a n t s e x a m i n e d r e g u l a r l y b y a c o m m u n i t y h e a l t h n u r s e f o r s e v e r a l m o n t h s d e m o n s t r a t e a b e t t e r h e a l t h a n d d e v e l o p m e n t a l s t a t u s t h a n a g r o u p n o t s o e x a m i n e d ? S i g n i f i c a n c e o f t h e P r o b l e m C o n c e r n s e x p r e s s e d b y o r t h o p t i s t s , s p e e c h p a t h o l o g i s t s a n d t e a c h e r s o f p r e s c h o o l a n d s c h o o l a g e c h i l d r e n o v e r t h e p a s t s e v e r a l y e a r s i n d i c a t e d t o t h e r e s e a r c h e r t h a t d i a g n o s e s 4 See A p p e n d i x A 4 o f d e v e l o p m e n t a l Impairments were n ot b e i n g made u n t i l l a t e p r e s c h o o l o r e a r l y s c h o o l y e a r s - o f c o n d i t i o n s w h i c h s h o u l d have been a s s e s s a b l e i n t h e f i r s t y e a r o f l i f e ( c o n g e n i t a l h e a r i n g i m p a i r m e n t , m u s c u l o s k e l e t a l d e f e c t s , o b e s i t y , s q u i n t ) . H a r d d a t a were n o t r e a d i l y a v a i l a b l e as t o how p r e v a l e n t t h e s e l a t e r e f e r r a l s were. I n t h e p r o p o s e d s t u d y , s c h e d u l e d community h e a l t h n u r s i n g a s s e s s m e n t s c o u l d be e v a l u a t e d as t o t h e i r e f f e c t i v e - n e s s i n d e t e c t i n g d e v e l o p m e n t a l i m p a i r m e n t s i n i n f a n c y . E v a l u a t i o n o f t h e c u r r e n t l y used pregnancy and i n f a n t p r o f i l e s as p r e d i c t i v e t o o l s c o u l d a l s o be made, i n terms o f t h e i r i d e n t i f i c a t i o n o f i n f a n t s a t g r e a t e r r i s k o f s u b s e q u e n t d i s a b i l i t y . I f shown t o be p r e d i c t i v e , t h e y c o u l d a s s i s t i n more e f f i c i e n t a l l o c a t i o n o f n u r s i n g r e s o u r c e s , by l i m i t i n g t h e number o f i n f a n t s r e q u i r i n g o n g o i n g h e a l t h s u r v e i l l a n c e . " * I f n o t , t h e c o n c e p t o f r e g u l a r h e a l t h s u r v e i l l a n c e o f a l l i n f a n t s c o u l d be s t r e n g t h e n e d . R e s p o n s i v e n e s s o f f a m i l i e s c o u l d be a s s e s s e d , w i t h r e g a r d t o o v e r l a p w i t h e x i s t i n g h e a l t h s e r v i c e s and p e r c e i v e d b e n e f i t f r om i n c r e a s e d community h e a l t h n u r s i n g c o n t a c t . F o r t h e i n d i v i d u a l i n f a n t and f a m i l y , e a r l i e r r e c o g n i - t i o n o f an e x i s t i n g o r p o t e n t i a l d e v e l o p m e n t a l i m p a i r m e n t c o u l d be v e r y s i g n i f i c a n t . E a r l i e r r e f e r r a l and t r e a t m e n t K.S. H o l t , " I n f a n c y and C h i l d h o o d , " L a n c e t . I I (Nov., 1 9 7 4 ) , 7888. o r even p r e v e n t i o n o f d i s a b i l i t y c o u l d be e f f e c t e d . I n an o s t e n s i b l y p r e v e n t i v e p u b l i c h e a l t h s e r v i c e , one o f t h e major a r e a s where p r i m a r y and s e c o n d a r y p r e v e n t i o n a r e e s s e n t i a l i s t h a t o f a s s u r i n g t h e o p t i m a l h e a l t h o f o u r 7 c h i l d r e n . ASSUMPTIONS OF THE STUDY 1. D e s p i t e i n d i v i d u a l d i f f e r e n c e s , g r o w t h i s a c o n t i n u o u s and o r d e r l y p r o c e s s i n c h i l d r e n . "The r e g u l a r i t y o f d e v e l o p m e n t a l p a t t e r n s . . . a p p l i e s t o more t h a n p h y s i c a l growth and i s r e f e r r e d t o by some as t h e n o r m a t i v e s equence, r e c o g n i z i n g t h a t t h e r e a r e i d e n t i f i a b l e s t a g e s i n a l l a s p e c t s o f g r o w t h and d e v e l o p m e n t . " 8 2. W i t h i n a g i v e n p o p u l a t i o n , a c e r t a i n p e r c e n t a g e a r e v u l n e r a b l e t o a v a r i e t y o f p h y s i c a l l y and d e v e l o p m e n t a l l y h a n d i c a p p i n g c o n d i t i o n s , many o f w h i c h a r e amenable t o e a r l y t r e a t m e n t . 9 3. E a r l y d e t e c t i o n and t r e a t m e n t / p r e v e n t i o n a l l o w s t h e a f f e c t e d c h i l d t o a c h i e v e a m e a s u r a b l y h i g h e r l e v e l o f w e l l n e s s . ^ 4 . V a l i d , r e l i a b l e t o o l s a r e a v a i l a b l e , and t h e t e c h n i q u e s o f a s s e s s m e n t a r e w i t h i n the c a p a b i l i t i e s o f community h e a l t h n u r s e s . H M̂.. S h e r i d a n , C h i l d r e n ' s D e v e l o p m e n t a l P r o g r e s s (London: N a t . F o u n d a t i o n o f E d u c a t i o n a l R e s e a r c h , 1 9 7 3 ) , 1. 7 M e i e r , o p . c i t . 8 G.D. S u t t e r l y and A.W. D o n n e l l y , P e r s p e c t i v e s o f Human Development ( T o r o n t o : L i p p i n c o t t , 1 9 7 3 ) , 28. g U. Haynes, A D e v e l o p m e n t a l A p p r o a c h t o C a s e f i n d i n q ( W a s h i n g t o n , D.C: Dept. H.E.W., 1969), 4. 10 S h e r i d a n , o p . c i t . 11 See C h a p t e r I I I - D e s i g n and M e t h o d o l o g y . 5. H e a l t h s t a t u s c a n b e m e a s u r e d i n t e r m s o f n o r m a l p h y s i c a l a n d d e v e l o p m e n t a l a s s e s s m e n t r e s u l t s . D E F I N I T I O N S OF TERMS USED I n f a n t . A c h i l d f r o m b i r t h t o n i n e m o n t h s o f a g e . A t r i s k . " . . . c o n s i d e r e d t o be a t i n c r e a s e d r i s k o f s u b s e q u e n t h a n d i c a p b e c a u s e o f g e n e t i c endowment o r a d v e r s e e n v i r o n m e n t a l i n f l u e n c e s d u r i n g f e t a l , p e r i n a t a l , n e o n a t a l o r 12 p o s t n a t a l d e v e l o p m e n t . " I m p a i r m e n t . "A d e v i a t i o n f r o m n o r m a l , w h i c h may 13 i n c l u d e d i s e a s e , d y s f u n c t i o n o r a n o m a l i e s . " D e v e l o p m e n t a l i m p a i r m e n t . "... a n y c o n d i t i o n ( s ) w h i c h i s l i k e l y t o p r e v e n t a c h i l d f r o m a c h i e v i n g o p t i m a l g r o w t h a n d d e v e l o p m e n t i n a n y o f t h e s o c i a l , e m o t i o n a l , i n t e l l e c t u a l , l i n g u i s t i c o r p h y s i c a l r e a l m s c o n s i d e r e d s i n g l y o r i n c o m b i n a - t i o n . . . i n c l u d e s t h o s e c h i l d r e n who w i l l p r e d i c t a b l y f u n c t i o n a t a l e s s t h a n n o r m a l d e v e l o p m e n t a l l e v e l d u e t o v a r i o u s i n b o r n a n d / o r e n v i r o n m e n t a l d e f i c i e n c i e s o f s u c h t h i n g s a s a d e q u a t e n u t r i t i o n , i n t e l l e c t u a l s t i m u l a t i o n , l a n g u a g e m o d e l s , 14 o r e m o t i o n a l a n d s o c i a l e x p e r i e n c e s . " D e t e c t i o n . I d e n t i f i c a t i o n b y a n u r s e o f a n i m p a i r - m e n t , e i t h e r t h r o u g h a s c r e e n i n g p r o c e d u r e o r e x a m i n a t i o n b a s e d o n p a r e n t a l s u s p i c i o n . 1 2M.G.H. R o g e r s , "The E a r l y R e c o g n i t i o n o f H a n d i c a p p i n g D i s o r d e r s i n C h i l d h o o d , " D e v e l o p . Med. C h i l d . N e u r o l . , X I I I ( 1 9 7 1 ) , 9 2 . 13 H a y n e s , o p . c i t . , 4. 14 M e i e r , o p . c i t . , 5. 7 D i a g n o s i s . M e d i c a l c o n f i r m a t i o n o f a n i d e n t i f i e d i m p a i r m e n t . . S c r e e n i n g p r o c e d u r e . A s i m p l e , r e l i a b l e p r o c e d u r e t o i d e n t i f y a p p a r e n t l y w e l l i n f a n t s who h a v e o r a r e l i k e l y t o d e v e l o p i m p a i r m e n t s . P r i m a r y p r e v e n t i o n . P r e v e n t i o n o f a d e v e l o p m e n t a l i m p a i r m e n t b y m e a s u r e s t a k e n o r i n s t i t u t e d when t h e p o t e n t i a l f o r s u c h i m p a i r m e n t i s s e e n t o e x i s t . S e c o n d a r y p r e v e n t i o n . " I d e n t i f i c a t i o n o f i m p a i r m e n t s a t t h e e a r l i e s t p o s s i b l e a g e t o e n a b l e r e m e d i a l a c t i o n t o be t a k e n , i n t h e k n o w l e d g e t h a t many d i s a b i l i t i e s c a n b e t r e a t e d much more e f f e c t i v e l y i n v e r y y o u n g c h i l d r e n a n d t h a t t h e l i m i t a t i o n s o f t r e a t m e n t o f t e n become p r o g r e s s i v e l y more 15 s e v e r e a s c h i l d r e n become o l d e r . " Optimum h e a l t h . " . . . f r e e f r o m d i s e a s e , b o d i l y a i l m e n t o r d e f e c t o r a s t a t e o f t h e s y s t e m p e c u l i a r l y s u s c e p t i b l e o r l i a b l e t o d i s e a s e o r b o d i l y a i l m e n t . . - w h o l e , r i g h t , n o t h i n g t h e m a t t e r w i t h i t . " M. Wynn a n d A. Wynn, The R i g h t o f E v e r y C h i l d t o H e a l t h C a r e ( L o n d o n : C o u n c i l f o r O c c a s i o n a l P a p e r s o n C h i l d W e l f a r e , 1 9 7 4 ) , 5. S.B. G o l d s m i t h e , "The S t a t u s o f H e a l t h S t a t u s I n d i - c a t o r s , " H e j O t h _ j S e r v ^ L X X X V I I ( M a r c h , 1 9 7 2 ) , 2 1 2 . 8 L I M I T A T I O N S OF THE S T U D Y T h e s t u d y w a s s u b j e c t t o t h e f o l l o w i n g l i m i t a t i o n s : 1 . T h e s t u d y w a s l i m i t e d t o a t i m e - s e q u e n t i a l s a m p l e o f o n e h u n d r e d i n f a n t s i n o n e g e o g r a p h i c a l a r e a o f o n e c i t y b o r n i n J u n e o r J u l y o f o n e y e a r . 2 . T h e i n f a n t s w e r e a s s i g n e d a l t e r n a t e l y , n o t r a n d o m l y , t o t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s . 3 . T h e r e s e a r c h e r c o m p l e t e d t h e a c t u a l a s s e s s m e n t s e x c e p t f o r t h e f i n a l o n e s o f t h e e x p e r i m e n t a l g r o u p . 4 . T h e t o o l s c h o s e n f o r t h e a s s e s s m e n t s w e r e l i m i t e d t o t h o s e w i t h i n t h e p r e s e n t c a p a b i l i t i e s o f c o m m u n i t y h e a l t h n u r s e s , a n d c u r r e n t l y i n u s e b y t h e V a n c o u v e r H e a l t h D e p a r t - m e n t . 5 . No m e t h o d w a s u s e d t o c o n t r o l o r i n f l u e n c e a c c e s s t o o t h e r p u b l i c o r p r i v a t e h e a l t h s e r v i c e s . 6. C o m p l e t i o n o f t h e p r e g n a n c y p r o f i l e a n d 2 4 h o u r n u t r i t i o n a l i n t a k e o f t h e i n f a n t w e r e d e p e n d e n t u p o n t h e m o t h e r ' s r e c a l l . H Y P O T H E S E S T E S T E D I N T H E S TUDY T h e n u l l h y p o t h e s e s t e s t e d i n t h e s t u d y w e r e : I T h a t t h e s c h e d u l e d c o m m u n i t y h e a l t h n u r s i n g a s s e s s m e n t s b e t w e e n b i r t h a n d n i n e m o n t h s o f a g e w i l l n o t d e t e c t a n y d e v e l o p m e n t a l i m p a i r m e n t s w h i c h h a v e n o t a l r e a d y b e e n d e t e c t e d b y e x i s t i n g h e a l t h s e r v i c e s . I I T h a t t h e r e i s n o s i g n i f i c a n t d i f f e r e n c e i n t h e n u m b e r o f d e v e l o p m e n t a l i m p a i r m e n t s d e t e c t e d a t n i n e m o n t h s o f a g e , between a group o f i n f a n t s s c r e e n e d by t h e pro p o s e d s c h e d u l e o f a s s e s s m e n t s and a group n o t so s c r e e n e d . I l l T h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f c h i l d r e n e x h i b i t i n g d e v e l o p m e n t a l i m p a i r m e n t s by n i n e months o f age, between a group o f " a t r i s k " i n f a n t s and a group n o t " a t r i s k " , u s i n g t h e c r i t e r i a f r o m t h e V a n c o u v e r H e a l t h Department's p r e g n a n c y and i n f a n t p r o f i l e s . OVERVIEW OF THE REMAINDER OF THE STUDY C h a p t e r I I i s a r e v i e w o f t h e l i t e r a t u r e f o c u s i n g on th e c o n t r o v e r s y s u r r o u n d i n g s e l e c t e d f o l l o w - u p o f i n f a n t s v e r s u s mass s c r e e n i n g programs; t h e p r e d i c t a b i l i t y o f sub- sequent i n f a n t d i s a b i l i t y f r o m p r e n a t a l and b i r t h c r i t e r i a ; t h r e e programs o f i n f a n t s c r e e n i n g ; and t h e c h o i c e o f a s s e s s - ment t o o l s . C h a p t e r I I I i s a d e s c r i p t i o n o f t h e d e s i g n . a n d method- o l o g y o f the s t u d y . C h a p t e r IV i s an a n a l y s i s o f t h e d a t a o b t a i n e d f r o m t h e s t u d y . C h a p t e r V i s a summary o f t h e f i n d i n g s o f t h e s t u d y ; t h e c o n c l u s i o n s a r r i v e d a t ; i m p l i c a t i o n s ; and recommendations f o r f u r t h e r r e s e a r c h . 10 CHAPTER I I REVIEW OF THE.'-'LITERATURE .' The l i t e r a t u r e r e v i e w i s d i s c u s s e d under t h e f o l l o w i n g h e a d i n g s : a t r i s k v e r s u s mass s c r e e n i n g ; two European i n f a n t p r o t e c t i o n programs; t h e Edmonton program; c r i t e r i a p r o p o s e d f o r i n d e n t i f y i n g i n f a n t s " a t r i s k " and c h o i c e o f measurement p r o c e d u r e s . AT RISK VERSUS MASS SCREENING E a r l y i d e n t i f i c a t i o n and t r e a t m e n t o f h a n d i c a p p i n g c o n d i t i o n s i n c h i l d r e n was a r e c u r r e n t theme i n t h e l i t e r a t u r e , f o c u s i n g n o t o n l y on t h o s e who w i l l p r e d i c t a b l y f u n c t i o n a t a below-normal l e v e l , b u t t h o s e whose h a n d i c a p ( s ) may be h i d d e n a t b i r t h , and t h e p r e d i c t i o n be l e s s r e a d i l y made. I n f a n t " a t r i s k " r e g i s t e r s were d e v e l o p e d i n . an a t t e m p t t o more e f f e c t i v e l y a p p l y e x i s t i n g h e a l t h r e s o u r c e s . On t h e b a s i s o f e p i d e m i o l o g i c a l s u r v e y s and s c r e e n i n g programs i n e x i s t e n c e , v u l n e r a b l e s e c t o r s o f t h e i n f a n t p o p u l a t i o n were i d e n t i f i e d as b e i n g a t r e l a t i v e l y g r e a t e r r i s k t h a n o t h e r s . S h e r i d a n was t h e e a r l i e s t r e f e r e n c e p o i n t a l l u d e d t o i n t h e l i t e r a t u r e r e v i e w e d u r g i n g t h e s u r v e i l l a n c e o f " a t r i s k " i n f a n t s u n t i l p h y s i c a l and m e n t a l development p r o g r e s s e s 1 n o r m a l l y . She gave s p e c i f i c c r i t e r i a and recommended s c r e e n i n g p r o c e d u r e s . F o l l o w i n g h er recommendations, a number M.D. S h e r i d a n , " I n f a n t s a t R i s k o f H a n d i c a p p i n g C o n d i t i o n s , " M o n t h l y B u l l e t i n M i n . H e a l t h Lab. S e r v i c e s , X X I I ( 1 9 6 2 ) , 238. 11 o f r i s k r e g i s t e r s were d e v e l o p e d u s i n g v a r i a t i o n s o f h e r 2 c r i t e r i a , s u c h as K e t t e r i n g ' s . C o n t r o v e r s y f o l l o w e d c l o s e on t h e h e e l s o f p o p u l a r i z a - t i o n o f the r e g i s t e r c o n c e p t , on t h r e e f r o n t s : e t h i c a l , 3 economic and s c i e n t i f i c . M e i e r summed up t h e e t h i c a l p r o b l e m as l i m i t i n g a s c r e e n i n g and f o l l o w - u p program t o a number o f c h i l d r e n who, b a s e d on a r b i t r a r y c r i t e r i a , were f e l t t o be a t r i s k , w i t h t h e p o s s i b i l i t y o f m i s s i n g o t h e r s who d e v e l o p e d an a b n o r m a l i t y l a t e r o r p o s s e s s e d a l a t e n t one n o t d e t e c t e d on e a r l y e x a m i n a t i o n . Economic arguments c e n t r e d a r o u n d t h e l a c k o f c o s t - b e n e f i t a n a l y s i s . A h i g h l y s e n s i t i v e r e g i s t e r c o u l d be expen- s i v e and l a c k s p e c i f i c i t y (some i n c l u d e d up t o 60% o f a l l 4 b i r t h s ) y e t a l e s s s e n s i t i v e one w i t h h i g h s p e c i f i c i t y , a l l o c a t i n g t h e b u l k o f h e a l t h r e s o u r c e s t o a s m a l l g r o u p o f c h i l d r e n , c o u l d have m i s s e d c h i l d r e n whose su b s e q u e n t c a r e c c. *7 was e x p e n s i v e t o s o c i e t y a t l a r g e . ' ' 2 R. W i g g l e s w o r t h , Department o f P e d i a t r i c s and C h i l d • H e a l t h , K e t t e r i n g G e n e r a l H o s p i t a l C l a s s i f i e d L i s t o f B a b i e s a t R i s k : H i g h , Medium and Low Groups, (Londomi: u n p u b l i s h e d , 1970) 3 J . M e i e r , S c r e e n i n g and Assessment o f Young C h i l d r e n a t D e v e l o p m e n t a l R i s k , ( W a s h i n g t o n , D.C: DHEW P u b l i c a t i o n s , 1 9 7 3 ) , 17. 