New AAP Policy on Detecting and Addressing Developmental and Behavioral Problems
2007; Elsevier BV; Volume: 21; Issue: 6 Linguagem: Inglês
10.1016/j.pedhc.2007.08.008
ISSN1532-656X
AutoresFrances Page Glascoe, Nicholas S. Robertshaw,
Tópico(s)Child and Adolescent Health
ResumoSection EditorMary Margaret Gottesman, PhD, RN, CPNP, FAANOhio State University College of NursingColumbus, OhioPatient EducationMost health care providers attempt to identify children with developmental and behavioral problems in order to confer the potentially enormous benefits of early intervention (e.g., Reynolds et al 2007Reynolds A.J. Temple J.A. Ou S.-R. Robertson D.L. Mersky J.P. Topitzes J.W. et al.Effects of a school-based, early childhood intervention on adult health and well-being: A 19-year follow-up of low-income families.Archives of Pediatrics and Adolescent Medicine. 2007; 161: 730-739Crossref PubMed Scopus (244) Google Scholar). Unfortunately, 70% of clinicians rely on informal milestone checklists (Sand et al 2005Sand N. Silverstein M. Glascoe F.P. Gupta V.B. Tonniges T.P. O’Connor K.G. Pediatricians’ reported practices regarding developmental screening: Do guidelines work? Do they help?.Pediatrics. 2005; 116: 174-179Crossref PubMed Scopus (202) Google Scholar, Sices et al 2003Sices L. Feudtner C. McLaughlin J. Drotar D. Williams M. How do primary care physicians identify young children with developmental delays? A national survey.Journal of Developmental and Behavioral Pediatrics. 2003; 24: 409-417Crossref PubMed Scopus (122) Google Scholar). These checklists lack reliability, validity, accuracy, or scoring criteria. The apparent result is that only one fourth of children eligible for early intervention services actually receive them. To address this problem, the American Academy of Pediatrics (AAP) issued a new policy statement that calls for detailed developmental surveillance (American Academy of Pediatrics 2006American Academy of Pediatrics, Council on Children With DisabilitiesSection on Developmental Behavioral PediatricsBright Futures Steering CommitteeMedical Home Initiatives for Children With Special Needs Project Advisory CommitteeIdentifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening.Pediatrics. 2006; 118: 405-420Crossref PubMed Scopus (1009) Google Scholar).What is Developmental Surveillance?Surveillance is a longitudinal process designed to help clinicians focus on the “big picture” or context of children’s lives. Unlike screening that can only detect existing delays, however subtle, surveillance embraces identification and intervention into the precursors of problems in order to potentially prevent them (Blair and Hall 2006Blair M. Hall D.M.B. From health surveillance to health promotion: The changing focus in preventive Children’s Services.Archives of Diseases of Childhood. 2006; 91: 730-735Crossref PubMed Scopus (45) Google Scholar). These precursors or psychosocial risk factors include parental depression, poverty, limited parental education, housing instability, absence of social support, and a parenting style characterized by minimal verbal mediation (e.g., only talking to infants when they cry, issuing mostly commands, and not talking about things children notice) (Aylward 1992Aylward G.P. The relationship between environmental risk and developmental outcome.Journal of Developmental and Behavioral Pediatrics. 1992; 13: 222-229Crossref PubMed Scopus (104) Google Scholar, Sameroff et al 1987Sameroff A.J. Seifer R. Barocas R. Zax M. Greenspan S. Intelligence quotient scores of 4-year-old children: Social-environmental risk factors.Pediatrics. 1987; 79: 343-350PubMed Google Scholar). Efforts to ameliorate or reduce risk factors broaden conventional notions of early intervention services to include parent education, quality day care and preschool programs, special education, Head Start, social services, parenting classes, housing assistance, and mental health treatment.The process of information gathering within a surveillance model is multidimensional and involves eliciting and addressing parents’ concerns, monitoring developmental/behavioral emotional progress, screening for development problems periodically, measuring and promoting resilience factors, and addressing risk factors. Although the process of surveillance may seem overwhelming, if viewed as a multi-step process with varying foci at each well-child visit, it is readily doable and very effective.Step 1: Eliciting and Addressing Parents’ ConcernsSurveillance begins by