4 T . E . Oppe, " R i s k R e g i s t e r s f o r B a b i e s , " D e v e l o p . Med. C h i l d . N e u r o l . , IX ( 1 9 6 7 ) , 13. 5 I . D . G . R i c h a r d s and C . J . R o b e r t s , "The a t r i s k I n f a n t , " L a n c e t . , I I (1967) 714. 6 J . S a c k e t t , "W.H.O. Symposium 1971," L a n c e t . , I I ( 1 9 7 4 ) , 7890. 7 A. S m i t h , " I d e n t i f i c a t i o n o f H i g h - R i s k P e r s o n s and P o p u l a t i o n G roups," WHO C h r o n i c l e , XXVII(February, 1 9 7 3 ) , 72. 12 S c i e n t i f i c c r i t i c i s m s o f t h e a t r i s k r e g i s t e r s f o c u s e d on t h e soundness o f t h e p r e m i s e s on w h i c h t h e y were based;8/9 o r on m i s a p p l i c a t i o n o f t h e c o n c e p t , b u t d e f e n c e o f t h e c o n c e p t 10/11/12 i t s e l f f o r t h e l i m i t e d p u r p o s e s f o r w h i c h i t was meant. Wa l k e r s u p p o r t e d t h e use o f r i s k r e g i s t e r s i n S c o t l a n d , where s t u d i e s showed t h a t , f o r s p e c i f i c c o n d i t i o n s such as h e a r i n g and v i s i o n d e f e c t s , c e r e b r a l p a l s y and r e t a r d a t i o n , t h r e e t i m e s as many c h i l d r e n c o n s i d e r e d " a t r i s k " by a r i s k r e g i s t e r a t 13 b i r t h d e v e l o p e d subsequent i m p a i r m e n t s . P r i n g l e , B u t l e r and D a v i e , i n a l o n g i t u d i n a l s t u d y were a b l e t o c o r r e l a t e b i r t h d a t a t o s u b s e q u e n t d e v e l o p m e n t , h e a l t h and e d u c a t i o n a l a c h i e v e - 14 ment i n 14,862 c a s e s s t i l l i n t h e s t u d y a t age seven and Q R.S. I l l i n g w o r t h , The Development o f t h e I n f a n t and Young C h i l d Normal and Abnormal (London: C h u r c h i l l L i v i n g s t o n e , 1 9 7 2 ) , 21. 9 M.G.H. Rogers, "The E a r l y R e c o g n i t i o n o f H a n d i c a p p i n g D i s o r d e r s i n C h i l d h o o d , " D e v e l o p . Med. C h i l d . N e u r o l . , X I I I ( 1 9 7 1 ) , 101. 10 M. Downs, "A C r i t i c a l Approach t o Newborn H e a r i n g S c r e e n i n g and H i g h R i s k R e g i s t e r , " B i r e q i o n a l I n s t i t u t e on E a r l i e r D e t e c t i o n and T r e a t m e n t of H a n d i c a p p i n g C o n d i t i o n s i n C h i l d r e n ( C a l i f o r n i a : B e r k e l e y U n i v . P r e s s , 1970), 14~. 1 1 L . F i s c h , "The a t r i s k I n f a n t " , L a n c e t , I I ( 1 9 6 7 ) , 940. 1 2 K . Howorth, "At R i s k I n f a n t s , " L a n c e t , I I ( 1 9 5 8 ) , 886. 13 R.G. W a l k e r , "An Assessment o f t h e C u r r e n t S t a t u s o f t h e A t R i s k R e g i s t e r , " L a n c e t , I I ( 1 9 6 7 ) , 889. M. P r i n g l e e t . a l . , 1,1,000 S e v e n - Y e a r - O l d s (London: Longmans, 1 9 6 6 ) , 2. 13 s u g g e s t e d d e v e l o p m e n t o f a w e i g h t e d f a c t o r l i s t t o f o c u s on f a c t o r s w h i c h may h a v e a g r e a t e f f e c t o n d e v e l o p m e n t i n c o m b i - n a t i o n , b u t n o t s i n g l y . T h i s w o u l d i n c r e a s e t h e y i e l d o f e a r l y s c r e e n i n g a s s e s s m e n t s a l o n g t h e i n f a n c y c o n t i n u u m . M i t c h e l l s u g g e s t e d t h a t t h e e m p h a s i s be moved f r o m r e p r o d u c t i v e c a s u a l t y t o e n v i r o n m e n t a l f a c t o r s i n t h e a t r i s k c o n c e p t . T h e s e f a c t o r s i n c l u d e d i n f a n t n u t r i t i o n , p a r e n t a l 15 s t i m u l a t i o n a n d s o c i o e c o n o m i c s t a t u s . W e r n e r , e t . a l . r e i n f o r c e d t h i s n e e d i n a H a w a i i a n s t u d y o f t e n y e a r s d u r a t i o n , i n w h i c h t h e y s t u d i e d t h e s h o r t a n d l o n g t e r m e f f e c t s o f p e r i n a t a l s t r e s s a n d e n v i r o n m e n t a l f a c t o r s i n e a r l y c h i l d h o o d . T h e y f o u n d t h e l a t t e r t o b e s i g n i f i c a n t i n t e n t i m e s a s many c a s e s o f h a n d i c a p p i n g c o n d i t i o n s a s t h e f o r m e r . A s i g n i f i c a n t number o f p h y s i c a l a n d m e n t a l h a n d i c a p s d i a g n o s e d b e f o r e t h e 16 a g e o f two c o r r e l a t e d w i t h t h o s e p r e s e n t a t age t e n . A number o f a r t i c l e s showed a t r e n d away f r o m t h e " i n f a n t a t r i s k " r e g i s t e r c o n c e p t t o w a r d a c o n c e p t o f t h e h i g h r i s k i n f a n t , who c o u l d be i d e n t i f i e d f r o m c o n c e p t i o n t h r o u g h i n f a n c y . R e g u l a r h e a l t h s u r v e i l l a n c e was recommended w i t h more i n t e n s i v e s u p e r v i s i o n o f t h e s m a l l number o f h i g h 15 R.G. M i t c h e l l , " C h a n g i n g C o n c e p t s o f R i s k , " D e v e l o p . Med. C h i l d . N e u r o l . , X V I I ( 1 9 7 5 ) , 2 7 8 . 16 W e r n e r , e t . a l . , T h e C h i l d r e n o f K a u a i ( H o n o l u l u : U n i v . o f H a w a i i P r e s s , 1 9 7 1 ) , 1. 14 r i s k b a b i e s . R i s k r e g i s t e r s , t h e n , w o u l d complement r a t h e r t h a n r e p l a c e r e g u l a r s c r e e n i n g r e g i m e s f o r a l l . - . 17,18,19,20 i n f a n t s . ' ' ' TWO EUROPEAN INFANT PROTECTION PROGRAMS Some European c o u n t r i e s , n o t a b l y F r a n c e and Sweden, have d e m o n s t r a t e d t h e e f f e c t i v e n e s s o f r i g o r o u s m a t e r n a l - c h i l d p r o t e c t i v e s e r v i c e s by p u b l i c h e a l t h a u t h o r i t i e s . Wynn and Wynn d e s c r i b e d how F r a n c e had l o w e r e d i t s p e r i n a t a l m o r t a l i t y r a t e s d r a s t i c a l l y o v e r t h e p a s t t e n y e a r s . C o n c e r n had a r i s e n o v e r t h e o f f i c i a l e s t i m a t e o f 2.5% o f t h e c o u n t r y ' s g r o s s n a t i o n a l p r o d u c t b e i n g s p e n t on t h e c o s t s o f permanent d i s a b i l i t y o r i g i n a t i n g i n e a r l y l i f e , as w e l l as t h e c o s t s t o s o c i e t y as a whole i n terms o f p r o d u c t i v i t y , and t h e 22 immeasureable c o s t s t o t h e i n d i v i d u a l and f a m i l y . L e g i s l a - 1 7 J . O . F o r f a r , "At R i s k R e g i s t e r s , " D e v e l o p . Med. C h i l d . N e u r o l . , X (1968) 384. 1 8 T . T . Ingram "The New Approach t o E a r l y D i a g n o s i s o f H a n d i c a p s i n C h i l d h o o d , " D e v e l o p . Med. C h i l d . N e u r o l . , X I (1968) 290. 19 Oppe, o p . c i t . , 12. WHO Symposium on C h i l d H e a l t h , WHO C h r o n i c l e , XXV ( J u l y , 1 9 7 1), 319. 2 1M. Wynn and A. Wynn, The R i g h t o f E v e r y C h i l d t o H e a l t h C a r e (London: C o u n c i l f o r O c c a s i o n a l P a p e r s on C h i l d W e l f a r e , 1 9 7 4 ) , 4. 22 " i b i d . , 6. 15 t i o n w a s p a s s e d i n 1 9 7 0 r e q u i r i n g t h a t e v e r y c h i l d b e s e e n b y t h e l o c a l h e a l t h a u t h o r i t y f o r c e r t a i n h e a l t h c h e c k s , i n c l u d i n g 2 3 d e v e l o p m e n t a l a s s e s s m e n t s . H e a l t h v i s i t o r s p l a y e d a n a c t i v e r o l e i n p r e a n d p o s t n a t a l home a n d c l i n i c c o n t a c t s . A l t h o u g h m o r e i n t e n s i v e s u r v e i l l a n c e w a s a c c o r d e d t h e c h i l d c o n s i d e r e d a t r i s k , t h e e m p h a s i s , a s t h e t i t l e s u g g e s t s , w a s o n t h e r i g h t o f e v e r y c h i l d t o o n g o i n g a s s e s s m e n t a n d p r e v e n t i v e h e a l t h c a r e . F r a n c e ' s h e a l t h b u d g e t w a s l a r g e b u t j u s t i f i e d b y t h e g o v e r n - m e n t b y t h e l o n g t e r m s a v i n g s i n t r e a t m e n t c o s t s , a n d t h e i m p r o v e d q u a l i t y o f l i f e w h i c h e a r l y i n t e r v e n t i o n ' a n d p r e v e n - 24 t i o n b r o u g h t a b o u t . T h e W y n n s d e s c r i b e d S w e d e n ' s c o m p r e h e n s i v e p r e n a t a l a n d p o s t n a t a l p r o g r a m , i n w h i c h t h e h e a l t h v i s i t o r a l s o p l a y e d a m a j o r r o l e : F o r t h e m a j o r i t y o f m o t h e r s w i t h w e l l b a b i e s , t h e m a i n v a l u e o f t h e v i s i t s a n d e x a m i n a t i o n s p r o b a b l y l a y i n t h e i r c o n t r i b u t i o n t o h e r h e a l t h e d u c a t i o n a n d e d u c a t i o n i n h e a l t h c a r e , a p a r t f r o m t h e u s u a l i m m u n i - z a t i o n s . T h e r e w a s , h o w e v e r , a s u b s t a n t i a l m i n o r i t y o f i n f a n t s n e e d i n g r e f e r r a l t o a d o c t o r o r p e d i a t r i c i a n a t s o m e s t a g e . 2 5 R e a d i n g t h e t w o w o r k s o f t h e W y n n s f o l l o w i n g t h e i r v i s i t t o V a n c o u v e r i n 1 9 7 4 m o t i v a t e d t h e r e s e a r c h e r t o i n v e s t i g a t e t h e l o c a l n e e d f o r , a n d t h e f e a s i b i l i t y o f s u c h a p r o g r a m . L i t t l e 2 3 " i b i d . 2 4 ^ I b i d . , 7. 25 M. Wynn a n d A . W y n n , T h e P r o t e c t i o n o f M a t e r n i t y a n d I n f a n c y ( L o n d o n : C o u n c i l f o r C h i l d r e n ' s W e l f a r e , 1 9 7 4 ) , 2 2 . 16 r e f e r e n c e was f o u n d i n t h e l i t e r a t u r e t o C a n a d i a n p r o g r a m s o f t h e same n a t u r e , e x c e p t f o r o n e i n E d m o n t o n . EDMONTON'S "AT R I S K " P E D I A T R I C PROGRAM E d m o n t o n h a s o p e r a t e d a n " a t r i s k " p e d i a t r i c p r o g r a m 26 s i n c e 1 9 6 9 . The c r i t e r i a f o r t h e A t R i s k R e g i s t e r was o b t a i n e d f r o m t h e P h y s i c i a n ' s N o t i c e o f L i v e B i r t h a n d t h e i n i t i a l n e w b o r n v i s i t t o t h e home b y a c o m m u n i t y h e a l t h n u r s e . A t t h e f i r s t c o n t a c t a n d t h e n b e t w e e n s i x a n d t w e l v e m o n t h s o f a g e , a t c l i n i c o r home v i s i t , a l l b a b i e s w e r e g i v e n a c o m p l e t e p h y s i c a l e x a m i n a t i o n i n c l u d i n g h e a d c i r c u m f e r e n c e m e a s u r e m e n t ; l e n g t h a n d w e i g h t ; D e n v e r D e v e l o p m e n t a l T e s t ; H e a r i n g t e s t o f r e s p o n s e t o s p e e c h a n d g r o s s h e a r i n g ; a n d v i s i o n t e s t f o r a b s e n c e o f s q u i n t a n d e q u a l p u p i l l a r y l i g h t r e f l e x e s . D e p e n d i n g u p o n f i n d i n g s a n d a s s e s s m e n t o f t h e f a m i l y a s t o l i k e l i h o o d o f s e e k i n g g o o d m e d i c a l s u p e r v i s i o n , r e c h e c k s w e r e s c h e d u l e d a t o n e y e a r o f a g e a n d e i g h t e e n m o n t h s . I f a l l was t h e n n o r m a l , t h e c h i l d ' s name was r e m o v e d f r o m t h e A t R i s k S u p e r v i s i o n F i l e a n d r e c a l l e d f o r a p r e s c h o o l e x a m i n a t i o n . The a s s e s s m e n t s w e r e d o n e b y t h e c o m m u n i t y . h e a l t h n u r s e s . R e f e r r a l s o f a n y i m p a i r - m e n t s d e t e c t e d w e r e made t o t h e t r a d i t i o n a l m e d i c a l s e r v i c e s . P a r t o f t h e s u c c e s s o f t h i s p r o g r a m was a t t r i b u t e d t o t h e 26 E d m o n t o n , B o a r d o f H e a l t h , S u g g e s t e d F o l l o w - U p o f " A t R i s k " B a b i e s . u n p u b l i s h e d g u i d e f o r C o m m u n i t y H e a l t h N u r s e s , 1 9 6 9 . 1 7 9 0 - 9 5 % a t t e n d a n c e o f i n f a n t s a t t h e c i t y i m m u n i z a t i o n c l i n i c s , w h e r e h e a l t h c o u n s e l l i n g a n d e x a m i n a t i o n s w e r e i n c l u d e d a s 2 7 p a r t o f t h e s e r v i c e . A T R I S K C R I T E R I A P R O P O S E D F o r t h i s s t u d y c r i t e r i a f o r i d e n t i f i c a t i o n o f t h o s e i n f a n t s a t r i s k o f s u b s e q u e n t d e v e l o p m e n t a l i m p a i r m e n t w e r e c h o s e n f r o m a r e v i e w o f p e r t i n e n t l i t e r a t u r e i n c o n j u n c t i o n w i t h e x a m i n a t i o n o f t h e c u r r e n t l y u s e d t o o l s i n t h e V a n c o u v e r H e a l t h D e p a r t m e n t : t h e P r e g n a n c y P r o f i l e a n d t h e I n f a n t P r o - f i l e A t R i s k C r i t e r i a . 2 8 T h e P r e g n a n c y P r o f i l e w a s d e v e l o p e d i n 1 9 7 4 , d e s i g n e d p r i m a r i l y t o a s s i s t c o m m u n i t y h e a l t h n u r s e s t e a c h i n g p r e n a t a l c l a s s e s i n i d e n t i f y i n g t e a c h i n g n e e d s o f c l a s s p a r t i c i p a n t s a s a g r o u p ; a n d p o s s i b l e r i s k f a c t o r s i n i n d i v i d u a l c a s e s . T h e c r i t e r i a u s e d t o a s s e s s r i s k t o t h e f e t u s a n d s u b s e q u e n t 2 9 3 0 c h i l d w e r e c o n s i s t e n t w i t h t h o s e o f G o o d w i n a n d N e s b i t t , a n d t h o s e i n c o r p o r a t e d m o r e r e c e n t l y i n t o t h e P e r i n a t a l P r o - 3 1 gramme of B r i t i s h Columbia's new prenatal record. 2 7 * I b i d . 2 8 S e e A p p e n d i x A 2 9 W.G. G o o d w i n , " T h e S t r a t e g y o f F e t a l R i s k M a n a g e m e n t , " C a n a d i a n F a m i l y P h y s i c i a n , r e p r i n t , A p r i l , 1 9 7 3 . 3 0 R . E . L . N e s b i t t a n d R.H. A u b r y , " N e s b i t t S c o r i n g S y - s t e m - t h e M a t e r n a l - C h i l d H e a l t h C a r e I n d e x , " A m e r . J . O b s t e t r i c s a n d G y n e c o l o g y , C I I I ( 1 9 6 7 ) , 1 3 . 3 1 P e r i n a t a l P r o g r a m m e o f B . C . , " B . C . ' s New P r e n a t a l R e - c o r d , " B . C . M e d i c a l J o u r n a l , X V I I ( M a y , 1 9 7 5 ) , 2 4 . 18 A n u t r i t i o n a l a s s e s s m e n t and a q u e s t i o n a b o u t smoking h a b i t s were added t o t h e u s u a l q u e s t i o n s about p r e v i o u s p r e g - n a n c i e s , m e d i c a l h i s t o r y and t h e c o u r s e o f t h e p r e s e n t p r e g - nancy. B o t h p r e n a t a l n u t r i t i o n and smoking d u r i n g p r e g n a n c y were r e c e i v i n g i n c r e a s e d a t t e n t i o n i n t h e l i t e r a t u r e as t o t h e i r e f f e c t s , on t h e unborn c h i l d . H i g g i n s o f t h e M o n t r e a l D i e t D i s p e n s a r y has p r e s e n t e d e v i d e n c e o v e r t h e p a s t t h i r t y y e a r s s u p p o r t i n g t h e s i g n i f i c a n c e o f n u t r i t i o n (and n u t r i t i o n i n t e r v e n t i o n ) d u r i n g p r e g n a n c y on t h e g r o w t h and development 32 o f t h e r e s u l t i n g i n f a n t . S t o v e l , i n a c o m p r e h e n s i v e r e v i e w o f t h e l i t e r a t u r e c o n c e r n i n g n u t r i t i o n i n p r e g n a n c y summarized c u r r e n t t h o u g h t s on i t s e f f e c t on i n f a n c y : " . . . t h e l i t e r a t u r e s t r o n g l y s u p p o r t s t h e i m p o r t a n c e o f good n u t r i t i o n and an adequate w e i g h t g a i n d u r i n g p r e g - nancy t o a v o i d t h e f o l l o w i n g p a t t e r n : U n d e r w e i g h t Mother and/or Low Weight G a i n D u r i n g Pregnancy 5» Low B i r t h Weight I n f a n t — » h i g h e r m o r t a l i t y r a t e —f> g r e a t e r chance o f p h y s i c a l and m e n t a l r e t a r d a t i o n . " 3 3 A. H i g g i n s , " N u t r i t i o n and t h e Outcome.of P r e g n a n c y " t e x t o f t h e a d d r e s s g i v e n by Mrs H i g g i n s a t t h e IV I n t e r n a t i o n a l C o n g r e s s o f E n d o c r i n o l o g y Symposium, June 2 3 r d , 1972, 1. S. S t o v e l , N u t r i t i o n i n P r e g n a n c y , ( V a n c o u v e r : P a c i f i c H e a l t h E d u c a t i o n A s s o c i a t i o n ) , 1975, i . 19 B oth a l s o spoke t o t h e d e f i n i t e r e l a t i o n s h i p o f smoking t o l o w e r b i r t h w e i g h t i n f a n t s , a l t h o u g h t h e e x a c t r e l a t i o n s h i p was n ot known. The I n f a n t P r o f i l e A t R i s k C r i t e r i a was d e v e l o p e d i n 1975, as a c h e c k l i s t f o r m a t f o r t h e i n f o r m a t i o n p r o v i d e d on t h e P h y s i c i a n ' s N o t i f i c a t i o n o f L i v e B i r t h . I t a l e r t e d t h e com- m u n i t y h e a l t h n u r s e t o b i r t h i n f o r m a t i o n w h i c h may have put t h e i n f a n t a t r i s k o f s u b s e q u e n t c o m p l i c a t i o n s , and s e r v e d as a w o r k s h e e t f o r r e c o r d i n g n o t e s o f t h e i n i t i a l newborn v i s i t . CHOICE OF MEASUREMENT PROCEDURES The measurement p r o c e d u r e s c h o s e n f o r use i n t h e s t u d y were s e l e c t e d f r o m t h o s e c u r r e n t l y u sed by community h e a l t h n u r s e s and known t o g r a d u a t e s o f b a c c a l a u r e a t e n u r s i n g p r o - grams. T h i s was a l i m i t a t i o n o f t h e s t u d y , as s t a t e d , b u t a l s o a s t r e n g t h s h o u l d i m p l e m e n t a t i o n o f su c h a program be i n d i c a t e d f o l l o w i n g t h e s t u d y . A r e v i e w o f t h e l i t e r a t u r e was p u r s u e d t o c o n f i r m t h e a p p r o p r i a t e n e s s o f t h e as s e s s m e n t t o o l s c h o s e n and t o d e t e r m i n e t h e assessment s c h e d u l e . SUMMARY The l i t e r a t u r e r e v i e w i n c l u d e d an i n v e s t i g a t i o n o f e x i s t i n g p e d i a t r i c programs w i t h emphasis on two European programs and one C a n a d i a n program. The i s s u e o f s e l e c t i v e v e r s u s mass s c r e e n i n g was seen I b i d . , 24. 20 t o be c o n t r o v e r s i a l , b u t i t a p p e a r e d t h a t t h e t r e n d was away f r o m a t r i s k r e g i s t e r s t o w a r d r e g u l a r s u r v e i l l a n c e o f a l l i n f a n t s w i t h i n c r e a s e d a t t e n t i o n d i r e c t e d t o w a r d t h e i n f a n t a t r i s k . C h o i c e o f a t r i s k c r i t e r i a v a r i e d i n t h e a r t i c l e s r e - v i e w e d , b u t t h e d a t a c o m p r i s i n g t h e V a n c o u v e r H e a l t h D e p a r t - m e n t ' s P r e g n a n c y a n d I n f a n t P r o f i l e s w e r e c o n s i s t e n t w i t h t h e c u r r e n t l y a c c e p t e d a t r i s k c r i t e r i a a s o u t l i n e d b y G o o d w i n a n d B r i t i s h C o l u m b i a ' s New P r e n a t a l R e c o r d . The l i t e r a t u r e s e a r c h was d i r e c t e d l a s t l y t o w a r d c o n f i r m a t i o n o f t h e a p p r o p r i a t e n e s s o f t h e p r o p o s e d a s s e s s m e n t t o o l s a n d d e t e r m i n a t i o n o f a s c r e e n i n g s c h e d u l e f o r t h e s t u d y . F u r t h e r d i s c u s s i o n o f t h i s l a s t a r e a w i l l be c o n t i n u e d i n C h a p t e r I I I , D e s i g n a n d M e t h o d o l o g y . 21 CHAPTER I I I DESIGN AND METHODOLOGY T h i s c h a p t e r w i l l f o c u s on t h r e e m a j o r a r e a s : t h e p r e l i m i n a r y s t u d y ; t h e d e s i g n o f t h e s t u d y , i n c l u d i n g s e t t i n g a n d s a m p l e ; a n d t h e m e t h o d o l o g y o f t h e s t u d y . The m e t h o d o l o g y s e c t i o n c o m p r i s e s d i s c u s s i o n s o f s t a f f i n s t r u c t i o n , m e a s u r e - ment p r o c e d u r e s , d a t a c o l l e c t i o n a n d d a t a a n a l y s i s . THE P RELIMINARY STUDY F o l l o w i n g an i n - s e r v i c e p r o g r a m i n i n f a n t a s s e s s m e n t i n 1 9 7 3 , t h e r e s e a r c h e r h a d c o m p l e t e d a number o f a p p r a i s a l s on n e w b o r n s i n h e r a s s i g n m e n t a s a c o m m u n i t y h e a l t h n u r s e . E i g h t e e n o f t h e s e i n f a n t s , t h e n t w e l v e t o e i g h t e e n m o n t h s o l d , w e r e r e v i s i t e d b e t w e e n F e b r u a r y a n d M a r c h 1975 t o d e t e r m i n e h e a l t h s t a t u s . I n c l u d e d i n t h i s d e t e r m i n a t i o n w e r e a p h y s i c a l e x a m i n a t i o n ; D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t ; v i s i o n a n d h e a r i n g t e s t ; a n d a h e a l t h h i s t o r y o b t a i n e d f r o m t h e p a r e n t s . W i t h i n t h e l i m i t a t i o n s o f t h e s a m p l e s i z e a n d non r a n - dom s e l e c t i o n , t h e f i n d i n g s i n d i c a t e d a u s e f u l n e s s o f i n f a n t a s s e s s m e n t s . O n l y t h r e e o f t h e i n f a n t s h a d had a p h y s i c a l e x a m i n a t i o n s i n c e s i x w e e k s o f a g e , y e t s i x w e r e r e f e r r e d t o t h e i r f a m i l y p h y s i c i a n s f o r e x i s t i n g p r o b l e m s : o b e s i t y , " s q u i n t , d e l a y e d f i n e m o t o r c o o r d i n a t i o n , s k i n c o n d i t i o n s o f l o n g d u r a t i o n ; a s a r e s u l t o f t h e s t u d y . A l l o f t h e c o n d i t i o n s s a v e one ( d e l a y e d s p e e c h ) c o u l d h a v e b e e n i d e n t i f i e d e a r l i e r , a n d t r e a t e d o r t h e i r i m p a c t l e s s e n e d a t t h e t i m e . Of i n t e r e s t 22 was t h a t a l l o f t h e c h i l d r e n h a d t h e i r i m m u n i t y s t a t u s up t o d a t e , o f t e n u s e d a s a h e a l t h s t a t u s i n d i c a t o r , a n d a l l o f t h e p a r e n t s saw t h e i r c h i l d r e n a s h e a l t h y . A l t o g e t h e r , t e n o f t h e e i g h t e e n w e r e r e f e r r e d t o a t l e a s t o n e h e a l t h p r o f e s s i o n a l f o r f o l l o w - u p o f i d e n t i f i e d p r o b l e m s . P a r e n t a l r e s p o n s e was p o s i t i v e a n d a d v i s e d f o l l o w - u p was p u r s u e d . A l t h o u g h no c o r r e l a t i o n s w e r e made b e t w e e n i n d i v i d u a l b i r t h a n d i n i t i a l a s s e s s m e n t d a t a a n d s u b s e q u e n t h e a l t h s t a t u s , o f t h o s e s e v e n c h i l d r e n w i t h some r i s k f a c t o r s i d e n t i f i e d a t b i r t h , f i v e h a d e x h i b i t e d some d e v e l o p m e n t a l i m p a i r m e n t s , a s c o m p a r e d w i t h f i v e o f e l e v e n n o t c o n s i d e r e d a t r i s k i n i t i a l l y . The sample was t o o small a n d t h e s t u d y t o o i n f o r m a l t o d e t e r m i n e w h e t h e r t h i s m i g h t i n d i c a t e a n e e d f o r f o l l o w - u p o f t h e " a t r i s k " i n f a n t o n l y , o r r e g u l a r a s s e s s m e n t o f a l l i n f a n t s . O n l y s i x o f t h e i n f a n t s h a d a t t e n d e d c h i l d h e a l t h c e n t r e s . On r e v i e w o f t h e V a n c o u v e r H e a l t h D e p a r t m e n t ' s 1974 a n n u a l r e p o r t , t h i s was c o n s i s t e n t w i t h c i t y - w i d e s t a t i s t i c s . O n l y 3 0 . 8 % o f i n f a n t s w e r e e n r o l l e d i n a c h i l d h e a l t h c e n t r e b e f o r e t w e l v e m o n t h s o f a g e . I t was c o n c l u d e d t h a t a c h i l d h e a l t h c e n t r e - b a s e d a s s e s s m e n t p r o g r a m s u c h a s E d m o n t o n ' s w o u l d n o t be a s e f f e c t i v e i n t h i s s e t t i n g a s one b a s e d on home v i s i t s . C i t y V a n c o u v e r H e a l t h D e p a r t m e n t , o f V a n c o u v e r , 1 9 7 5 ) , 6. H e a l t h 1974 ( V a n c o u v e r : DESIGN OF THE STUDY E x p e r i m e n t a l D e s i g n The t h r e e p u r p o s e s o f t h e s t u d y w e r e : t o d e t e r m i n e w h e t h e r a n y d e v e l o p m e n t a l i m p a i r m e n t s c o u l d be d e t e c t e d s o l e l y b y c o m m u n i t y h e a l t h n u r s e a s s e s s m e n t s ; w h e t h e r a t n i n e m o n t h s o f age t h a t g r o u p o f i n f a n t s a s s e s s e d b y t h e p r o p o s e d s c h e d u l e o f a s s e s s m e n t s w o u l d d i f f e r f r o m a g r o u p n o t s o a s s e s s e d i n t h e number o f d e v e l o p m e n t a l i m p a i r m e n t s p r e s e n t ; a n d w h e t h e r t h e V a n c o u v e r H e a l t h D e p a r t m e n t ' s P r e g n a n c y a n d I n f a n t P r o f i l e s h a d p r e d i c t i v e v a l i d i t y f o r t h o s e i n f a n t s who w o u l d d e v e l o p s u b s e q u e n t i m p a i r m e n t s . The d e s i g n e m p l o y e d f o r H y p o t h e s i s I was q u a s i - e x p e r i - 2 m e n t a l t i m e s e r i e s d e s i g n : 0 0 0 X 0 0 w h e r e X was t h e d e t e c t i o n a n d r e f e r r a l o f d e v e l o p m e n t a l i m p a i r m e n t s ; a n d 0 t h e s c h e d u l e d a s s e s s m e n t s p r o p o s e d . O n l y t h e e x p e r i m e n t a l g r o u p w e r e a s s e s s e d a n d t h e X c o u l d be a p p l i e d b e t w e e n a n y o r a l l o f t h e 0 s . C a u s a l r e l a t i o n s h i p s b e t w e e n v a r i a b l e s w e r e b e i n g t e s t e d i n H y p o t h e s e s I I a n d I I I b u t a t r u e e x p e r i m e n t a l d e s i g n was r u l e d o u t a s " . . . t h e r e was no f o r m a l means o f c e r t i f y i n g t h a t t h e g r o u p s w o u l d h a v e b e e n e q u i v a l e n t had i t n o t b e e n 3 X 0 f o r t h e X." A s t a t i c g r o u p c o m p a r i s o n was c h o s e n : — - 7?. D.T. C a m p b e l l a n d J . C . S t a n l e y , E x p e r i m e n t a l a n d Q u a s i - E x p e r i m e n t a l D e s i g n s f o r R e s e a r c h , ( C h i c a g o : Rand M c N a l l y and a n d C o . , 1966), 40. 3 I b i d , 12. 24 F o r H y p o t h e s i s I I , X was t h e p r o p o s e d s c h e d u l e o f a s s e s s m e n t s a n d 0 was t h e n i n e month a s s e s s m e n t s a p p l i e d t o b o t h t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s . F o r H y p o t h e s i s I I I , X was t h e " a t r i s k " c a t e g o r i z a t i o n b y t h e p r e g n a n c y a n d i n f a n t p r o f i l e s , a n d 0 t h e s u b s e q u e n t d e t e c t i o n o f d e v e l o p m e n t a l i m p a i r m e n t s . The D e s i g n a l s o i n c l u d e d an i n t e r v i e w c o m p o n e n t w i t h a s e m i s t a n d a r d i z e d f o r m a t t o a l l o w f o r t h e u s u a l s e r v i c e n e e d s o f v i s i t s t o be met: d i s c u s s i o n o f f e e d i n g and s l e e p h a b i t s , f a m i l y r e l a t i o n s h i p s , n o r m a l g r o w t h a n d d e v e l o p m e n t , a n d a n t i - c i p a t o r y g u i d a n c e f o r t h e p a r e n t s . I n f o r m a t i o n r e g a r d i n g t h e h e a l t h o f t h e i n f a n t b e t w e e n v i s i t s a n d u s e o f p r i v a t e a n d p u b l i c h e a l t h s e r v i c e s was a l s o n o t e d . The S e t t i n g The s e t t i n g was o n e h e a l t h u n i t a r e a i n a l a r g e c i t y , c o m p r i s i n g a g e o g r a p h i c a l a r e a o f s e v e n t e e n s q u a r e m i l e s , a n d a p o p u l a t i o n o f 1 2 7 , 1 6 5 . " The s o c i o e c o n o m i c r a n g e was b r o a d , a n d a w i d e r e p r e s e n t a t i o n o f e t h n i c g r o u p s i n c l u d e d . ^ T h e S u b j e c t s A t i m e - s e q u e n t i a l s a m p l e o f one h u n d r e d i n f a n t s was c h o s e n , c o m p o s e d o f a l l t h o s e i n f a n t s b o r n i n t h e s e t t i n g f r o m mid-May t o ^ i d - J u l y , 1 9 7 5 . I n f a n t s w e r e a l t e r n a t e l y V a n c o u v e r C i t y P l a n n i n g D e p a r t m e n t , V a n c o u v e r L o c a l A r e a s , ( V a n c o u v e r : C i t y o f V a n c o u v e r , A p r i l , 1 9 7 5 ) , b a s e d on 1 9 7 1 C e n s u s D a t a . 5 I b i d . 25 a s s i g n e d t o t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s b y t h e c l e r i c a l s t a f f u n t i l f i f t y w e r e i n c l u d e d i n e a c h g r o u p . No a t t e m p t was made t o m a t c h i n f a n t s i n t h e two g r o u p s a s t h e p r o f i l e s c o n t a i n e d d e m o g r a p h i c a l d a t a w h i c h was b e i n g t e s t e d f o r p r e d i c t i v e v a l i d i t y , s u c h a s p a r i t y o f t h e m o t h e r , s o c i o - e c o n o m i c s t a t u s o f t h e f a m i l y o r b i r t h w e i g h t . METHODOLOGY OF THE STUDY S t a f f I n s t r u c t i o n N u r s i n g a n d c l e r i c a l s t a f f w e r e g i v e n i n s t r u c t i o n s h e e t s a n d m e e t i n g s w e r e h e l d p r i o r t o t h e s t a r t o f t h e s t u d y t o c l a r i f y t h e i r i n v o l v e m e n t . The c l e r i c a l s t a f f , o n r e c e i v i n g t h e P h y s i c i a n ' s N o t i c e o f L i v e B i r t h f r o m t h e P r o v i n c i a l D e p a r t m e n t o f V i t a l S t a t i s t i c s , c o m p l e t e d an I n f a n t - P r o f i l e f r o m t h e i n f o r m a t i o n g i v e n o n t h e b i r t h n o t i c e , a t t a c h e d a b l a n k P r e g n a n c y P r o f i l e , a n d a l t e r n a t e l y a s s i g n e d t h e i n f a n t s t o t h e e x p e r i m e n t a l and c o n t r o l g r o u p s . The e x p e r i m e n t a l g r o u p ' s f o r m s w e r e g i v e n t o t h e r e s e a r c h e r f o r t h e i n i t i a l n e w b o r n v i s i t a n d t h e c o n t r o l g r o u p ' s t o t h e d i s t r i c t c o m m u n i t y h e a l t h n u r s e s a s u s u a l , f o r ' t h e i r i n i t i a l n e w b o r n v i s i t s . The c o m m u n i t y h e a l t h n u r s e s w e r e i n s t r u c t e d t o e x p l a i n t o t h e m o t h e r s , d u r i n g t h o s e v i s i t s , t h a t a r e s e a r c h s t u d y was See A p p e n d i x C 26 b e i n g done about i n f a n t d e v e l o p m e n t a l a s s e s s m e n t s , and t h a t when t h e i r i n f a n t s were n i n e months o f age t h e r e s e a r c h e r w o u l d be c o n t a c t i n g them t o r e q u e s t t h e i r p a r t i c i p a t i o n . They were a l s o i n s t r u c t e d t o ask t h e mothers t o c o m p l e t e a . Pregnancy P r o f i l e from r e c a l l . Notes o f t h e v i s i t were t o be made on t h e I n f a n t P r o f i l e and two p r o f i l e s f i l e d t o g e t h e r i n the h e a l t h u n i t o f f i c e , as n o r m a l l y done. I t was e x p l a i n e d t h a t t h e s t u d y was not t o hamper t h e no r m a l f o l l o w - u p t h a t w o u l d r o u t i n e l y be i n i t i a t e d , such as r e p e a t e d home c o n t a c t s where c o n c e r n s had been i d e n t i f i e d . Measurement P r o c e d u r e s 7 F i v e assessment t o o l s were c h o s e n f o r use i n v a r i o u s Q c o m b i n a t i o n s f o r f i v e s c h e d u l e d i n f a n t v i s i t s . The p h y s i c a l e x a m i n a t i o n was ba s e d on o b s e r v a t i o n , 9 p a l p a t i o n , p e r c u s s i o n and a u s c u l t a t i o n (McLean) and i n c l u d e d 10 r e f l e x e s (Haynes) and c o m p l e t i o n o f s t a n d a r d i z e d g r o w t h g r i d s 11 ( S t u a r t ) . V i s i o n t e s t i n g was done a c c o r d i n g t o t h e g u i d e - 7 See A p p e n d i x B 8 S e e T a b l e I 9 H.E. McLean, P h y s i c a l H e a l t h and i t s E v a l u a t i o n : A Manual F o r Nu r s e s ( V a n c o u v e r : C i t y o f V a n c o u v e r , 1 9 7 1 ) . 10 U. Haynes, A D e v e l o p m e n t a l Approach t o C a s e f i n d i n g ( W ashington, D.C: Dept. HEW, 1969). '. 11 H C S t u a r t , A n t h r o p o m e t r i c C h a r t ( B o s t o n : H a r v a r d S c h o o l o f P u b l i c H e a l t h , u n d a t e d ) . 2 7 1 2 l i n e s f o r i n f a n t s i n a v i s i o n t e s t ( B a r k e r , e t a l . ) s t a n d a r d i z e d i n D e n v e r i n 1 9 7 2 , a n d f o u n d t o b e a c c u r a t e w h e n 1 u s e d b y a v a r i e t y o f p r o f e s s i o n a l a n d p a r a p r o f e s s i o n a l p e r s o n s . A n a s s e s s m e n t g u i d e w a s u s e d f o r t h e t e s t i n g o f 1 4 h e a r i n g a t t h r e e a n d n i n e m o n t h s ( V a n c o u v e r H e a l t h D e p a r t m e n t ) b a s e d o n t h e o b s e r v a t i o n o f b e h a v i o u r a s t h e m o s t e f f e c t i v e 1 5 w a y t o i d e n t i f y a b n o r m a l h e a r i n g i n i n f a n t s . P h y s i c a l e x a m i n a t i o n s w e r e c o m p l e t e d o n e a c h v i s i t , i n c l u d i n g w e i g h i n g a n d m e a s u r i n g ; t h e v i s i o n t e s t w a s c o m p l e t e d a t s i x m o n t h s w h e n a m b l y o p i a c o u l d b e d e t e c t e d ; a n d t h e h e a r i n g t e s t a t t h r e e m o n t h s . E a r l i e r h e a r i n g b e h a v i o u r s w e r e i n c l u d e d i n H a y n e s ' r e f l e x t e s t i n g . 