eliciting and addressing parents’ concerns at every well-child visit. Most suitable for this task is Parents’ Evaluation of Developmental Status (PEDS), a 10-question measure that indicates, based on evidence, when to refer, screen further, advise parents, or reassure (Glascoe 2002Glascoe F.P. Collaborating with parents: Using parents’ evaluations of developmental status to detect and address developmental and behavioral problems. Ellsworth & Vandermeer Press, Ltd, Nashville, TN2002Google Scholar, Glascoe 2007Glascoe F.P. Parents’ evaluations of developmental status: A method for detecting and addressing developmental and behavioral problems in children. Ellsworth & Vandermeer Press Ltd, Nashville, TN2007Google Scholar). Research on the PEDS shows that when parents’ concerns are routinely elicited and addressed, families are more likely to return for well-child visits and to use positive parenting practice such as time-out and praise rather than punishment; in addition, it helps providers better focus visits on issues of interest to families (Bethell et al 2001Bethell C. Peck C. Schor E. Assessing health system provision of well-child care: The Promoting Healthy Development Survey.Pediatrics. 2001; 107: 1084-1094Crossref PubMed Scopus (107) Google Scholar, Smith 2005Smith P.K. Center for Health Care StrategiesBCAP toolkit: Enhancing child development services in Medicaid managed care. 2005Google Scholar). The consequence is a reduction in “door-knob concerns”—those “grenades of the day” that are so disruptive to patient flow (Glascoe and Kundell 2002Glascoe F.P. Kundell S. How to improve patient flow, satisfaction, and quality of care.Patient Care. 2002; 36 (83-84): 77-80Google Scholar). The PEDS seems to help parents discover that clinicians desire to be true collaborators in child-rearing issues and encourages them to think carefully about development as a range of domains.Step 2: Monitoring Milestones and Screening PeriodicallySurveillance also involves routinely monitoring milestones and screening periodically. Both these tasks can be accomplished simultaneously while also ensuring accurate detection of delays. A new measure can help with both recommendations: Parents’ Evaluation of Developmental Status: Developmental Milestones (PEDS:DM) (Glascoe and Robertshaw 2007Glascoe F.P. Robertshaw N.S. Parents’ evaluation of developmental status: Developmental milestones (PEDS-DM).in: Ellsworth & Vandermeer Press, LLC, Nashville, TN2007Google Scholar). The PEDS:DM is for children birth to 8 eight years of age and consists of six to eight questions per visit. There is one question per developmental domain: fine motor, gross motor, social-emotional, self-help, expressive language, receptive language, and for older children, reading and math. Parents can answer these questions on their own, or providers can elicit the skills directly from children (however, parent report saves time and is equally accurate). Each question serves as a screen for the domain from which it is derived, and problematic performance is tied to a cutoff at the 16th percentile or below (the point below which children have great difficulty with regular curricula). Standardized and validated on more than 1600 children throughout the United States who participated from health care settings as well as day-care centers and preschools, the PEDS:DM has sensitivity and specificity across domains as well as age ranges of 83% to 84%, well within standards for screening tools (Glascoe and Robertshaw 2007Glascoe F.P. Robertshaw N.S. Parents’ evaluation of developmental status: Developmental milestones (PEDS-DM).in: Ellsworth & Vandermeer Press, LLC, Nashville, TN2007Google Scholar).The PEDS:DM consists of a book of laminated forms, one for each age range, that parents complete with a dry erase marker. The six to eight questions per form are written at the high first-grade level and answered, via multiple choice, in less than 5 minutes. To score the PEDS:DM, a single scoring template is laid on top of the completed PEDS:DM form to reveal correct and incorrect answers. These answers then are transferred to a one-page longitudinal growth chart that remains in the patient record. Over time, the growth chart builds a graph of children’s developmental strengths and weaknesses while consistently revealing when referrals are needed. The reverse side of the growth chart shows how to integrate parents’ concerns on the PEDS with the PEDS:DM results in order to refine clinical decisions about the need