1 2 J . B a r k e r , A. G o l d s t e i n a n d W.K. F r a n k e n b u r g , D e n v e r E y e S c r e e n i n g T e s t ( D e n v e r : U n i v e r s i t y o f C o l o r a d o M e d i c a l C e n t r e , 1 9 7 2 ) . 1 3 1 J I b i d . , 1 . . 14 V a n c o u v e r H e a l t h D e p a r t m e n t , " I d e n t i f i c a t i o n o f A b n o r m a l H e a r i n g i n I n f a n t s a n d Y o u n g C h i l d r e n " , P u b l i c H e a l t h N u r s e ' s H a n d b o o k ( V a n c o u v e r : C i t y o f V a n c o u v e r , 1 9 7 0 ) , 9 1 . 1 2 5 5 . 1 5 L . F i s c h , " T h e A t R i s k I n f a n t , " L a n c e t . 2 ( 1 9 6 7 ) , J . B a r k e r e t . a l . , i b i d . , 2 . 2 8 F o r d e v e l o p m e n t , t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g 1 7 T e s t w a s u s e d a t s i x m o n t h s . I t w a s s t a n d a r d i z e d i n D e n v e r , C o l o r a d o , w h e r e i n t e n s i v e v a l i d i t y a n d r e l i a b i l i t y t e s t s w e r e 18 c o n d u c t e d i n 1 9 6 9 . T h o r p e a n d W e r n e r , i n a c r i t i c a l r e v i e w o f f i v e d e v e - l o p m e n t a l i n v e n t o r i e s i n c l u d i n g t h e D e n v e r , d i s c u s s e d t h e 1 9 l i m i t a t i o n s o f e a c h . A l t h o u g h c a u t i o n i n g a g a i n s t t h e u s e o f a n y o n e a s a p r e d i c t o r o f f u t u r e p o t e n t i a l o f g r o s s m o t o r a b i l i t i e s , c o m m u n i c a t i o n s k i l l s , f i n e m o t o r c o - o r d i n a t i o n o r p e r s o n a l - s o c i a l b e h a v i o u r , t h e y s u g g e s t e d t h a t a d m i n i s t e r e d b y a t r a i n e d p e r s o n , t h e DDST c o u l d b e u s e d a s e f f e c t i v e l y a s a n y o t h e r t o p r o v i d e a n a r r a t i v e d e s c r i p t i o n o r p r o f i l e o f t h e 2 0 c h i l d i n t h e f o u r p s y c h o m o t o r a r e a s . ""W.K. F r a n k e n b u r g , J.W. D o d d s a n d A.W. F a n d a l , D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t ( D e n v e r : U n i v e r s i t y o f C o l o r a d o P r e s s , 1 9 7 0 ) . 18 F r a n k e n b u r g , D o d d s a n d F a n d a l , i b i d . , A p p e n d i x A. 1 9 H . S . T h o r p e a n d E . E . W e r n e r , " D e v e l o p m e n t a l S c r e e n i n g o f P r e - s c h o o l C h i l d r e n : A C r i t i c a l R e v i e w o f I n v e n t o r i e s U s e d i n H e a l t h E d u c a t i o n a l P r o g r a m s , " P e d i a t r i c s , L ( M a r c h , 1 9 7 4 ) , 3 6 2 - 3 6 9 . I b i d . , 3 6 9 . 2 9 R o b e r t s a n d K h o s l a , i n a s t u d y o f 1 9 3 i n f a n t s 1 1 t o 1 3 m o n t h s o f a g e f o u n d a s t r o n g c o r r e l a t i o n b e t w e e n g r o s s m o t o r a b n o r m a l i t y a s m e a s u r e d o n t h e DDST a n d t h e f o l l o w i n g : d e l a y e d l a n g u a g e , a u d i t o r y i m p a i r m e n t a n d v i s u a l d e f e c t s . L i t t l e c o r r e l a t i o n w a s f o u n d b e t w e e n t h e l a n g u a g e c o m p o n e n t 2 1 a n d s p e e c h o r h e a r i n g p r o b l e m s . T h x s w a s c o n s i s t e n t w i t h B r y a n t ' s f i n d i n g s , s u g g e s t i n g t h a t t h e t e s t s h o u l d b e u s e d i n c o n j u n c t i o n w i t h a n i n d e p e n d e n t h e a r i n g a n d v i s i o n t e s t , t h e n a d e t a i l e d e x a m i n a t i o n b e c a r r i e d o u t i f a n y a b n o r m a l i t y i s 2 2 f o u n d . " . I n 1 9 7 4 , h o w e v e r , a s t u d y b y t h e S o u t h O k a n a g a n H e a l t h U n i t c o n f i r m e d t h e s t a n d a r d i z a t i o n b y F r a n k e n b u r g e t . a l . o n 1 , 0 0 0 c h i l d r e n i n D e n v e r i n c l u d i n g t h e l a n g u a g e s e c t o r o f t h e 2 3 t e s t . T h e d i f f e r e n c e s i n s e t t i n g ( r u r a l , C a n a d i a n ) a p p e a r e d n o t t o a f f e c t t h e e x p e c t e d r a n g e o f r e s u l t s . A s p h y s i c a l e x a m i n a t i o n , v i s i o n a n d h e a r i n g t e s t s w e r e t o b e d o n e c o n c u r r e n t l y w i t h t h e d e v e l o p m e n t a l t e s t i n g , i t w a s 2 1 C . J . R o b e r t s a n d T. K h o s l a , " A n E v a l u a t i o n o f D e v e l o p - m e n t a l E x a m i n a t i o n s a s a M e t h o d o f D e t e c t i n g N e u r o l o g i c a l , V i s u a l a n d A u d i t o r y H a n d i c a p s i n I n f a n c y , " B r i t . J . P r e v . M e d . X X V I ( F e b r u a r y , 1 9 7 2 ) , 9 4 . 1 — — • 2 2 I b i d . 2 3 G.M. B r y a n t a n d K . J . D a v i e s , "A P r e l i m i n a r y S t u d y o f t h e U s e o f t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t i n a H e a l t h D e p a r t m e n t , " ' D e v e l o p . M e d . C h i l d . N e u r o l . , X V ( J a n u a r y , 1 9 7 3 ) . 3 3 - 4 0 ' ' 30 d e c i d e d t h a t t h e l i m i t a t i o n s p o s s i b l y i n h e r e n t i n t h i s t o o l w o u l d n o t p r e s e n t a p r o b l e m . The n u t r i t i o n a s s e s s m e n t was b a s e d o n a 2 4 - h o u r i n t a k e c o m p l e t e d b y a p a r e n t a t t h e v i s i t , b y r e c a l l . C a l o r i c c o m p u t a t i o n o f t h e i n t a k e a n d b r e a k d o w n o f t h e n u t r i e n t s a s t o f a t , p r o t e i n a n d c a r b o h y d r a t e c o n t e n t was done a c c o r d i n g t o 24 a c u r r e n t l y u s e d g u i d e , a n d a d e q u a c y o f t h e i n f a n t ' s d i e t e v a l u a t e d . One month o f a g e was c h o s e n f o r t h e f i r s t n u t r i - t i o n a l a s s e s s m e n t . I n a s t u d y o f 300 n o r m a l i n f a n t s , S h u l k a e t . a l . , f o u n d t h a t 50 w e r e s u f f e r i n g f r o m i n f a n t i l e o b e s i t y , 25 a n d 83 w e r e o v e r w e i g h t . T h i s c o r r e l a t e d h i g h l y w i t h t h e e a r l y i n t r o d u c t i o n o f s o l i d f o o d s t o a f u l l m i l k i n t a k e . I n 3 9 . 7 % o f t h e c a s e s s t u d i e d , s o l i d - f o o d s w e r e i n t r o d u c e d b e f o r e 4 w e e k s o f a g e ; i n 9 3 . 3 % , b e f o r e 13 w e e k s o f a g e . B o t t l e - f e e d i n g m o t h e r s t e n d e d t o i n t r o d u c e s o l i d f o o d s e a r l i e r . The c h o i c e o f n i n e m o n t h s a s a t e r m i n a t i o n o f t h e s t u d y was b a s e d o n a q u o t a t i o n o f D a r g a s s i e s , an e x p e r t o n e a r l y d e v e l o p m e n t a l t e s t i n g : 24 V a n c o u v e r H e a l t h D e p a r t m e n t , I n f a n t N u t r i t i o n G u i d e ( V a n c o u v e r : C i t y o f V a n c o u v e r , 1 9 7 4 ) , 4 2 . 25 S h u l k a , e t . a l . , " I n f a n t i l e O v e r n u t r i t i o n i n t h e F i r s t Y e a r o f L i f e : A F i e l d S t u d y i n D u d l e y , W o r c e s t e r s h i r e , " B r i t i s h M e d i c a l J o u r n a l , I I , ( D e c e m b e r , 1 9 7 2 ) , 5 0 7 . 2 6 I b i d . "The i n f a n t a t 7 t o 9 m o n t h s . T h i s i s an i m p o r t a n t age f o r t h e c h i l d who h a s h a d o r s t i l l h a s a b n o r m a l s i g n s . C l o s e o b s e r v a t i o n h a s t o be m a i n t a i n e d a t t h i s a g e s i n c e he may l o s e h i s n e u r o l o g i c a l a b n o r m a l i t i e s , e v e n s e v e r e o n e s , o r he may become w o r s e . O n l y t o w a r d t h e e n d o f t h i s p e r i o d c a n a r e l i a b l e p r o g n o s i s b e made f o r t h e f u t u r e . T h i s i s a k e y age b e c a u s e p r e s u m p t i v e s i g n s o b s e r v e d e a r l i e r may o r may n o t b e c o n f i r m e d . " 2 7 The c h o i c e o f f i v e v i s i t s was made k e e p i n g i n m i n d t h e l i m i t a t i o n s o n t h e v i s i t i n g t i m e o f a c o m m u n i t y h e a l t h n u r s e i n a g e n e r a l i z e d p r o g r a m , b u t a l s o t h e i d e a l o f t h e F r e n c h 28 p r o g r a m ' s n i n e v i s i t s i n t h e f i r s t n i n e m o n t h s o f l i f e . F i v e v i s i t s s p a c e d o v e r t h i s t i m e w e r e d e c i d e d u p o n , m e e t i n g t h e s u g g e s t e d a g e s f o r t h e v a r i o u s t o o l s a n d s c r e e n i n g p r o c e d u r e s c h o s e n , a n d t h e recommended t i m e s f o r t h e e a r l i e s t i n t e r v e n t i o n / p r e v e n t i o n i n t h e d e v e l o p m e n t a l i m p a i r m e n t s b e i n g s o u g h t . D a t a C o l l e c t i o n F o r t h e e x p e r i m e n t a l g r o u p a s w e l l a s t h e c o n t r o l , t h e i n i t i a l v i s i t i n c l u d e d c o m p l e t i o n o f t h e P r e g n a n c y P r o f i l e b y 29 r e c a l l . A more c o m p l e t e e x p l a n a t i o n o f t h e s t u d y was g i v e n a n d v e r b a l c o n s e n t was o b t a i n e d f r o m t h e p a r e n t ( s ) f o r i n c l u - s i o n i n t h e s t u d y . V e r b a l c o n s e n t was c o n s i d e r e d a d e q u a t e a s e a c h s u b s e q u e n t e n t r y t o t h e home was v o l u n t a r y on t h e p a r t o f "~'M. Wynn and A. Wynn, The R i g h t o f E v e r y C h i l d t o H e a l t h C a r e , 2 2 . 2 8 I b i d . 29 See A p p e n d i x C. 32 the parent. As the researcher was a community health nurse, employed i n the health u n i t area of the study, no d i f f i c u l t y was ant i c i p a t e d regarding repeated entry to the home. Re- assurance was given that the parent(s) could withdraw the i n f a n t from the study at any time without a f f e c t i n g any other services by the health department. The i n i t i a l v i s i t s extended over a one and one-half month period, from early June through July 1 9 7 5 , and the study was completed at the end of A p r i l 1 9 7 6 , when the l a s t i n f a n t reached nine months of age. The schedule of assessments proposed f o r each i n f a n t i n the experimental group i s shown in Table I. TABLE I THE PROPOSED ASSESSMENT SCHEDULE FOR INFANTS IN THE EXPERIMENTAL GROUP Age of Infant Proposed Assessments On r e c e i p t of b i r t h Physical Appraisal, notice (within 2 Interview - semistandardized, weeks of b i r t h ) i n c l u d i n g observations of general health and behaviour, use of other health services One Month Physical Appraisal 24 hr. N u t r i t i o n a l Intake Interview - as above Three Months Physical Appraisal Hearing Assessment Interview - as above Six Months Physical Appraisal V i s i o n Test Denver Developmental Screening Test Interview - as above Nine Months Physical Appraisal Hearing Test V i s i o n Test 24 hr. N u t r i t i o n a l Intake Denver Developmental Screening Test Interview - as above + Immunizations 33 The n i n e month a s s e s s m e n t s o f t h e c o n t r o l g r o u p i n f a n t s w e r e t h e same a s f o r t h e e x p e r i m e n t a l o n e s , e x c e p t f o r t h e a d d i t i o n o f n u t r i t i o n a l a n d h e a l t h h i s t o r i e s . T h i s i n f o r m a t i o n w o u l d h a v e b e e n r e c o r d e d o v e r t h e n i n e m o n t h p e r i o d f o r t h e e x p e r i m e n t a l g r o u p . F o u r c o m m u n i t y h e a l t h n u r s e s e x p r e s s i n g i n t e r e s t i n i n f a n t a s s e s s m e n t w e r e i n v o l v e d i n t h e f i n a l v i s i t s t o t h e e x p e r i m e n t a l g r o u p , w h i l e t h e r e s e a r c h e r c o m p l e t e d a l l o f t h e n i n e month v i s i t s t o t h e c o n t r o l g r o u p . I t was f e l t t h a t g r e a t e r o b j e c t i v i t y w o u l d be l e n t t o t h e s t u d y r e s u l t s i f r e l i a b l e o t h e r s c o m p l e t e d t h e f i n a l a s s e s s m e n t s o n t h e e x p e r i - m e n t a l g r o u p i n f a n t s . P r i o r t o t h e i r i n v o l v e m e n t , i n t e r - r a t e r r e l i a b i l i t y was m e a s u r e d f o r e a c h o f t h e a s s e s s m e n t s t o b e g i v e n , u s i n g e i g h t n o n - s t u d y i n f a n t s . O t h e r t h a n d i f f e r e n c e s o f one h a l f t o o n e c e n t i m e t e r i n m e a s u r i n g h e a d c i r c u m f e r e n c e a n d l e n g t h , a n d d i f f e r e n c e s o f l e s s t h a n o n e t e n t h o f a k i l o g r a m i n w e i g h t , no d i s c r e p a n c i e s w e r e f o u n d i n t e c h n i q u e s o r r e s u l t s . D a t a A n a l y s i s A n a l y s i s o f t h e d a t a i n c l u d e d b o t h d e s c r i p t i v e a n a l y s i s a n d s t a t i s t i c a l t e s t s . D a t a i n r e l a t i o n t o H y p o t h e s i s I w e r e t a b u l a t e d a n d d e s c r i b e d a c c o r d i n g t o m e a s u r e m e n t p r o c e d u r e s u s e d , t y p e o f i m p a i r m e n t d e t e c t e d a n d a g e a t w h i c h t h e i m p a i r m e n t was a s s e s s e d . D a t a i n r e l a t i o n t o H y p o t h e s e s I I a n d I I I w e r e s u b j e c t e d 3 4 3 0 t o F i s h e r ' s e x a c t t e s t o f p r o b a b i l i t y u s i n g 2 x 2 c o n t i n - g e n c y t a b l e s . T h i s n o n - p a r a m e t r i c t e s t w a s c h o s e n a s i t w a s b a s e d o n e x a c t p r o b a b i l i t i e s a n d t h e r e f o r e n o t r u l e d o u t b y t h e l o w f r e q u e n c i e s o b t a i n e d i n s ome o f . ' t h e c e l l s i n t h e c o n - 3 1 t i n g e n c y t a b l e s . E a c h h y p o t h e s i s w a s t e s t e d b y d e t e r m i n i n g n o t o n l y t h e p r o b a b i l i t y o f o c c u r e n c e b y c h a n c e o f t h e p a r t i c u l a r f r e q u e n c y o b s e r v e d , b u t t h a t o f a l l o t h e r p o s s i b l e r a n d o m i z a t i o n s o f t h a t s a m p l e i n t h e t a b l e . A s s u m p t i o n o f a n 32 u n d e r l y i n g n o r m a l w a s n o t r e q u i r e d . A l e v e l o f s i g n i f i c a n c e o f .05 w a s u s e d f o r a l l t e s t s . SUMMARY T h i s c h a p t e r f o c u s s e d o n t h e d e s i g n a n d m e t h o d o l o g y o f t h e s t u d y , i n c l u d i n g a p r e l i m i n a r y s t u d y ; t h e d e s i g n o f t h e s t u d y ; a n d t h e m e t h o d o l o g y i n c l u d i n g s t a f f o r i e n t a t i o n , m e a s u r e m e n t p r o c e d u r e s , d a t a c o l l e c t i o n a n d t h e m e t h o d s o f d a t a a n a l y s i s . 3 0 W.L. H a y s , S t a t i s t i c s (New Y o r k : H o l t , R i n e h a r t a n d W i n s t o n , 1 9 6 3 ) , 5 9 9 . 3 1 I b i d . , 5 9 8 . 3 2 J I b i d . 55 CHAPTER I V A N A L Y S I S OF THE DATA A n a l y s i s o f t h e d a t a w i l l be d i s c u s s e d u n d e r t h e a c c e p t a n c e o r r e j e c t i o n o f e a c h h y p o t h e s i s , w i t h a d i s c u s s i o n o f a d d i t i o n a l d a t a f o l l o w i n g . A N A L Y S I S RELATED TO THE HYPOTHESES D a t a A n a l y s i s R e l a t e d t o H y p o t h e s i s I H y p o t h e s i s I s t a t e d t h a t s c h e d u l e d c o m m u n i t y h e a l t h n u r s i n g a s s e s s m e n t s b e t w e e n b i r t h a n d n i n e m o n t h s o f a g e w i l l n o t d e t e c t a n y d e v e l o p m e n t a l i m p a i r m e n t s w h i c h h a v e n o t a l r e a d y b e e n d e t e c t e d b y e x i s t i n g h e a l t h s e r v i c e s . T a b l e I I shows t h e n u m b e r s o f d e v e l o p m e n t a l i m p a i r m e n t s d e t e c t e d i n t h e e x p e r i m e n t a l g r o u p i n f a n t s , b y t y p e o f i m p a i r - ment a n d a g e a t w h i c h a s s e s s e d . T h o s e i m p a i r m e n t s d e t e c t e d b y t h e r e s e a r c h e r a n d s u b s e q u e n t l y d i a g n o s e d a s n o r m a l b y a p h y - s i c i a n a r e n o t e d , i n d i c a t i n g t h e a p p r o p r i a t e n e s s o f t h e r e f e r r a l s . A t o t a l o f t h i r t y - s i x i m p a i r m e n t s w e r e i d e n t i f i e d i n t h e s t u d y a n d r e f e r r e d t o t r a d i t i o n a l m e d i c a l s e r v i c e s f o r d i a g n o s i s a n d t r e a t m e n t . I n t h r e e c a s e s t h e m e d i c a l f i n d i n g s w e r e n o r m a l b u t t h e . r e f e r r a l s s a i d t o be a p p r o p r i a t e b y t h e p h y s i c i a n . E i t h e r f u r t h e r t e s t i n g o f t h e i n f a n t h a d b e e n c a r r i e d o u t , o r c o n s u l t a t i o n a n d e x a m i n a t i o n b y a s p e c i a l i s t h a d b e e n c a r r i e d o u t b e f o r e n o r m a l c y was c o n f i r m e d . I n o n e c a s e an i n f a n t was r e f e r r e d f o r a p o s s i b l e v i s i o n d e f e c t w h i c h was d i a g n o s e d a s b e i n g n o r m a l a n d t h e r e f e r r a l i n a p p r o p r i a t e . B a s e d on t h e f i n d i n g s , t h e n u l l h y p o t h e s i s was r e j e c t e d . 36 T A B L E I I I N F A N T D E V E L O P M E N T A L I M P A I R M E N T S D E T E C T E D BY S C H E D U L E D A S S E S S M E N T S W H I C H • H A D NOT A L R E A D Y B E E N D E T E C T E D B Y E X I S T I N G H E A L T H S E R V I C E S ^ A s s e s s m e n t A s s e s s m e n t A g e s . T o t a l I m p a i r > U s e d t o = 2 D e t e c t , w e e k s I m p a i r m e n t N - 5 0 1 m o n t h N = 4 9 3 m o n t h s N = 4 8 6 m o n t h s N = 4 4 9 m o n t h s N = 4 2 m e n t s b y A s s e s s m e n t T o o l U s e d P H Y S I C A L E X A M I N A T I O N G e n e r a l A p p e a - r a n c e 1* 0 0 0 0 1 • S k i n 2 2 2 1 0. 7 E a r s 1 1 . 1 1 0 4 E y e s 2 2 0 0 0 4 M o u t h & T h r o a t 1 0 1 0 0 2 C h e s t - R e s p i r a - t o r y c a r d i o - v a s c u l a r 0 0 0 0 0 0 A b d o m e n 0 0 1 0 0 1 G e n i t a l i a 1' 0 0 0 1 2 M u s c u l a s k e l e t a l 3 2 1 + 1* 2 + 1* 0 1 0 N e r v o u s S y s t e m 0 0 0 0 0 . 0 W e i g h t 0 2 0 1 0 3 D E V E L O P M E N T A L T E S T 0 0 0 0 0 0 V I S I O N T E S T 1 ,: 2 H E A R I N G T E S T ( 1 ) 0 ( 1 ) 2 4 HR N U T R I T I O N ( 2 ) 0 ( 2 ) T o t a l I m p a i r - m e n t s D e t e c t e d b y A g e : 1 1 9 7 7 2 3 6 * S u b s e q u e n t l y d i a g n o s e d n o r m a l , r e f e r r a l a p p r o p r i a t e * * S u b s e q u e n t l y d i a g n o s e d n o r m a l , r e f e r r a l i n a p p r o p r i a t e ( ) N o t i n c l u d e d i n t o t a l o ' f i m p a i r m e n t s a s a l s o d e t e c t e d i n p h y s i c a l e x a m i n a t i o n 1 S e e A p p e n d i x D, T a b l e X I f o r d e s c r i p t i o n s o f t h e i m - p a i r m e n t s d e t e c t e d . 37 D a t a A n a l y s i s R e l a t e d t o H y p o t h e s i s I I H y p o t h e s i s I I s t a t e d t h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f d e v e l o p m e n t a l i m p a i r m e n t s d e t e c t e d a t n i n e m o n t h s o f age b e t w e e n a g r o u p o f i n f a n t s s c r e e n e d b y t h e p r o p o s e d s c h e d u l e o f a s s e s s m e n t s a n d a g r o u p n o t s o s c r e e n e d . A n a l y s i s o f t h e d a t a showed t h a t o f e i g h t e e n i m p a i r m e n t s d e t e c t e d , s i x t e e n w e r e i n t h e c o n t r o l g r o u p . The F i s h e r ' s e x a c t t e s t o f p r o b a b i l i t y s h o w e d t h a t t h i s was s i g n i f i c a n t . T a b l e I I I s h o w s a c o m p a r i s o n o f t h e t w o g r o u p s . T h e n u l l h y p o t h e s i s was r e j e c t e d . T ABLE I I I COMPARISON OF TWO GROUPS OF INFANTS BY NUMBER OF DEVELOPMENTAL IMPAIRMENTS DETECTED AT NINE MONTHS OF A G E 2 N = 82 D e v e l o p m e n t a l No D e v e l o p m e n t a l G r o u p I m p a i r m e n t I m p a i r m e n t D e t e c t e d D e t e c t e d E x p e r i m e n t a l 0 - n N = 42 ^ 4 U C o n t r o l N = 40 16 24 T o t a l 18 64 1 1 ^ p r o b . = 114293 x lOttt ( s i g n i f i c a n t ) 589677 x 10 1 -x See A p p e n d i x D, T a b l e X I I f o r d e s c r i p t i o n s o f t h e i m p a i r m e n t s d e t e c t e d . 38 Da t a A n a l y s i s R e l a t e d t o H y p o t h e s i s I I I H y p o t h e s i s I I I s t a t e d t h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n thenumber o f c h i l d r e n e x h i b i t i n g d e v e l o p m e n t a l i m p a i r m e n t s by n i n e months o f age, between a group o f " a t r i s k " i n f a n t s and a group o f "not a t r i s k " , u s i n g t h e c r i t e r i a f r o m t h e V a n c o u v e r H e a l t h Department's Pregnancy and I n f a n t P r o f i l e s . T a b l e IV shows a c o m p a r i s o n between t h o s e i n f a n t s c o n - s i d e r e d a t r i s k o r not a t r i s k by t h e pregnancy p r o f i l e ; and t h o s e c o n s i d e r e d a t r i s k o r n o t a t r i s k by t h e i n f a n t p r o f i l e . Those c r i t e r i a common t o b o t h , such as m a t e r n a l age and p a r i t y , were n o t i n c l u d e d i n t h e t a b u l a t i o n . TABLE IV COMPARISON OF INFANTS CONSIDERED AT RISK OR NOT AT RISK BY THE PREGNANCY PROFILE WITH THOSE CONSIDERED AT RISK OR NOT AT RISK BY THE INFANT PROFILE 3 N = 100 G r o A t R i s k By The Not A t R i s k By The I n f a n t P r o f i l e I n f a n t P r o f i l e A t R i s k By The Pregnancy P r o f i l e 35 13 N = 48 Not A t R i s k By The Pregnancy P r o f i l e 21 31 N = 52 T o t a l 56 .44 274. p r o b . = 785866 x 1 0 ^ (not s i g n i f i c a n t ) 660548.x 1 0 " J See A p p e n d i x D, T a b l e X I I I and XIV f o r t a b u l a t i o n s by c r i t e r i a . 3 9 T a b l e s V, V I , a n d V I I show c o m p a r i s o n s o f i n f a n t s c o n s i d e r e d a t r i s k o r n o t a t r i s k b y e i t h e r o r b o t h p r o f i l e s w i t h s u b s e q u e n t d e v e l o p m e n t a l i m p a i r m e n t s i d e n t i f i e d a t o r b e f o r e n i n e m o n t h s o f . a g e . F i s h e r e x a c t t e s t s o f p r o b a b i l i t y w e r e a p p l i e d t o 2 x 2 c o n t i n g e n c y t a b l e s . b a s e d o n t h e f o u r s e t s o f d a t a . T h e r e s u l t s a r e shown o n t h e r e s p e c t i v e t a b l e s , h y p o t h e s i s I I I was r e j e c t e d o n t h e b a s i s o f s i g n i f i c a n c e e s t a b l i s h e d i n T a b l e s V, V I , and V I I . T ABLE V . COMPARISON OF INFANTS CONSIDERED AT R I S K OR NOT AT R I S K BY THE COMBINED PREGNANCY AND INFANT P R O F I L E S BY PRESENCE OR LACK OF SUBSEQUENT DEVELOPMENTAL IMPAIRMENT N = 82 G r o u p S u b s e q u e n t I m p a i r m e n t I d e n t i f i e d No S u b s e q u e n t I m p a i r m e n t I d e n t i f i e d A t R i s k By T h e C o m b i n e d P r o f i l e s N = 7 3 N o t A t R i s k By T h e C o m b i n e d P r o f i l e s N = 9 28 4 5 8 T o t a l 29 5 3 P r o b . = 929692 x loH^ ( s i g n i f i c a n t ) 4 7 5 3 6 4 T A B L E V I C O M P A R I S O N OF I N F A N T S C O N S I D E R E D A T R I S K OR NOT A T R I S K BY THE P R E G N A N C Y P R O F I L E BY P R E S E N C E OR L A C K OF S U B S E Q U E N T D E V E L O P M E N T A L I M P A I R M E N T N = 8 2 S u b s e q u e n t No S u b s e q u e n t G r o u p I m p a i r m e n t I m p a i r m e n t I d e n t i f i e d I d e n t i f i e d A t R i s k B y T h e P r e g n a n c y P r o f i l e 26 37 N = 6 3 N o t A t R i s k B y T h e P r e g n a n c y P r o f i l e 5 :, 1 4 "N = 19 T o t a l 3 1 5 1 p r o b . = 7 2 2 6 3 7 x 10^1 ( s i g n i f i c a n t ) 785137 x 1 0 X / 4 t T A B L E V I I C O M P A R I S O N OF I N F A N T S C O N S I D E R E D A T R I S K OR NOT A T R I S K BY THE I N F A N T P R O F I L E B Y P R E S E N C E OR L A C K OF S U B S E Q U E N T D E V E L O P M E N T A L I M P A I R M E N T N =-82 S u b s e q u e n t No S u b s e q u e n t G r o u p I m p a i r m e n t I m p a i r m e n t I d e n t i f i e d I d e n t i f i e d A t R i s k B y T h e I n f a n t P r o f i l e 2 4 3 3 N = 5 7 N o t A t R i s k B y T h e I n f a n t P r o f i l e 7 18 N a 25 T o t a l 3 1 5 1 P r o b - = 100.428 x l o f f i ( s i g n i f i c a n t ) 995305 x 1 0 1 4 / 41 ADDITIONAL DATA F o r t h o s e i n f a n t s r e m a i n i n g i n t h e s t u d y a t n i n e months o f age, a d d i t i o n a l d a t a were o b t a i n e d f r o m t h e p a r e n t i n t e r v i e w s . I t w i l l be p r e s e n t e d under f o u r h e a d i n g s : c h i l d h e a l t h c e n t r e a t t e n d a n c e f o r i m m u n i z a t i o n ; p h y s i c a l e x a m i n a t i o n by p h y s i - c i a n ; i n f a n t n u t r i t i o n ; and p a r e n t i n i t i a t i o n o f community h e a l t h n u r s e c o n t a c t s . C h i l d H e a l t h C e n t r e A t t e n d a n c e F o r I m m u n i z a t i o n A l l o f t h e i n f a n t s , e x c e p t one i n t h e e x p e r i m e n t a l g r o u p , had up t o d a t e i m m u n i z a t i o n s t a t u s . T a b l e V I I I shows a compa- . r i s o n o f a t t e n d a n c e a t c h i l d h e a l t h c e n t r e s f o r t h i s s e r v i c e w i t h a t t e n d a n c e a t p h y s i c i a n s ' o f f i c e s . TABLE V I I I COMPARISON BETWEEN TWO GROUPS OF INFANTS BY ATTENDANCE AT CHILD HEALTH CENTRES OR PHYSICIANS' OFFICES FOR IMMUNIZATION N = 81 Group A t t e n d e d C h i l d ' H e a l t h C e n t r e Number P e r c e n t a g e A t t e n d e d P h y s i c i a n ' s O f f i c e Number P e r c e n t a g e E x p e r i m e n t a l 86 N = 41 6 14 35 C o n t r o l N = 40 10 25 30 75 Combined T o t a l N = 81 16 20 65 80. 42 P h y s i c a l E x a m i n a t i o n By P h y s i c i a n F o r t y - f o u r o f t h e e i g h t y - t w o i n f a n t s r e m a i n i n g i n t h e s t u d y a t n i n e m o n t h s o f a g e h a d b e e n g i v e n a p h y s i c a l e x a m i n a - t i o n s i n c e s i x w e e k s o f a g e , e l e v e n o f t h e s e b e c a u s e o f i l l - n e s s . T h i s number d o e s n o t i n c l u d e t h o s e e x a m i n a t i o n s f o l l o w i n g r e f e r r a l b y t h e r e s e a r c h e r . N u t r i t i o n a l D a t a T a b l e I X shows a c o m p a r i s o n o f t h e t w o g r o u p s o f i n f a n t s b y i n t r o d u c t i o n o f s o l i d f o o d s b e f o r e t h e recommended age o f t h r e e t o f o u r m o n t h s , a l s o t h o s e i n f a n t s who w e r e o v e r w e i g h t a t n i n e m o n t h s . TABLE I X COMPARISON BETWEEN TWO GROUPS OF INFANTS BY EARLY INTRODUCTION OF SOLID FOODS AND BY NINE MONTH ASSESSMENT AS BEING OVERWEIGHT N = 82 G r o u p S o l i d F o o d s I n t r o d u c e d B e f o r e Recommended Age S o l i d F o o d s I n t r o d u c e d A t Recommended Age E x p e r i m e n t a l N = 42 1 * ( 0 ) 4 1 * ( 0 ) C o n t r o l N = 40 5 * ( 3 ) 35 * ( 0 ) T o t a l 6 ( 3 ) 76 ( 0 ) * ( ) O v e r w e i g h t a t n i n e m onths o f age 43 T a b l e X shows a c o m p a r i s o n b e t w e e n t h e two g r o u p s o f i n f a n t s b y a g e o f w e a n i n g f r o m t h e b r e a s t . F i f t y m o t h e r s b r e a s t f e d t h e i r i n f a n t s i n i t i a l l y . T A BLE X COMPARISON BY BETWEEN TWO GROUPS OF BREASTFED AGE OF WEANING FROM THE BREAST INFANTS N = 55 G r o u p Age To W h i c h B r e a s t f e e d i n g C o n t i n u e d 1 m o n t h 3 m o n t h s 6 m o n t h s o r more No. % No. % No. % E x p e r i m e n t a l N = 23 23 100 22 96 10 43 C o n t r o l N = 32 22 69 15 47 9 28 C o m b i n e d T o t a l N = 55 45 8 1 37 67 19 35 P a r e n t I n i t i a t i o n o f C o m m u n i t y H e a l t h N u r s e C o n t a c t P a r e n t a l r e s p o n s e t o t h e s t u d y was p o s i t i v e i n b o t h t h e e x p e r i m e n t a l a n d c o n t r o l g r o u p s . No i n f a n t s w e r e e x c l u d e d f r o m t h e s t u d y a t a n y s t a g e d u e t o p a r e n t a l r e f u s a l t o p a r t i c i - p a t e . C o m m u n i t y h e a l t h n u r s e c o n t a c t s o v e r a n d a b o v e t h o s e c o n t a c t s i n v o l v i n g home v i s i t a r r a n g e m e n t s a n d f o l l o w up o f d e t e c t e d i m p a i r m e n t s w e r e d o c u m e n t e d o v e r t h e n i n e m o n t h p e r i o d . T h i r t y - o n e s u c h c o n t a c t s b y t e l e p h o n e a n d a d d i t i o n a l home v i s i t s w e r e i n i t i a t e d b y p a r e n t s o f i n f a n t s i n t h e e x p e r i - m e n t a l g r o u p . By p a r e n t r e p o r t , o n l y t h i r t e e n s u c h c o n t a c t s w e r e i n i t i a t e d i n t h e c o n t r o l g r o u p w i t h t h e d i s t r i c t c o m m u n i t y h e a l t h n u r s e s . 44 SUMMARY The a n a l y s i s of the data and a d d i t i o n a l f i n d i n g s were presented i n t h i s chapter. Analysis of the data r e l a t i n g to Hypothesis I revealed that developmental impairments not already detected by e x i s t i n g health services could be detected by a schedule of community health nursing assessments. The n u l l hypothesis was accordingly rejected.. Analysis of the data r e l a t i n g to Hypothesis II revealed a s i g n i f i c a n t d i f f e r e n c e between the number of developmental impairments detected i n the experimental and control groups of i n f a n t s . This n u l l hypothesis was consequently r e j e c t e d a l s o . Analysis of the data i n r e l a t i o n to Hypothesis III indicated a s i g n i f i c a n t d i f f e r e n c e between the number of i n f a n t s considered at r i s k by the pregnancy and/or i n f a n t p r o f i l e s , and the number not considered at r i s k , i n the number ex h i b i t i n g subsequent developmental impairments. The n u l l hypothesis was accordingly r e j e c t e d . The data analysis showed a c o r r e l a t i o n between at r i s k c a t e g o r i z a t i o n on the pregnancy and the infant p r o f i l e s beyond that which would be obtained by chance alone. The data i n Hypotheses II and I I I were analysed by a p p l i c a t i o n of Fisher's exact test of p r o b a b i l i t y based on 2 x 2 contingency tables, at a .05 l e v e l of s i g n i f i c a n c e . Implications of -these f i n d i n g s and those discussed under the heading of a d d i t i o n a l data w i l l be explored i n Chapter V. 45 CHAPTER V SUMMARY, FI N D I N G S , CONCLUSIONS, I M P L I C A T I O N S , AND RECOMMENDATIONS FOR FURTHER RESEARCH SUMMARY The p r o b l e m i d e n t i f i e d f o r t h i s s t u d y was t h e p o s s i b l e l a c k o f d e t e c t i o n o f d e v e l o p m e n t a l i m p a i r m e n t s i n i n f a n t s i n t h e f i r s t s e v e r a l m o n t h s o f l i f e , d e s p i t e t h e a c c e s s i b i l i t y t o h e a l t h s e r v i c e s a n d t h e a v a i l a b i l i t y o f p r e p a i d m e d i c a l p l a n s . The s p e c i f i c q u e s t i o n s p o s e d f o r t h e s t u d y w e r e : . I . W o u l d s c h e d u l e d p h y s i c a l a n d d e v e l o p m e n t a l a s s e s s m e n t s b y a c o m m u n i t y h e a l t h n u r s e d e t e c t a n y r e a l o r p o t e n t i a l i m - p a i r m e n t s i n i n f a n t s , o r w o u l d t h i s b e a d u p l i c a t i o n o f p r e s e n t p h y s i c i a n s u r v e i l l a n c e ? I I . I s i n c r e a s e d c o m m u n i t y h e a l t h n u r s e s u r v e i l l a n c e o f a l l i n f a n t s i n d i c a t e d , o r s e l e c t i v e f o l l o w - u p o f t h o s e i n f a n t s deemed t o b e a t g r e a t e r r i s k o f i m p a i r m e n t o n l y ? I I I . I f t h e l a t t e r , a r e c r i t e r i a o n t h e p r e s e n t l y u s e d V a n c o u v e r H e a l t h D e p a r t m e n t P r e g n a n c y P r o f i l e a n d I n f a n t A t R i s k C r i t e r i a f o r m s p r e d i c t i v e o f s u b s e q u e n t i m p a i r m e n t ? I V . I f a n a s s e s s m e n t p r o g r a m w e r e i m p l e m e n t e d , w o u l d t h o s e i n f a n t s e x a m i n e d r e g u l a r l y b y a c o m m u n i t y h e a l t h n u r s e f o r s e v e r a l m o n t h s d e m o n s t r a t e a b e t t e r h e a l t h a n d d e v e l o p m e n t a l s t a t u s t h a n a g r o u p n o t s o e x a m i n e d ? The f o l l o w i n g h y p o t h e s e s w e r e t e s t e d i n t h e s t u d y : I . T h a t t h e s c h e d u l e d c o m m u n i t y h e a l t h n u r s i n g a s s e s s m e n t s b e t w e e n b i r t h a n d n i n e m o n t h s o f age w i l l n o t d e t e c t a n y d e v e - l o p m e n t a l i m p a i r m e n t s w h i c h h a v e n o t a l r e a d y b e e n d e t e c t e d b y 46 e x i s t i n g h e a l t h s e r v i c e s . I I . T h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f d e v e l o p m e n t a l i m p a i r m e n t s d e t e c t e d a t n i n e m o n t h s o f a g e , b e t w e e n a g r o u p o f i n f a n t s s c r e e n e d b y t h e p r o p o s e d s c h e d u l e s o f a s s e s s m e n t s a n d a g r o u p n o t s o s c r e e n e d . I I I . T h a t t h e r e i s no s i g n i f i c a n t d i f f e r e n c e i n t h e number o f c h i l d r e n e x h i b i t i n g d e v e l o p m e n t a l i m p a i r m e n t s b y n i n e m o n t h s o f age b e t w e e n a g r o u p o f " a t r i s k " a n d a g r o u p o f n o t " a t r i s k " i n f a n t s , u s i n g t h e c r i t e r i a f r o m t h e V a n c o u v e r H e a l t h D e p a r t m e n t ' s p r e g n a n c y a n d i n f a n t p r o f i l e s . T he l i t e r a t u r e r e v i e w e d i n c l u d e d a n i n v e s t i g a t i o n o f t h r e e e x i s t i n g p e d i a t r i c p r o g r a m s ; a n e x p l o r a t i o n o f t h e i s s u e o f mass v e r s u s s e l e c t i v e s c r e e n i n g o f i n f a n t s ; a n d a c o n f i r m a t i o n o f t h e a p p r o p r i a t e n e s s o f t h e m e a s u r i n g p r o c e d u r e s c h o s e n . The s t u d y ' w a s c o n d u c t e d i n one h e a l t h u n i t a r e a o f a l a r g e c i t y . S u b j e c t s i n c l u d e d one h u n d r e d i n f a n t s a s s i g n e d a l t e r n a t e l y t o a n e x p e r i m e n t a l a n d a c o n t r o l g r o u p a s t h e b i r t h n o t i f i c a t i o n s w e r e r e c e i v e d a t t h e h e a l t h u n i t . T h e e x p e r i m e n t a l g r o u p r e c e i v e d s c h e d u l e d a s s e s s m e n t s o v e r a n i n e m o n t h p e r i o d i n a d d i t i o n t o t h e one m a n d a t e d n e w b o r n v i s i t . T h e c o n t r o l g r o u p r e c e i v e d o n l y t h e o n e v i s i t a s u s u a l a n d a n i n e month a s s e s s m e n t , a l t h o u g h no c o n t r o l was a p p l i e d t o p r e v e n t a c c e s s t o f u r t h e r p u b l i c h e a l t h s e r v i c e s . P r e g n a n c y a n d i n f a n t p r o f i l e s w e r e c o m p l e t e d f o r i n f a n t s i n b o t h g r o u p s a t t h e i n i t i a l n e w b o r n v i s i t . 