for referrals, parent education, watchful waiting, and reassurance.Step 3: Promoting DevelopmentThe PEDS:DM also encourages parents to read to their child a short story (presented on the page opposite the screening test questions) (Box 1). The stories focus on age-appropriate parenting practices (such as talking and reading to your baby, giving toddlers choices, making clean-up or bath time into a game, and dealing with sibling rivalry). Because parents also are known to learn about child development through assessment, the PEDS:DM offers both an opportunity to learn about developmental skills and to practice and learn important parenting skills. The photographs and drawings that accompany the stories and test items reflect the diverse ethnicities within American society. In addition, the PEDS:DM manual contains photocopy-ready parent education handouts (Box 2), a list of links helpful for finding local services, and parent summary and referral letter templates. Spanish translations of handouts and the parent summary report are downloadable without charge at www.pedstest.com.Sample story from the PEDS:DM for parents to read aloud at the 5- to 7-month visitThe Baby Who Stared at EverythingOnce upon a time there was a daddy who saw that his baby liked to look at everything. She looked and she looked and she looked and she looked. Her daddy held her and told her the names of everything she saw. He named trees and dogs and books and bottles, and he even told her that her mother’s name was Mama.One day the baby said, “Ma ma ma ma ma ma ma ma.” Her daddy smiled at his baby.“That’s right. That’s your Mama,” he said. The baby smiled back at her daddy. Then she said “Da da da da da da da da.”Her daddy smiled and said, “That’s right, I’m your daddy. And your da da da daDaddy just loves you.”© 2007 Frances Page Glascoe, Nicholas S. Robertshaw. Ellsworth & Vandermeer Press, LLC, 1013 Austin Court, Nolensville, TN 37135, phone: 615-776-4121, fax: 615-776-4119, Web: www.pedstest.com. Reprinted with permission.Sample parenting information handout most useful for parents of children 2 years of age and olderDiscipline and BehaviorDiscipline is not mostly punishment. Discipline is teaching new behaviors—in yourself and your children. Children often do the same troubling things over and over because they don’t know another way to act or because they don’t know how to ask for what they really want or tell you what’s bothering them. So, one of the main goals of discipline is to teach a better way to behave and communicate. Discipline, unlike punishment, also prevents misbehavior. These suggestions should help:1The single most important part of discipline is to catch your child being good and let him know how proud you are (“You put on your shoes this morning—way to go!”). Use praise often. It motivates your child to want to behave well and to seek approval in positive ways. Every 5 to 10 minutes, try to catch your toddler being good—every 15 minutes or so for preschoolers and every 30 minutes or so with older children.2Spend some time every day doing some things your child likes to do and that you like to do. A child who has special attention from her parents is less likely to misbehave.3Childproof your house. Remove dangerous, breakable, and valuable objects from areas where you spend time with your young child so that constant nagging is not necessary. If possible, make your outside yard as safe and child-friendly as possible—get a fence, give away a dangerous dog, move lawn chemicals and equipment. If you cannot make changes in your yard or play area, take turns with other parents supervising children outside.4Anticipate children’s needs for activities. Have a list of things your child likes to do (you can create this together). When he is restless and needs a new activity, go to the list and let him chose something. When driving long distances, even on the way to and from the grocery store, have some fun activities prepared, like “I see something…,” “20 Questions,” and drawing pads or books that are only for use in the car or bus.5Rotate your child’s toys. Keep some in a closet out of your child’s reach and some where she can play with them. When she needs a new activity and is tired of the toys she has out, switch them with ones in the closet.6Distract young children from things you don’t want them doing by starting another activity—getting out a different toy, reading a book with them, singing a song, etc.7Praise your child when she does something you expect her to do. Make a short list of things you want your child to do on his own. Put these on a chart (with older children you can also list the days of the week and hours of the day). With younger children every 30 minutes or so, go with him to the chart and draw a star or put a sticker on it if he has done what was required. For older children, two or three times a day may be enough. You can mention a few minutes in advance that it’s almost chart time—as a reminder to do what he should.8Practice in a playful way how you want your child to behave. Try saying, “Now we are going to play ‘The Obey Game.’ I’m going to ask you to do something and then when you do it, I’m going to give you a big hug. Are you ready? OK, go get your shoes!” When your child returns with his shoes, say, “That was very good obeying. I am proud of you. Here is your hug. Now, let’s obey Daddy again….” You can also use this to practice social skills like taking turns, waiting patiently, and so forth.9Have family time for talking about behavior. Let your children talk about why rules are important, what the rules should be, and rewards and consequences. Children are more likely to agree and cooperate when they understand and are involved in rule making.10Offer choices of activities, foods, etc. This helps your child feel some sense of control even while you restrict the options to things that are workable, available, safe, etc. (e.g., “We can’t do that right now but here are two things you can do….. Which would you like to do?”).11Try making up a song about things your child may not want to do but must (like taking a bath, getting ready for bed, washing up, getting dressed). This will keep you calm and happy even when you have to repeat yourself, and, best of all, your child is more likely to follow through, perhaps because it seems more like a game.12Take time for yourself: You will do better with your children when you are refreshed. If you have given your child special time, it is easier to insist on your own special time too.Even if you do the above often and well, children will misbehave at times. These suggestions should help you manage problem behavior:1For older children, use natural consequences whenever possible and safe. For example, if you have to nag your child to get dressed every morning, let her know you will be taking her whether she is dressed or not. When the time comes, quietly and gently walk her out to the bus or car in her pajamas and let her get dressed there. One time is usually enough!2When your preschool-aged child keeps doing something that you have asked him not to do, give one warning and then “time out.” Put your child in another room for a few minutes (only a few minutes is needed) and give her no attention. With older children, use “reverse time out.” Say, “I can’t be around you when you act like this. I’ll be back when you can….” Do not respond to pounding on the door, etc. Let your child return when he is or agrees (quickly) to behave appropriately. Keep conversations short and commands clear. Once your child is able to return, practice with your child the behavior you want to see. Another way to do this is to have a time-out chair (turned away from you) that your child must sit in briefly until he is ready to behave better.3Sometimes parents don’t try good discipline methods for enough time. When you have tried lots of methods and nothing seems to work, decide whether one approach made things worse. This is the one to try again. Children usually try a misbehavior a few last times (professionals call this a “response burst”) before they learn it’s not working any more.4Talk with older children during a calm moment about their behavior and help them understand what you want. Listen to what they say, rephrasing it carefully. Ask them how they think things should be handled.5Don’t hit your child. It only shows them that aggression and anger are a way to solve problems. Spankings drive misbehavior underground. It just makes children sneaky.6Don’t call your children names. Name-calling hurts and causes children to act worse.7Don’t label your child (e.g., “He’s my shy one,” “She’s my problem child.”). He or she will just try to live up to what you call them.It’s also a good idea to read books from time to time about child-rearing so you can better understand why your child acts as she does. There are several excellent books (All are available on www.amazon.com):Wyckoff, J., & Unell, B. C. (1984). Discipline without shouting or spanking. New York: Meadowbrook Press. (Includes short chapters on specific problem behaviors like sibling rivalry, temper tantrums, talking back, resisting bedtime, not eating, etc.)Dinkmeyer, D., McKay, G. D., & Dinkmeyer, J. S. (1989). Parenting young children. Circle Pines, Minnesota: American Guidance Services. (Phone: 800-328-2560.)Dinkmeyer, J. S. (1989). Systematic training for effective parenting. Circle Pines, Minnesota: American Guidance Services. (Phone: 800-328-2560.) (Both Dinkmeyer books help parents learn a wide range of proven discipline techniques. There are Spanish and Christian editions as well as versions for teenagers. Videotapes and instructional manuals are available for use in parenting classes.)EveryDay matters: Activities for you and your child. Circle Pines, Minnesota: American Guidance. (Phone: 800-328-2560; Web site: http://www.agsnet.com/)Take a parenting class. These are not only helpful but you can get many ideas and lots of support from other parents. Parenting classes are often offered by community mental health centers, local churches, through the public schools, colleges, etc.National ServicesParents’ Hotline: 800-356-6767Parents As Teachers (provides parenting support, training, etc.): www.parentsasteachers.orgFor help locating parenting programs, go to http://www.patnc.org© 2007 Glascoe F. P., Robertshaw N. S. Parents’ Evaluation of Developmental Status: Developmental Milestones (PEDS:DM), www.pedstest.com.Step 4: Screening for Autism Spectrum Disorders and Detecting/Addressing Psychosocial Risk and ResilienceThe AAP recommends screening for autism spectrum disorders at 18 and 24 months, which involves capturing, monitoring, and addressing risk factors such as maternal depression. Also recommended is searching for and encouraging protective or resilience factors that point to a more positive outcome, even in the presence of risk. To address these components of surveillance, the second section of the PEDS:DM Family Book contains supplementary measures (also laminated and all rooted in research), including the Modified Checklist of Autism in Toddlers, the Brigance Parent-Child Interactions Scale, to determine whether parenting style is likely to lead to healthy development, and the Family Psychosocial Screen, a measure of parental depression and other risk factors.Also included are two measures useful with children older than 8 years: the Safety Word Inventory and Literacy Screener, a measure of school skills, and the Pictorial Pediatric Symptom Checklist-17, a screen for depression, attention, and conduct problems. While not a screening tool, the Vanderbilt ADHD Scale, a diagnostic measure of attention, hyperactivity, and impulsivity, is included because it is helpful if the Pictorial Pediatric Symptom Checklist-17 reveals problems with attention. The PEDS:DM manual identifies when to use supplementary measures, because not all are needed at any single well-child visit. In terms of electronic applications, the PEDS (the measure eliciting and addressing parents’ concerns), and the (optional) Modified Checklist of Autism in Toddlers are already available online. The site can be used with or without integration with electronic medical records. The PEDS:DM will be added to the Web site by late fall 2007, and the Spanish edition is due out in October 2007.Teaching and TrainingBoth the PEDS and the PEDS:DM are supported by an abundance of training materials. The PEDS:DM manual includes guidance for trainees on managing children during testing and adapting the testing situation for children with various kinds of disabilities and risks. In addition, the training materials provide guidance on giving difficult news and explain how to use the Assessment Level version, which is useful for early intervention, NICU follow-up programs, and training young professionals.The Web site for both measures includes slide shows with case examples, links to services, parenting handouts, and a short video on scoring the PEDS:DM. The site also sponsors a discussion list on early detection (www.pedstest.com).Other Points of InterestThe PEDS:DM was created with items from several of the Brigance Diagnostic Inventories. Albert Brigance and his publisher, Curriculum Associates, along with Ellsworth & Vandermeer Press, have jointly agreed to donate a portion of PEDS:DM sales to the AAP’s Section on Developmental and Behavioral Pediatrics in support of its Web site devoted to helping health care providers learn about screening and surveillance—www.dbpeds.org—including other screening tools. Section EditorMary Margaret Gottesman, PhD, RN, CPNP, FAANOhio State University College of NursingColumbus, Ohio Mary Margaret Gottesman, PhD, RN, CPNP, FAANOhio State University College of NursingColumbus, Ohio Mary Margaret Gottesman, PhD, RN, CPNP, FAAN Ohio State University College of Nursing Columbus, Ohio Patient EducationMost health care providers attempt to identify children with developmental and behavioral problems in order to confer the potentially enormous benefits of early intervention (e.g., Reynolds et al 2007Reynolds A.J. Temple J.A. Ou S.