47 The d a t a were c o l l e c t e d by t h e r e s e a r c h e r u s i n g t h e pro p o s e d a s s e s s m e n t t o o l s . F o u r community h e a l t h nurses, a s s i s t e d i n t h e as s e s s m e n t s o f t h e e x p e r i m e n t a l group i n f a n t s a t n i n e months. The d a t a were c o l l e c t e d o v e r a p e r i o d o f t e n months. The d a t a were a n a l y s e d as f o l l o w s : 1. Data r e l a t i n g t o H y p o t h e s i s I were t a b u l a t e d and d e s c r i b e d by t y p e , a s sessment t o o l used f o r d e t e c t i o n s and age a t w h i c h a s s e s s e d . 2. Data r e l a t i n g t o Hy p o t h e s e s I I and I I I were s u b j e c t e d t o a n a l y s i s by F i s h e r ' s e x a c t t e s t o f p r o b a b i l i t y , u s i n g 2 x 2 c o n t i n g e n c y t a b l e s and a .05 l e v e l o f s i g n i f i c a n c e . FINDINGS A t o t a l o f 233 home v i s i t s were made t o t h e e x p e r i m e n t a l group i n f a n t s and 40 t o t h e c o n t r o l group f o r t h e p u r p o s e o f ass e s s m e n t . Each v i s i t was o f o n e - h a l f t o t h r e e - q u a r t e r s o f an hour d u r a t i o n and i n c o r p o r a t e d s e r v i c e needs o f t h e f a m i l y . Of t h e one hundred i n f a n t s e n r o l l e d i n t h e s t u d y i n i t i a l l y , e i g h t y - t w o r e m a i n e d a t n i n e months o f age, f o r t y - t w o i n t h e e x p e r i m e n t a l group and f o r t y i n t h e c o n t r o l group. F a m i l i e s moving house a c c o u n t e d f o r t h e a t t r i t i o n i n b o t h g r o u p s . P a r e n t a l r e s p o n s e was p o s i t i v e and no i n f a n t s were e x c l u d e d f r o m t h e s t u d y a t any s t a g e due t o p a r e n t a l r e f u s a l t o p a r t i - c i p a t e . The f i n d i n g s w i l l be d i s c u s s e d r e l a t e d t o t h e t h r e e h y p o t h e s e s . 48 F i n d i n g s R e l a t e d t o H y p o t h e s i s I I n t h e e x p e r i m e n t a l g r o u p a t o t a l o f f o r t y d e v e l o p - m e n t a l i m p a i r m e n t s w e r e d e t e c t e d w h i c h h a d n o t a l r e a d y b e e n d e t e c t e d b y e x i s t i n g h e a l t h s e r v i c e s . T h e s e w e r e d e t e c t e d a p p r o x i m a t e l y e q u a l l y a m o n g s t t h e f i r s t f o u r v i s i t s , o n l y two i m p a i r m e n t s b e i n g i d e n t i f i e d a t n i n e m o n t h s o f a g e . The p r e d o m i n a n t i m p a i r m e n t s w e r e : s k i n c o n d i t i o n s o f l o n g d u r a t i o n o r s h o w i n g s i g n s o f i n f e c t i o n ( s e v e n ) ; v i s i o n a n d h e a r i n g d e f e c t s ( f o u r a n d f i v e r e s p e c t i v e l y ) ; a n d m u s c u l o s k e l e t a l d e f e c t s s u c h a s i n - t u r n e d f e e t a n d h e r n i a s ( t e n ) . Of t h o s e i m p a i r m e n t s d e t e c t e d , o n e was s u b s e q u e n t l y deemed a n i n a p p r o p r i a t e r e f e r r a l b y t h e i n f a n t ' s p h y s i c i a n ; t h r e e w e r e deemed a p p r o p r i a t e a l t h o u g h n o r m a l c y was c o n f i r m e d b y f u r t h e r e x a m i n a t i o n o f t h e i n f a n t s i n v o l v e d . No r e s p i r a - t o r y , c a r d i o v a s c u l a r o r n e r v o u s s y s t e m i m p a i r m e n t s w e r e d e t e c t e d , a n d no i m p a i r m e n t s w e r e d e t e c t e d b y t h e D e n v e r D e v e l o p m e n t a l S c r e e n i n g T e s t . One i m p a i r m e n t was d e t e c t e d b y t h e h e a r i n g t e s t ; two e a c h b y t h e v i s i o n t e s t a n d t h e 24 h o u r n u t r i t i o n i n t a k e g u i d e s . A l l o f t h e i m p a i r m e n t s c o n - f i r m e d b y m e d i c a l d i a g n o s i s w e r e r e s o l v e d o r u n d e r m e d i c a l t r e a t m e n t o r s u r v e i l l a n c e b y t h e t e r m i n a t i o n o f t h e s t u d y . S ee A p p e n d i x D f o r a d e s c r i p t i o n o f t h e i m p a i r m e n t s d e t e c t e d * 49 F i n d i n g s R e l a t e d t o H y p o t h e s i s I I D u r i n g t h e n i n e m o n t h a s s e s s m e n t s o f b o t h g r o u p s o f 2 i n f a n t s , e i g h t e e n d e v e l o p m e n t a l i m p a i r m e n t s w e r e d e t e c t e d , s i x t e e n i n t h e c o n t r o l g r o u p . Two e a c h w e r e d e t e c t e d b y t h e v i s i o n a n d h e a r i n g t e s t s a n d t h r e e b y t h e 24 h o u r n u t r i t i o n g u i d e , i n c o n j u n c t i o n w i t h t h e p h y s i c a l e x a m i n a t i o n s r e l a t i n g t o e y e s , e a r s a n d w e i g h t , r e s p e c t i v e l y . S e v e n i m p a i r m e n t s w e r e d e t e c t e d b y t h e p h y s i c a l e x a m i n a t i o n . A l l i m p a i r m e n t s d e t e c t e d w e r e u n d e r t r e a t m e n t o r s u r v e i l l a n c e w i t h i n a month o f t h e t e r m i n a t i o n o f t h e s t u d y ; t h i r t e e n b y t h e i n f a n t ' s p h y s i c i a n o r s p e c i a l i s t , t h r e e b y m o d i f i c a t i o n o f d i e t f o r o v e r w e i g h t . The t w o i m p a i r m e n t s d e t e c t e d i n t h e e x p e r i m e n t a l g r o u p w e r e : one u n d e s c e n d e d t e s t e s a n d one v i s i o n d e f e c t . T h e f o r m e r i s b e i n g w a t c h e d b y t h e p h y s i c i a n , t h e l a t t e r b y a p e d i a t r i c e y e s p e c i a l i s t . F i n d i n g s R e l a t e d t o H y p o t h e s i s I I I P r e g n a n c y a n d i n f a n t p r o f i l e s w e r e c o m p a r e d f o r t h e o n e h u n d r e d i n f a n t s e n r o l l e d i n t h e s t u d y . The p r o b a b i l i t y o f t h e c e l l f r e q u e n c i e s o c c u r i n g by c h a n c e was s u c h t h a t t h e r e l a t i o n s h i p b e t w e e n t h e two p r o f i l e s was n o t f o u n d t o be s i g n i f i c a n t . H o w e v e r t h e r e l a t i o n s h i p b e t w e e n t h e tw o p r o - f i l e s ( i n d i v i d u a l l y a nd i n c o m b i n a t i o n ) a n d d e t e c t i o n o f s u b s e - See A p p e n d i x D f o r a d e s c r i p t i o n o f t h e i m p a i r m e n t s d e t e c t e d . 5 0 q u e n t d e v e l o p m e n t a l i m p a i r m e n t was f o u n d t o be s i g n i f i c a n t . B o t h p r o f i l e s a l s o c o n s i d e r e d l a r g e n u m b e r s o f i n f a n t s a t r i s k o f s u b s e q u e n t i m p a i r m e n t who d i d n o t , a t l e a s t b y n i n e m o n t h s o f a g e , e x h i b i t i m p a i r m e n t s . The n u m b e r s o f i n f a n t s n o t c o n s i d e r e d a t r i s k who d i d d e v e l o p s u b s e q u e n t i m p a i r m e n t s w e r e a s f o l l o w s : o ne f r o m t h e c o m b i n e d , p r o f i l e s ; f i v e f r o m t h e p r e g n a n c y p r o f i l e a l o n e ; a n d s e v e n f r o m . t h e i n f a n t p r o f i l e a l o n e . F i n d i n g s R e l a t e d To The A d d i t i o n a l D a t a T h e s e f i n d i n g s a r e s u m m a r i z e d i n C h a p t e r I V , a n d w i l l be d i s c u s s e d f u r t h e r i n r e l a t i o n t o t h e i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e a n d r e c o m m e n d a t i o n s f o r f u r t h e r r e s e a r c h . CONCLUSIONS I . F i v e c o m m u n i t y h e a l t h n u r s i n g a s s e s s m e n t s b e t w e e n b i r t h a n d n i n e m o n t h s o f age w e r e u s e f u l i n d e t e c t i n g d e v e l o p m e n t a l i m p a i r m e n t s i n i n f a n t s . I I . The c u r r e n t l y u s e d V a n c o u v e r H e a l t h D e p a r t m e n t P r e g - n a n c y P r o f i l e a n d I n f a n t A t R i s k C r i t e r i a were- p r e d i c t i v e s i n g l y a n d i n c o m b i n a t i o n f o r t h o s e i n f a n t s who e x h i b i t e d d e v e l o p m e n t a l i m p a i r m e n t s ' i n t h e f i r s t n i n e m o n t h s o f l i f e . H o w e v e r , a s t h e y a l s o i d e n t i f i e d a s a t r i s k a l a r g e number o f i n f a n t s who d i d n o t d e v e l o p , s u b s e q u e n t i m p a i r m e n t s i n t h i s p e r i o d , t h e i r u s e a s s e l e c t i v e t o o l s f o r i n f a n t s c r e e n i n g was q u e s t i o n a b l e . I t was c o n c l u d e d t h a t t h e y w e r e u s e f u l a d j u n c t s t o t h e r e g u l a r h e a l t h s u r v e i l l a n c e o f a l l i n f a n t s a s s e n s i t i v e b u t n o t s p e c i f i c p r e d i c t i v e t o o l s . 51 I I I . The l o w e n r o l m e n t o f i n f a n t s a t c h i l d h e a l t h c e n t r e s w i t h i n t h e a r e a s t u d i e d r u l e d o u t t h i s s e t t i n g f o r w i d e - s p r e a d i n f a n t a s s e s s m e n t s a t t h e p r e s e n t t i m e . I V . A home v i s i t i n g p r o g r a m was w e l l r e c e i v e d b y t h e p a r e n t s and r e s u l t e d i n more c o m m u n i t y h e a l t h n u r s e c o n t a c t s i n i t i a t e d b y t h e p a r e n t s t h a n was t h e c a s e f o r t h e c o n t r o l g r o u p , f o r d i s c u s s i o n o f o t h e r h e a l t h m a t t e r s . V. D u p l i c a t i o n o f p h y s i c i a n s e r v i c e s was n o t a c o n c e r n i n a p r o g r a m o f c o m m u n i t y h e a l t h n u r s i n g ' a s s e s s m e n t s f o r d e v e l o p - m e n t a l i m p a i r m e n t s i n i n f a n t s . V I . The i n c r e a s e d c o m m u n i t y h e a l t h n u r s i n g c o n t a c t f o r i n f a n t a s s e s s m e n t may h a v e more f a r - r e a c h i n g e f f e c t s t h a n p u r e l y d e t e c t i o n o f i m p a i r m e n t . F o r e x a m p l e , t h e r e may h a v e b e e n a r e l a t i o n s h i p b e t w e e n t h e i n c r e a s e d c o n t a c t a n d t h e l o n g e r c o n t i n u a n c e o f b r e a s t f e e d i n g . I M P L I C A T I O N S FOR NURSING PRACTICE E a r l i e r r e c o g n i t i o n o f an e x i s t i n g o r p o t e n t i a l d e v e l o p - m e n t a l i m p a i r m e n t c o u l d be v e r y s i g n i f i c a n t t o a n i n d i v i d u a l i n f a n t a n d f a m i l y , i n t e r m s o f e a r l i e r r e f e r r a l a n d t r e a t m e n t 3 o r e v e n p r e v e n t i o n o f t h a t i m p a i r m e n t . C o m m u n i t y h e a l t h n u r s e s a r e a n i n t e g r a l p a r t o f p r i m a r y a n d s e c o n d a r y p r e v e n - t i v e s e r v i c e s t o y o u n g c h i l d r e n , a n d h a v e i n i t i a l a c c e s s t o M. S h e r i d a n , C h i l d r e n ' s D e v e l o p m e n t a l P r o g r e s s ( L o n d o n : N a t . F o u n d a t i o n o f E d u c a t i o n a l R e s e a r c h , 1 9 7 3 ) , 1. 52 a l m o s t t h e t o t a l i n f a n t p o p u l a t i o n b y v i r t u e o f t h e m a n d a t e d n e w b o r n v i s i t . T h e p r e s e n t s t u d y i n d i c a t e d t h a t t h e r e i s a u s e f u l n e s s t o a s c h e d u l e o f f i v e i n f a n t a s s e s s m e n t s o v e r a p e r i o d o f b i r t h t o n i n e m o n t h s o f , a g e b y c o m m u n i t y h e a l t h n u r s e s u s i n g t h e i r p r e s e n t s k i l l s a n d t h e m e a s u r e m e n t p r o c e d u r e s a v a i l a b l e t o t h e m. T h e f i n d i n g s o f t h i s s t u d y h a v e t h e f o l l o w i n g i m p l i c a - t i o n s f o r p r a c t i c e : I . S u f f i c i e n t p r i o r i t y s h o u l d be a c c o r d e d t h e i n f a n t p o p u l a t i o n t o p e r m i t t h e c o n s i s t e n t o f f e r i n g o f t h e f i v e a s s e s s m e n t c o m b i n a t i o n s t o a l l i n f a n t s . A s s e s s m e n t s o f i n f a n t s s h o u l d be c o m p l e t e d a t t h e i n i t i a l n e w b o r n v i s i t a n d r e p e a t e d i n t h e f i r s t n i n e m o n t h s o f l i f e . T h e s c h e d u l e c h o s e n may v a r y w i t h t h e c a s e l o a d o f t h e c o m m u n i t y h e a l t h n u r s e a n d t h e r e g i m e o f a s s e s s m e n t o f t h e i n d i v i d u a l i n f a n t ' s p h y s i c i a n , b u t n e i t h e r o f t h e s e f a c t o r s s h o u l d p r e c l u d e a s s e s s m e n t s o f t h e i n f a n t when c o n t a c t s a r e made i n t h e home o r a t t h e c h i l d h e a l t h c e n t r e . I I . T he P r e g n a n c y P r o f i l e a n d t h e I n f a n t A t R i s k C r i t e r i a a r e u s e f u l a s g r o s s p r e d i c t i v e t o o l s f o r r i s k o f s u b s e q u e n t i m p a i r m e n t , b u t s h o u l d n o t be u s e d f o r s e l e c t i v e f o l l o w - u p o f i n f a n t s . T h e i r c u r r e n t u s e a s a m e c h a n i s m t o a l e r t t h e c o m m u n i t y h e a l t h n u r s e o f a r e a s o f c o n c e r n i s a p p r o p r i a t e a n d e n h a n c e s r e g u l a r h e a l t h s u r v e i l l a n c e o f a l l i n f a n t s . 53 I I I . T he a s s e s s m e n t p r o g r a m c o u l d be e x t e n d e d t o t h e c h i l d h e a l t h c e n t r e s e t t i n g on a more w i d e s p r e a d b a s i s m a k i n g more e f f e c t i v e u s e o f c o m m u n i t y h e a l t h n u r s i n g t i m e . T e l e p h o n e c o n t a c t s when i n f a n t s a r e t h r e e m o n t h s o f a g e t o i n v i t e t h e m o t h e r s t o t h e n e a r e s t c e n t r e f o r t h e s e a s s e s s m e n t s may i m p r o v e t h e e n r o l m e n t . RECOMMENDATIONS FOR FURTHER RESEARCH B a s e d o n t h e f i n d i n g s o f t h e p r e s e n t s t u d y , t h e f o l l o w i n g r e c o m m e n d a t i o n s f o r f u r t h e r r e s e a r c h a r e s u g g e s t e d : I . F u r t h e r s t u d y o f t h e p r e g n a n c y a n d i n f a n t p r o f i l e s t o d e t e r m i n e w h e t h e r o r n o t c e r t a i n c r i t e r i a s i n g l y o r i n c o m b i n a - t i o n , a r e more s p e c i f i c i n d i c a t o r s o f s u b s e q u e n t d e v e l o p m e n t a l i m p a i r m e n t . E x t e n s i o n o f t h e s t u d y t o o b s e r v e t h e d e v e l o p m e n t o f i m p a i r m e n t s i n o l d e r c h i l d r e n may i n d i c a t e a g r e a t e r u s e f u l - n e s s o f t h e t o o l s . I I . F u r t h e r r e s e a r c h a s t o t h e e f f e c t s o f i n c r e a s e d commu- n i t y h e a l t h n u r s i n g c o n t a c t i n r e l a t i o n t o i n f a n t n u t r i t i o n . I I I . E x t e n s i o n o f t h e s t u d y t o i n c l u d e t h e p r e s c h o o l c h i l d t o d e t e r m i n e t h e n e e d f o r a s i m i l a r a s s e s s m e n t p r o g r a m . 54 B I B L I O G R A P H Y A . BOOKS A m e r i c a n A c a d e m y o f P e d i a t r i c s . C o u n c i l o n P e d i a t r i c P r a c t i s e : S t a n d a r d s o f C h i l d H e a l t h C a r e . E v a n s t o n , I l l i n o i s : A m e r i c a n A c a d e m y o f P e d i a t r i c s , 1 9 6 7 . A m e r i c a n P u b l i c H e a l t h A s s o c i a t i o n . C o m m i t t e e o n C h i l d H e a l t h : H e a l t h S u p e r v i s i o n o f Y o u n g C h i l d r e n . New Y o r k : A m e r i c a n P u b l i c H e a l t h A s s o c i a t i o n , 1 9 6 1 . B a r k e r , J . , G o l d s t e i n , A . , a n d F r a n k e n b u r g , W. D e n v e r Eye ' S c r e e n i n g T e s t . D e n v e r : U n i v e r s i t y o f C o l o r a d o M e d i c a l C e n t r e , 1 9 7 2 . B a y l e y , N . Bay l e y S c a l e ' s o f I n f a n t D e v e l o p m e n t . N e w Y o r k : T h e P s y c h o l o g i c a l C o r p . , 1 9 6 9 . ' B e r r y , M . F . L a n g u a g e D i s o r d e r s i n C h i l d r e n . N e w Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 6 9 . B u r o s , O . K . T h e S i x t h M e n t a l M e a s u r e m e n t s Y e a r b o o k . H i g h - l a n d P a r k , N . J . : G r y p h o n P r e s s , 1 9 6 5 . B r e c k e n r i d g e , M . E . , a n d M u r p h y , M . G r o w t h a n d D e v e l o p m e n t o f t h e Y o u n g C h i l d . P h i l a d e l p h i a : W . B . S a u n d e r s C o . , 1 9 5 8 . C a m p b e l l , D . T . , a n d S t a n l e y , J . C . E x p e r i m e n t a l a n d Q u a s i - E x p e r i m e n t a l D e s i g n s f o r R e s e a r c h . C h i c a g o : R a n d , M c N a l l e y a n d C o . , 1 9 6 6 . C h i p r n a n , S . S . , L i l i e n f i e l d , A . M . , G r e e n b e r g , B . G . , a n d D o n n e l l y , J . 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Med., C a r d i f f . B r i t . J . P r e v . Med. MXXVI ( 1 9 7 2 ) , 94. R o b i n s o n , G. " D e l a y e d D i a g n o s i s on C o n g e n i t a l H e a r i n g L o s s i n P r e s c h o o l C h i l d r e n . " P u b l i c H e a l t h R e p o r t s . LXXX (September 1965), 790. R o f f , M.A. "A F a c t o r i a l S t u d y o f t h e F e l s P a r e n t B e h a v i o u r R a t i n g S c a l e . " C h i l d Dev. XX ( 1 9 4 9 ) , 29-44. R o g e r s , M.G.H. "The E a r l y R e c o g n i t i o n o f H a n d i c a p p i n g D i s - o r d e r s i n C h i l d r e n . " Dev. Med. C h i l d N e u r o l . X I I I (March 1 9 7 1 ) , 88-101. Rosenburg, J.B. "Minor P h y s i c a l A n o m a l i e s and Academic P e r f o r m a n c e i n Young S c h o o l C h i l d r e n . " Dev^ Med, and C h i l d N e u r o l . XV ( 1 9 7 3 ) , 131-35. 61 R u b i n , R. " A t t a i n m e n t o f t h e M a t e r n a l R o l e . " N u r s i n g .Research. XVI ( 1 9 6 7 ) , 237. S a c k e t t , J . "W.H.O. Symposium 1971." L a n c e t . I I ( 1 9 7 4 ) , 7890 S h a p i r o , S. e t a l . " R e l a t i o n s h i p o f S e l e c t e d P r e n a t a l F a c t o r s t o P r e g n a n c y Outcome and C o n g e n i t a l A n o m a l i e s . " AJPH.LV - ( F e b r u a r y 1965), 268. S h e r i d a n , M.D. "D e v e l o p m e n t a l T e s t i n g P r o c e d u r e s . " M e d . O f f i c e r MXVIII ( 1 9 6 7 ) , 319. . C h i l d r e n ' s D e v e l o p m e n t a l P r o g r e s s (London: N a t . Found. E d u c a t i o n a l R e s e a r c h , 1973), 1. . " I n f a n t s a t R i s k o f H a n d i c a p p i n g C o n d i t i o n s . " Mth. B u l l e t i n M i n i s t . H l t h . Lab. S e r v . XXI ( 1 9 6 2 ) , 238. S h u l k a , e t a l . " I n f a n t i l e O v e r n u t r i t i o n i n t h e F i r s t Y e a r o f L i f e : A F i e l d Study- i n D u d l e y , W o r c e s t e r s h i r e . " B r i t i s h M e d i c a l J o u r n a l , I I (December 1 9 7 2 ) , 507-512. S m i t h , A. " I d e n t i f i c a t i o n o f H i g h - R i s k P e r s o n s and P o p u l a t i o n Groups." WHO C h r o n i c l e . X X V I I ( 1 9 7 3 ) , 72. S t a n d a r d , R.L. "D.C.'s New P e d i a t r i c P r a c t i t i o n e r s . " H e a l t h S e r v i c e ' R e p o r t s . V o l . 87 (May 1 9 7 2 ) , 387. Tho r p e , H.S. and Werner, E.E. " D e v e l o p m e n t a l S c r e e n i n g o f P r e s c h o o l C h i l d r e n : A C r i t i c a l Review o f I n v e n t o r i e s used i n H e a l t h and E d u c a t i o n a l P r o g r a m s . " P e d i a t r i c s . L I I (March 1974), 362-70. T o n k i n , R.S., R o b i n s o n , G.C. and K i n n o s , C. "A Study o f K i n d e r g a r t e n C h i l d r e n i n B r i t i s h Columbia."' H e a l t h . S e r v i c e R e p o r t s . ' LXXX (Dec. 1973) 947-55. W a l k e r , R.G. "An Assessment o f th e C u r r e n t S t a t u s o f t h e A t R i s k R e g i s t e r . " L a n c e t . I I ( 1 9 6 7 ) , 889. W.H.O. E x p e r t Committee. " E a r l y D e t e c t i o n o f Eye C o n d i t i o n s . " WHO C h r o n i c l e . ( J u l y 1971), 319-25. W.H.O. E x p e r t Committee. " C h i l d H e a l t h i n t h e European R e g i o n . " WHO C h r o n i c l e . XXV ( J u l y 1971), 319. W.H.O. Working Group. D e t e c t i o n and T r e a t m e n t o f H a n d i c a p p i n g D e f e c t s i n Young C h i l d r e n . Copenhagen, R e g i o n a l O f f i c e f o r E u r o p e , 1967. W o o l f , P.H. " O b s e r v a t i o n s o f Newborn I n f a n t s . " P s y c h o s o m a t i c M e d e c i n e . New S e r i e s , X X I ( 1 9 5 9 ) , 110-18. 62 Wynn, M. , a n d Wynn, A. The P r o t e c t i o n o f M a t e r n i t y a n d I n f a n c y . A n o t e o n s e r v i c e s i n F i n l a n d a n d B r i t a i n . L o n d o n . C o u n c i l f o r C h i l d r e n ' s W e l f a r e , 1 9 7 4 . The R i g h t o f E v e r y C h i l d t o H e a l t h C a r e . O c c a s i o n a l P a p e r s on C h i l d W e l f a r e No. 2: A S t u d y o f t h e Youn g C h i l d i n F r a n c e . L o n d o n , C o u n c i l f o r C h i l d r e n ' s W e l f a r e , 1 9 7 4 . 6 3 C . UNPUBLISHED WORKS A l l a n , J . B . "The I d e n t i f i c a t i o n and T r e a t m e n t o f ' D i f f i c u l t B a b i e s ' : E a r l y S i g n s o f D i s r u p t i o n i n P a r e n t - I n f a n t A t t a c h m e n t Bonds," ( P a p e r r e a d a t a s e r i e s o f l e c t u r e s f o r p u b l i c h e a l t h n u r s e s , The M a p l e s Y o u t h Development C e n t r e , Burnaby, B.C., 1972-73.) C a r p e n t e r , H. "The Need f o r A s s i s t a n c e o f M o t h e r s w i t h F i r s t B a b i e s D u r i n g a Three Month P e r i o d F o l l o w i n g t h e Baby's B i r t h . " U n p u b l i s h e d D o c t o r a l D i s s e r t a t i o n , T e a c h e r s ' C o l l e g e , C o l u m b i a U n i v e r s i t y , New Y o r k , 1965. Edmonton Board o f H e a l t h . " S u g g e s t e d F o l l o w - u p o f 'At R i s k ' B a b i e s . " Edmonton: C i t y o f Edmonton, 1969 (Mimeographed). W i g g l e s w o r t h , R. Department o f P e d i a t r i c s and C h i l d H e a l t h , K e t t e r i n g G e n e r a l H o s p i t a l , " C l a s s i f i e d L i s t o f B a b i e s a t R i s k : H i g h , Medium and Low Groups." (London: Department o f P e d i a t r i c s , 1970), (Mimeographed). 64 APPENDIX A PREGNANCY PRO F I L E INFANT P R O F I L E AT R I S K C R I T E R I A ( B o t h f o r m s [ c o p i e d w i t h p e r m i s s i o n , V a n c o u v e r H e a l t h D e p a r t m e n t ) 3-1-2/75 PREGNANCY PROFILE Date: 65 PLEASE FILL IN THIS QUESTIONNAIRE TO HELP YOUR PUBLIC HEALTH NURSE AND NUTRITION 1ST PROVIDE COUNSELLING TO MEET YOUR INDIVIDUAL INTERESTS AND NEEDS. A. Your Name Address Telephone B. Your Doctor's Name Address Telephone C. AGE: ( C h e c k s ) 18 Years or Less 19 to 34 35 and over D. WEIGHT BEFORE BECOMING PREGNANT: (1 pound = 0.45 kilograms; 1 inch - 2.54 centimetres; 1 foot = 0.3048 metre) (1) lbs. X 0.45 kg./lb. = kg. (2) YOUR PRESENT WEIGHT: lbs.. X 0.45 kg./lb. = kg. (3) YOUR WEIGHT GAIN: ( (2) minus (1) » ) m kg. (4) HEIGHT: in . X 2.54 cm./in. = cm. E„ Estimated due date . Number of weeks pregnant (on this date) F. PREVIOUS OBSTETRICAL HISTORY: (1) List Previous children: please give their birthdates & birthweights Sex Birthdate (month, day, year) Birthweights ( I f necessary continue on reverse side) Check here ( t ^ ) i f you have had no children . (2) Did you have any problems during your previous pregnancies or deliveries? (Such as toxemia, bleeding, Caesarian section, induced delivery, ear«ly delivery, abortion, s t i l l b i r t h , early death, etc.) Explain . Were you hospitalized or confined to bed at home at any time during any of your previous pregnancies? YES CD Nod- If "yes", why? (3) Did your baby(ies) have any problems? (Such as jaundice, breathing d i f f - iculty, physical defects, low birth weight, prematurity, etc.) Explain. 2-2/ 75 6 6 F. (4) How did you feed your previous babies? Breast | j Bottle|""""""j How do you plan to i n i t i a l l y feed this baby? Breast ["""""I Bottle] j 0. PRESENT PREGNANCY HISTORY; If you have any questions or problems you would like assistance with, please note them H. MEDICAL HISTORY: Do any of the following apply to you? Please check (ix-) i f applicable. 1. Allergy 2. Cancer 3. Depression 4. Diabetes 5. Epilepsy 6. Genetic Problem 7. Hemorrhoids 8. Headaches 9. Heart Condition 10. High Blood Pressure I. Do you smoke? 1 1 . Infectious Disease during this pregnancy 12. Kidney Condition 13. Recurrent Bleeding 14. Surgery in Past Year 15. Toxemia 16. Varicose Veins 17. Underweight 18. Overweight 19. Other (specify) How much? Do you plan to stop smoking now that you are pregnant? YES | | NO ( | J. Are you on any medication? YES| |N0[ [. Please specify, (.include al J. non- prescription drugs such as aspirin, antacids, laxatives, sleeping p i i l s , tranquilizers, etc.; and state what quantity of each you take and how otcen. K. What do you do for exercise? How often? L. What subjects are you or your husband particularly interested in having dis- cussed at prenatal class? ' * it ->V PLEASE COMPLETE THE ONE-DAY FOOD RECORD ATTACHED (H283-3-2/75) * * * NURSE'S COMMENTS: ACTION TAKEN: DATE: NURSE'S SIGNATURE ________ MKTHnPOLITAN HEALTH S^HVICE OF GREATER VANCOUVER -3-2/75 PREGNANCY PROFILE ONE DAY FOOD RECORD DAY OF WEEK Please l i s t a l l the foods that you eat or drink within a one day period: I t i s important to give the TIME you eat, and to state the KIND of food as well as the AMOUNT. Don't forget things l i k e gum or candy, sugar and cream i n coffee, jam on toast, in-between meal snacks and drinks: FOODS EATEN IN ONE DAY TIME TYPE OF FOOD: eg. whole wheat bread, hamburger QUANTITY • Are you taking any Vitamin or Mineral Supplements? YES j j NO IF "YES"; Name of Product Dosage - No. of Tabs./day Contents of each t a b l e t (Check the nutrient value on the Product Label.) MF"t*P CPfsT;!'̂  A*? HEALTH S^RVIC^- (W 'GKBA'TFP VAM^nHWR INFANT PROFILE AT RISK CRITERIA Name Birthdate Address Telephone Sex of Infant M n F ~n Birthweight Grams MARK IF THE ANSWERS TO ANY OF THE ITEMS DELOW ARE "YES, Ma r i t a l Status - Single and/or l i v i n g alone L Age of Mother - 35 y r s . & over 18 y r s . or under Native Indian B i r t h at Home Speci f i e d Measures Necessary to Promote Res p i r a t i o n M u l t i p l e B i r t h Infant Considered - Immature Post Mature Birthweight - 2500 gms. & under Gestation Period - Premature (under 38 weeks) - Post Mature (over 41 weeks) T o t a l Pregnancies - 5 & over Miscarriages; How Many? To t a l Pregnancies S t i l l b i r t h s ; How Many? | [ To t a l L i v e b i r t h s Mother's Blood - RH negative Operative Procedures - other than Low Forceps or Episiotomy Caesarian Section 1st j j 2nd r~-|more B i r t h Injury to Chi l d (Describe) Congenital Anomoly (Describe) Complications of Pregnancy, Labour or Delivery (Describe) Low Socioeconomic Family F i l e i n Unit Nurses Remarks: Date Signed (Month/Day/Year) METROPOLITAN HEALTH SERVICE OF GREATER VANCOUVER APPENDIX B ASSESSMENT TOOLS * G r o w t h A p p r a i s a l R e c o r d * G r o w t h G r i d s - I n f a n t G i r l s - I n f a n t B o y s * H e a r i n g T e s t G u i d e D e n v e r E y e S c r e e n i n g T e s t D e n v e r D e v e l o p m e n t S c r e e n i n g Test * 2.4 H r . N u t r i t i o n I n t a k e G u i d e - T r a d i t i o n a l M e t h o d o f . I n t r o d u c i n g S o l i d s - A v e r a g e C a l o r i c C o n c e n t r a t i o n s o f Common Baby F o o d s - Recommended C a l o r i c I n t a k e - Recommended C a l o r i c I n t a k e T a b l e s C o p i e d w i t h p e r m i s s i o n , V a n c o u v e r H e a l t h D e p a r t m e CH44-6/73 GROWTH APPRAISAL RECORD NAME ADDRESS TELEPHONE Surname First BIRTH DATE HEAD OF HOUSEHOLD Month Day- Year No abnormality . N " noted „„„„ 0 - Observe "\ 2= CODE: ) M R - Refer 4 j T - Under Treatment)w DATES j Age General Appearance Skin Head - Cranium Ears 1 Eyes Nose Mouth - Throat Neck Chest - Respiratory Cardiovascular Abdomen Genitalia Musculoskeletal Nervous System Measurements 1 Heijzht Weight ' Head Circumference Heart Rate Respiratory Rate Examiner COMMENTS - DATE AND SIGN (For More Detail Use CHC Record) METROPOLITAN HEALTH SERVICE OF GREATER VANCOUVER ! N F A N T G ! I R I S NINTH DATU NO. 8NFAMT BOYS I1IK1H DAT I! HEARING TEST GUIDE AGE EXPECTED HEARING/ LISTENING BEHAVIOUR SUGGESTED QUESTIONS TO USE WITH THE MOTHER Birth to 3 mos 0 to 1 month -Startle response to sudden, loud noise. -Arrests a c t i v i t y (cry- ing, moving) when approached by sound. -Quietened by familiar voice. 1 to 2 months -Searches for sound with eyes. -Often attends to speaker 2 to 3 months -May respond to mother's talking by vocalization. -May laugh and vocalise when played with. 1. Does your baby stop cry- ing/moving i f you speak to him as you approach him (unseen)? 2. Does a loud noise s t a r t l e him? 3. When spoken to d i r e c t l y , does he look at your face? A. Does he laugh and make noises when you talk to • him? 3 to 6 mos. 3 to A months -Turns head to source of sound. Looks about for speaker. -Babbles (repeats sounds) to himself. A to 5 months -Beginning to recognise and respond to his/her name. -Regularly locates source of sounds. 5 to 6 months -Appears to recognise general meaning of a) warning b) angry and c) friendly tones. -Often recognises words like "Mama", "Dada", "Bye-bye". -Withdraws i n response to "NO". Does your baby look around when an unusual noise occurs, or to see who is talking to him? Does he repeat sounds to himself? Does he sometimes respond to his name? Does he appear to look for. someone when you say "Where's Kama/Dada?" Does he appear to recognise the tone when you are: a) warning him not to do something b) angry c) fr i e n d l y L i t . 217 V i s i o n Tests .1. 2. 3. 4. "E" (3 years and above-3 to 5 t r i a l s ) P i c t u r e Card (2 1/2 - 2 11/12 yrs.-3 to 5 t r i a l s ) F i x a t i o n (6 months - 2 5/12 years) . . . . . . . Squinting . . . . . . 1ST SCREENING:DATE Right Eye o 3P 3P P o ti 3F 3F F yes <D H •S nl •u cn 0) +J ti U U U. L e f t Eye r H o 3P 3P P o ti 3 F 3F F. yes •3 4-1 CO cu 4-1 ti \=> U u u RESCREENING:DATE Right Eye ni fi o 25 3P 3P P Ctf O 3 3F 3F F yes CO 4-> cn cu 4-J ti f u u u L e f t Eye ca B u o 23 O ti 4-1 CD JJ ti 3P 3P P 3F 3F F yes U U U w <! w !*J w Ki w CO o s w Si M a H w H Tests f o r Non-Straight Eyes cd 6 u o 23 cd 6 u o ti <0 rH •3 4-> CD cy 4-1 . ti r H Cd o 25 r H CtJ O ti 4-1 cn 4J ti Do your c h i l d ' s eyes turn i n or out, or are they ever not s t r a i g h t ? 2. 3. Cover Test . . . . . . P u p i l l a r y Light Reflex NO P P YES F F U U U NO P P YES F F U U > s: s: a P J tl O ti a i i tn g rj CU Ti ro cn rt cn pj T o t a l Test Rating (Both Eyes) Normal (passed v i s i o n t e s t plus no squint, plus passed 2/3 tests f o r non-straight eyes) Abnormal (abnormal on any v i s i o n t e s t , squinting or 2 of 3 procedures f o r non-straight eyes) Untestable (untestable on any v i s i o n t e s t or untest- able on 2/3 tests f o r non-straight eyes) Future Rescreening Appointment f o r T o t a l Test Rating (Abnormal or Untestable) Normal Abnormal Untestable Normal Abnormal Untestable Date: Date: 14 15 16 17 18 19 20 21 22 23 24 YEARS 2Vi 3 5 5<6 6 •E-GAEDS FACE SMILES RESPONSIVB.Y . INITIALLY SHY WITH STRANGERS PLAYS PAT-A-CAKE IMITATES HOUSEWORK . PUTS ON O.OTHINO_ USES SPOON, SPILLING LITTLE u O SMILES SPONTANEOUSLY PLAYS BALL WITH EXAMINER WASHES & DRIES HANDS * 100% poss ot birtti FEEDS SELF CRACKERS RESISTS TOY PULL 5 0 % _ PLAYS PEEK-A-BOO WORKS FOR TOY OUT OF REACH INDICATES WANTS (NOT CRY) DRINKS FROM CUP HELPS IN HOUSE - SIMPLE TASKS REMOVES GARMENT DRESSES WITH SUPERVISION SEPARATES FROM MOTHER EASILY PLAYS INTERACTIVE GAMES e.g.. TAG DRESSES WITHOUT SUPERVISION FOLLOWS TO MIDLINE EQUAL MOVEMENTS FOLLOWS PAST MIDLINE I i I i i I GRASPS RATTLE REGARDS RAISIN REACHES FOR OBJECT FOLLOWS 180° HANDS TOGETHER SIT, LOOKS FOR YARN SIT, TAKES 2 CUBES RAKES RAISIN ATTAINS PASSES CUBE HAND TO HAND BANGS 2 CUBES HELD IN HANDS SCRIBBLES SPONTANEOUSLY TOWER OF 2 CUBES TOWER OF 4 CUBES TOWER OF 8 CUBES NEAT PINCER GRASP OF RAISIN IMITATES VERTICAL LINE WITHIN 30° COPIES + COPIES O COPIES • IMITATES • DEMONSTR. DRAWS MAN 3 PARTS IMITATES BRIDGE THUMB-FINGER GRASP DUMPS RAISIN FROM BOTTLE-SPONT. DUMPS RAISIN FROM BOTTIE-DEMONSTR DRAWS MAN 6 PARTS PICKS LONGER LINE 3 OF 3 RESPONDS TO BEU VOCALIZES -NOT CRYING DADA OR MAMA, NONSPECIFIC TURNS TO VOICE LAUGHS SQUEALS DADA OR MAMA. SPECIFIC IMITATES SPEECH SOUNDS 3 WORDS OTHER THAN MAMA. DADA COMBINES 2 DIFFERENT WORDS POINTS IO 1 NAMED , BODY PART NAMES 1 PICTURE FOLLOWS DiRECTIONS/2of3 •,T 1 r — i — r — f — r ~ T COMPREHENDS COLD, TIRED, HUNGRY/2 of 3 COMPREHENDS PREPOSITIONS/3 of 4 RECOGNIZES COLORS/3 of 4 OPPOSITE ANALOGIES _ 2 of 3 USES PLURALS DEFINES WORDS/6of9 GIVES 1ST & LAST NAME ~~ "* '1 t STO LIFTS HEAD STO HEAD UP 45° " T " COMPOSITION OF/3 of 3 BEAR SOME WEIGHT ON LEGS PULL TO SIT NO HEAD LAG STO HEAD UP 90° SITS WITHOUT SUPPORT STANDS MOMENTARILY WAIKS -HOLDING ON FURNITURE STANDS ALONE WELL KICKS BALL FORWARD THROWS BALL OVERHAND BALANCE ON 1 FOOT 1 SECOND STO CHEST UP ARM SUPPORT SIT - HEAD STEADY ROLLS OVER STANDS HOLDING ON PULLS SELF TO STAND - GETS TO SITTING STOOPS & RECOVERS WALKS WELL WALKS BACKWARDS JUMPS IN PLACE PEDALS TRICYCLE BROAD JUMP BALANCE ON 1 FOOT 10 SECONDS/2 of 3 HOPS ON 1 FOOT CATCHES" BOUNCED BALl/2of3 HEEL TO TOE WALK/2of3 BACKWARD HEEL - TOE/2 of 3 BALANCE ON 1 FOOT WALKS UP STEPS 5 SECONDS/2 of 3 . j | ,' . ' i I I ' ' ' ., I I— ) .„'.. ,.l I.., '.„,. l i u . ^ n — t 14 15 16 17 18 19 20 21 22 23 24 2V4 3 YEARS 3Vi 4V4 5 5<A 6 TRADITIONAL METHOD OF INTRODUCING SOLIVS Age, [in month*) 3 4 5 t ^ T I 9 ~ 10 11 12 CEREALS [in.on-ennJ.ched) Itb&p 4tb&p — r ' VEGETABLES Itb&p—4tb&p— FRUITS 1tbi>p—4tb6p MEAT, POULTRY, AND FISH ltl>p— 4tb6p FINGER FOODS StaAt — WHOLE COW'S MILK 500 ml. can replace fionmila on. bn.ea*t milk—: EGG YOLK 1/4t*p--1yolk VAIRY PRODUCTS li*p 4tbi>p EGG WHITE 1/4—1 ti>p—white WHOLE EGG StOAt N.B. - Thi* tAadiXionat method o£ intAoducing ioliAi i* pAovided a* one example. TheAe an.c othzn. acceptable methods. The ondeA in which cexeatt,, meat*, IniuX*, and vegetable* OAC tntn.odu.ced i* o^ le*6 imponXance than the age at which AtAained totid* ant given [not befioAe 3-4 month*). AVERAGE CALORIC CONCENTRATIONS OF COMMON BABY FOOVS kcal/ kcal/ Ron.denta.ge. Food Item 0 k Colo nie* lOOg tb&p Vnotzin tat CHO Vny CQAZOI {Rlcn} 570 8 ' 5 75 CeAzal [St/uained Oatmeal) 81 9- 7 3 90 STRA1NEV Juice* 65 10. 2 2 96 FhxiiX* 85 11- 2 2 96 V zg ztabl e*: Plain 45 6; 14 6 80 Hzati 106 18- 53 46 1 Egg Yolk* 192 29 21 76 3 Mzat with Vzgztable* 84 f /; 29 47 29 Soup4> and V0.g2Xa.bleJ> with Mzat VinnoAM 58 8 16 28 56 VzbhZhX* 96 14 4 7 89 JUNIOR Fn.uiM> 85 11 2 2 96 Vegetable*: Plain 46 6 12 7 81 Mzat* 103 • 15 , 56 43 I Mzat with Vegetable* Vinnzn* 85 11 30 42 28 Soup* and Ue.gzta.blte with, Meat Vinnzn* 61 • 9 15 17 58 Ve*i>eAX* 93 13 4 6 90 {adapted fiiom Fomon, 1974) Food value* o{ Pon.ti.ovi* Commonly ut>zd Bowe* and Ch.un.ch, 1970. RECOM.IENVEV CALORIC INTAKE tiotz* 1. Wziglit. WziglitA given cvxz fan thz ^nfront ofr thz 50th pznczntXtz ofr thz gnouitli chant. 2. VJJttnibution ofr Colonic*. An infrant't total colonic intake. Ah.ou.id be dividzd appfio Kunatzly ai> frollow*: CaA.bohijdA.atz: 35-651 (See p.10.) Tka> chant ha* been calculated on the. fallowing pznczntageA: 3. To-tô  Colonic Intake. The nzcommzndzd total colonic intakz fron infant* <U 110-120 kcal/kg/day. [Canadian Viztany Standand). ThJj> chant had been calculated at 1/5 kcal/kg/day. 4. Joule-i. Sincz 1 joulz * 4. IS kcol, thz nzcomxzndzd intakz ii> in thz nangz ofr 26.3-28.7 joulz6/kg/dau. Thii chant ii, calcuZatzd at 2% joulz*/ kg/day. 5. Fonmula. Tfr thz in front' 6 fronmula it> 20 kcal/oz, then thz infant in -Iti friAAt month nzzcU, 391/20 - 18 oz/day on. 9 oz/day ofr undilutzd fronmula. Pnotzin: Fat: 7-16% 30-55%. Pnotzin: Fat: 11% 41% 48% CaK.bohydh.atz: 7 9 KECOUMENVEV CALORIC INTAKE Female* Age Itiaight [month*] lb ka_ 0 1 2 3 4 5 9 10 11 12 7.5 9.5 11.2 12.5 13.7 14.8 16.0 17.0 18.0 19.0 20.0 20.5 21.2 4.3 5.1 5.7 6.2 6.7 7.3 7.7 8.2 8.6 9.1 9.5 9.6 TOTAL joule* I kcal/day AAOHI day WOitlN fAi TMf 95 120 143 160 174 182 204 216 230 241 255 260 269 43 55 65 72 78 85 92 97 104 109 115 118 121 160 203 240 269 292 316 345 363 386 405 429 438 453 188 237 282 315 392 370 405 426 453 475 503 514 530 TOTAL kcal/ ty 391 495 587 656 713 771 840 886 943 989 1047 1070 1104 tozight [month*] lb feg_ 0 1 2 3 4 5 6 7 8 9 10 11 12 7.5 9.5 11.8 12.5 13.8 14.5 16.5 18.0 19.0 19.8 20.5 21.5 22.0 Male* TOTAL joule*/ kcal/day Inx^n day nUTFlU tAT CHff 3.4 95 43 160 188 4.3 120 55 203 237 5.4 151 68 255 298 5.7 160 72 269 315 6.3 176 80 297 348 6.6 185 83 312 364 7.5 210 95 354 414 8.2 230 104 386 453 8.6 241 109 405 475 9.0 252 114 424 497 9.3 260 118 438 514 9.8 274 124 462 541 10.0 280 127 471 552 TOTAL kcal/ ty 391 495 621 656 725 759 863 943 989 1035 1070 1127 1150 APPENDIX C INSTRUCTIONS TO STAFF EXPLANATION TO PARENTS 81 I n f a n t Study - I n s t r u c t i o n s t o S t a f f The s t u d y w i l l s t a r t i n e a r l y June and f i n i s h i n A p r i l o r May 1976. E n r o l m e n t o f i n f a n t s i n t h e s t u d y w i l l c o n t i n u e from t h e s t a r t o f t h e s t u d y u n t i l 100 i n f a n t s a r e o b t a i n e d . The c l e r i c a l s t a f f w i l l : a) Complete an i n f a n t p r o f i l e as u s u a l and a t t a c h a b l a n k pregnancy p r o f i l e . b) G i v e a l t e r n a t e i n f a n t s t o t h e d i s t r i c t community h e a l t h n u r s e s f o r v i s i t s f o r newborn v i s i t s as u s u a l , k e e p i n g a l i s t o f t h e s e i n f a n t s ' names f o r G. D o h e r t y . c ) Keep e v e r y o t h e r i n f a n t f o r G. D o h e r t y t o v i s i t . d) F i l e t h e c o m p l e t e d p r o f i l e as u s u a l . The community h e a l t h n u r s e s w i l l : a) Request t h e i n f a n t ' s mother t o p a r t i c i p a t e i n r e s e a r c h p r o j e c t by c o m p l e t i n g a pregnancy p r o f i l e . b) Add n u r s i n g n o t e s t o t h e i n f a n t p r o f i l e as u s u a l . c ) A d v i s e t h e p a r e n t s t h a t G. D o h e r t y w i l l be making a c o n t a c t i n 9 months r e g a r d i n g a s s e s s m e n t s o f g r o w t h , development, v i s i o n , h e a r i n g and n u t r i t i o n . (G. D o h e r t y w i l l o b t a i n c o n s e n t t h e n . ) G. D o h e r t y w i l l : a) V i s i t t h e i n f a n t s a s s i g n e d and ( w i t h c o n s e n t o f t h e p a r e n t s ) r e v i s i t a t 1 month, 2 months, 3 months and 6 months o f age. b ) R e q u e s t t h e i n f a n t ' s m o t h e r t o c o m p l e t e a p r e g n a n c y p r o f i l e . c ) Add n u r s i n g n o t e s a n d a s s e s s m e n t f o r m s t o t h e i n f a n t p r o f i l e . d ) A d v i s e t h e d i s t r i c t n u r s e s a s t o who s h e i s v i s i t i n g on a n o n g o i n g b a s i s . e ) M a i n t a i n a s e p a r a t e f i l e o f t h e s e i n f a n t s ' r e c o r d s t o w h i c h s t a f f h a v e t h e same a c c e s s a s t h e h e a l t h u n i t f i l e s . 83 EXPLANATION TO PARENTS OF THE EXPERIMENTAL GROUP " I am d o i n g r e s e a r c h f o r t h e V a n c o u v e r H e a l t h D e p a r t m e n t a n d i n c o n n e c t i o n w i t h my s t u d i e s a t UBC i n v o l v i n g a s s e s s - m e n t s o f b a b i e s ' g r o w t h , d e v e l o p m e n t , v i s i o n , h e a r i n g a n d n u t r i t i o n . T h i s w i l l i n v o l v e r e t u r n v i s i t s when _____ ( b a b y ' s name) i s o n e m o n t h , t h r e e m o n t h s , s i x m o n t h s a n d n i n e m o n t h s o l d . I w i l l b e s t a r t i n g t h i s r e c o r d o f n o t e s a n d a g r o w t h c h a r t t o c o m p a r e 's ( b a b y ' s name) c h a n g e s i n d e v e l o p m e n t a n d t o r e c o r d e a c h v i s i t . A s w i t h t h e o t h e r r e c o r d s i n t h e d e p a r t m e n t t h i s i s c o n f i d e n t i a l a n d a n y m a t e r i a l u s e d f o r r e s e a r c h w i l l n o t h a v e y o u r name on i t . I w i l l e x p l a i n e a c h a s s e s s m e n t a s I do i t i n c l u d i n g a n y f i n d i n g s . T h e a s s e s s m e n t s i n no way r e p l a c e t h e s e r v i c e s o f y o u r d o c t o r b u t h o p e f u l l y w i l l a d d t o y o u r b a b y ' s h e a l t h c a r e . The f i n d i n g s o f t h e s t u d y w i l l h e l p u s d e c i d e i f c e r t a i n n u r s i n g a s s e s s m e n t s a t c e r t a i n a g e s h e l p t o p r e v e n t , o r p i c k up e a r l i e r , a n y p r o b l e m s i n t h e s e a r e a s . I f y o u a r e i n t e r e s t e d i n t h e r e s u l t s o f t h e s t u d y I w i l l p r o v i d e y o u w i t h a c o p y when, i t i s c o m p l e t e d . P l e a s e f e e l f r e e t o c a l l me i f y o u h a v e a n y q u e s t i o n s - o r a n y c o n c e r n s a b o u t y o u r b a b y b e t w e e n v i s i t s . " 84 APPENDIX D S T A T I S T I C A L TABLES TABLES OF D E S C R I P T I V E A N A L Y S I S I 85 TABLE X I DESCRIPTIONS OF THE IMPAIRMENTS DETECTED IN THE EXPERIMENTAL GROUP INFANTS FROM BIRTH TO NINE MONTHS OF AGE N = 40 Number Age T o t a l A r e a o f Impairment- D e t e c t e d D e t e c t e d By A r e a Head (lo w e a r s .'.)' 1* 2 weeks 1 ( l a r g e tongue ) S k i n s c a l y , g e n e r a l i z e d r a s h 1 2 weeks i n f e c t e d f a c i a l r a s h 1 2 weeks i i n f e c t e d g e n e r a l i z e d r a s h 2 1 month • , g e n e r a l i z e d a l l e r g i c r a c h 1 3 months i n f e c t e d d i a p e r r a s h 1 3 months i n f e c t e d d i a p e r r a s h 1 6 months - 7 E a r s i n f e c t e d o u t e r e a r c a n a l 1 2 weeks e a r c a n a l o c c l u d e d by wax 1 1 month b o t h e a r c a n a l s o c c l u d e d by wax 1 3 months abnormal e a r drum ( i n f e c t i o n ) 1 6 months 4 Eyes b l o c k e d t e a r d u c t 1 2 weeks i n f e c t e d eyes 1 1 month : i n f e c t e d eye 2 1 month s t r a b i s m u s 1** 6 months s t r a b i s m u s 1 9 months 6 Mouth h i g h , narrow p a l a t e , d i f f i c u l t y s u c k i n g 1 2 weeks t h r o a t t h r u s h i n f e c t i o n i 3 months 2 Abdomen i m p a c t e d s t o o l i n bowel I 3 months 1 G e n i t a l i a s k i n t a g on f o r e s k i n I 2 weeks undescended t e s t i c l e s I 1 month 2 M u s c u l o - . . u m b i l i c a l h e r n i a I 2 weeks s k e l e t a l i n - t u r n e d f o o t , bowed l e g 2 2 weeks s t r u c - i n - t u r n e d f e e t 1 1 month t u r e i n g u i n a l h e r n i a 1 1 month i n - t u r n e d f o o t 1 3 months a s s y m e t r i c a l h i p s , l e g l e n g t h s 1* 3 months i n - t u r n e d f e e t 1* 6 months i i n - t u r n e d f o o t 1 6 months o u t - t u r n e d f e e t 1 6 months 10 86 TABLE X I c o n t i n u e d Number Age T o t a l A r e a o f I m p a i r m e n t D e t e c t e d D e t e c t e d By A r e a W e i g h t o v e r w e i g h t 2 1 month u n d e r w e i g h t 1 6 m o n t h s 3 T o t a l . 36 * S u b s e q u e n t l y d i a g n o s e d as n o r m a l a f t e r f u r t h e r e x a m i n a t i o n , d i a g n o s t i c p r o c e d u r e s , r e f e r r a l a p p r o p r i a t e ** S u b s e q u e n t l y d i a g n o s e d n o r m a l , r e f e r r a l i n n a p p r o p r i a t e 87 TABLE X I I DESCRIPTIONS OF THE IMPAIRMENTS DETECTED IN THE CONTROL GROUP INFANTS AT NINE MONTHS OF AGE N = 40 A r e a o f Impairment Number D e t e c t e d T o t a l By A r e a H e a r i n g , E a r s wax o c c l u d i n g b o t h e a r c a n a l s abnormal eardum ( m i d d l e e a r i n f e c t i o n ) 1 1 2 V i s i o n , Eyes s t r a b i s m u s 4 4 R e s p i r a - t o r y wheezy r e s p i r a t i o n s ( d i a g n o s e d as asthma) 1 1 G e n i t a l p h i m o s i s undescended t e s t e s l a r g e s k i n t a g on f o r e s k i n 1 1 1 3 Abdomen u m b i l i c a l h e r n i a 1 M u s c u l o s - k e l e t a l s t r u c - t u r e i n - t u r n e d f o o d o u t - t u r n e d f e e t 1 1 . 3 Weight o b e s i t y 3 3 T o t a l 16 88 T A B L E X I I I A C O M P A R I S O N B E T W E E N M O T H E R S OF TWO G R O U P S OF I N F A N T S B Y N U M B E R S C O N S I D E R E D A T R I S K B Y I N D I V I D U A L C R I T E R I A ON T H E P R E G N A N C Y P R O F I L E N u m b e r s o f m o t h e r s c o n s i d e r e d a t r i s k A t R i s k C r i t e r i a o n t h e E x p e r i m e n t a l C o n t r o l P r e g n a n c y P r o f i l e G r o u p G r o u p N = 5 0 N = 5 0 1 8 y e a r s a n d u n d e r 0 2 3 5 y e a r s a n d o l d e r 6 1 P r e p r e g n a n t w t . o v e r 2 0 % i d e a l 2 5 " " u n d e r 2 0 % " 4 0 W e i g h t g a i n 2 4 l b s . n o t a c h i e v e d 7 5 H e i g h t u n d e r 5 f t . 0 2 O v e r 5 c h i l d r e n 0 3 N o p r e v i o u s c h i l d r e n 2 2 2 9 T o x e m a 0 4 B l e e d i n g 2 1 C - s e c t i o n 4 0 I n d u c e d D e l i v e r y 0 0 E a r l y d e l i v e r y 0 0 A b o r t i o n 3 2 S t i l l b i r t h 1 0 E a r l y d e a t h o f p r e v i o u s i n f a n t ( s ) „ 1 0 P e r n i c i o u s v o m i t i n g 1 0 J a u n d i c e o f p r e v i o u s i n f a n t ( s ) 1 0 B r e a t h i n g d i f f i c u l t i e s o f p r e v i o u s i n f ( s ) i 1 P h y s i c a l d e f e c t o f p r e v i o u s i n f a n t ( s ) 2 1 L o w b i r t h w t . , p r e m a t u r i t y o f p r e v i o u s i n f a n t e ' s ) 2 4 A l l e r g y 5 4 C a n c e r 0 6 D e p r e s s i o n 2 3 D i a b e t e s 0 . 0 E p i l e p s y 0 0 G e n e t i c p r o b l e m 0 0 H e m o r r h o i d s 3 3 H e a d a c h e s 6 6 H e a r t c o n d i t i o n 0 0 H i g h b . p . 0 5 I n f e c t i o u s d i s e a s e d u r i n g t h i s p r e g n a n c y 1 0 K i d n e y c o n d i t i o n 1 0. R e c u r r e n t b l e e d i n g 0 1 S u r g e r y i n p a s t y e a r 2 0 T o x e m i a 0 5 V a r i c o s e v e i n s 1 4 U n d e r w e i g h t 4 0 O v e r w e i g h t 2 5 O t h e r m e d i c a l p r o b l e m s 0 0 • S m o k e r 5 8 M e d i c a t i o n s t a k e n 0 2 F o o d r e c o r d 1 0 9 TABLE X I V A COMPARISON BETWEEN MOTHERS OF TWO GROUPS OF INFANTS BY NUMBERS CONSIDERED AT R I S K BY I N D I V I D U A L C R I T E R I A ON THE ""INFANT-/PROFILE Number o f m o t h e r s c o n s i d e r e d a t r i s k A t R i s k C r i t e r i a on t h e E x p e r i m e n t a l C o n t r o l I n f a n t P r o f i l e G r o u p G r o u p N'= 50 N = 50 M a r i t a l s t a t u s - s i n g l e a n d / o r l i v i n g a l o n e 2 3 Age o f m o t h e r - 35 y r s a n d o v e r 7 1 - 18 y r s a n d u n d e r • 0 2 N a t i v e I n d i a n 2 1 B i r t h a t home 0 . o M e a s u r e s n e c e s s a r y t o p r o m o t e r e s p i r a t i o n 1 2 M u l t i p l e b i r t h 2 0 I n f a n t c o n s i d e r e d - i m m a t u r e 4 5 - p o s t m a t u r e 3 1 B i r t h w e i g h t - 2500 gms a n d u n d e r 4 6 G e s t a t i o n p e r i o d - p r e m a t u r e ( u n d e r 38 w e e k s ) 5 4 - p o s t m a t u r e ( o v e r 4 1 w e e k s ) 2 3 T o t a l p r e g n a n c i e s - 5 o r o v e r 2 3 - f i r s t - 23 29 M i s c a r r i a g e s 3 3 S t i l l b i r t h s . 1 • 0 M o t h e r ' s b l o o d - RH n e g a t i v e 1 7 O p e r a t i v e p r o c e d u r e s o t h e r t h a n e p i s i o t o m y , l o w f o r c e p s 0 2 C a e s a r i a n s e c t i o n 8 6 B i r t h i n j u r y t o c h i l d ' •" 1 3 C o n g e n i t a l a n o m a l y 6 4 C o m p l i c a t i o n s o f p r e g n a n c y , l a b o u r o r d e l i v e r y 10 ' 11 Low s o c i o e c o n o m i c l e v e l 20 16

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