-R. Robertson D.L. Mersky J.P. Topitzes J.W. et al.Effects of a school-based, early childhood intervention on adult health and well-being: A 19-year follow-up of low-income families.Archives of Pediatrics and Adolescent Medicine. 2007; 161: 730-739Crossref PubMed Scopus (244) Google Scholar). Unfortunately, 70% of clinicians rely on informal milestone checklists (Sand et al 2005Sand N. Silverstein M. Glascoe F.P. Gupta V.B. Tonniges T.P. O’Connor K.G. Pediatricians’ reported practices regarding developmental screening: Do guidelines work? Do they help?.Pediatrics. 2005; 116: 174-179Crossref PubMed Scopus (202) Google Scholar, Sices et al 2003Sices L. Feudtner C. McLaughlin J. Drotar D. Williams M. How do primary care physicians identify young children with developmental delays? A national survey.Journal of Developmental and Behavioral Pediatrics. 2003; 24: 409-417Crossref PubMed Scopus (122) Google Scholar). These checklists lack reliability, validity, accuracy, or scoring criteria. The apparent result is that only one fourth of children eligible for early intervention services actually receive them. To address this problem, the American Academy of Pediatrics (AAP) issued a new policy statement that calls for detailed developmental surveillance (American Academy of Pediatrics 2006American Academy of Pediatrics, Council on Children With DisabilitiesSection on Developmental Behavioral PediatricsBright Futures Steering CommitteeMedical Home Initiatives for Children With Special Needs Project Advisory CommitteeIdentifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening.Pediatrics. 2006; 118: 405-420Crossref PubMed Scopus (1009) Google Scholar). Most health care providers attempt to identify children with developmental and behavioral problems in order to confer the potentially enormous benefits of early intervention (e.g., Reynolds et al 2007Reynolds A.J. Temple J.A. Ou S.-R. Robertson D.L. Mersky J.P. Topitzes J.W. et al.Effects of a school-based, early childhood intervention on adult health and well-being: A 19-year follow-up of low-income families.Archives of Pediatrics and Adolescent Medicine. 2007; 161: 730-739Crossref PubMed Scopus (244) Google Scholar). Unfortunately, 70% of clinicians rely on informal milestone checklists (Sand et al 2005Sand N. Silverstein M. Glascoe F.P. Gupta V.B. Tonniges T.P. O’Connor K.G. Pediatricians’ reported practices regarding developmental screening: Do guidelines work? Do they help?.Pediatrics. 2005; 116: 174-179Crossref PubMed Scopus (202) Google Scholar, Sices et al 2003Sices L. Feudtner C. McLaughlin J. Drotar D. Williams M. How do primary care physicians identify young children with developmental delays? A national survey.Journal of Developmental and Behavioral Pediatrics. 2003; 24: 409-417Crossref PubMed Scopus (122) Google Scholar). These checklists lack reliability, validity, accuracy, or scoring criteria. The apparent result is that only one fourth of children eligible for early intervention services actually receive them. To address this problem, the American Academy of Pediatrics (AAP) issued a new policy statement that calls for detailed developmental surveillance (American Academy of Pediatrics 2006American Academy of Pediatrics, Council on Children With DisabilitiesSection on Developmental Behavioral PediatricsBright Futures Steering CommitteeMedical Home Initiatives for Children With Special Needs Project Advisory CommitteeIdentifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening.Pediatrics. 2006; 118: 405-420Crossref PubMed Scopus (1009) Google Scholar). What is Developmental Surveillance?Surveillance is a longitudinal process designed to help clinicians focus on the “big picture” or context of children’s lives. Unlike screening that can only detect existing delays, however subtle, surveillance embraces identification and intervention into the precursors of problems in order to potentially prevent them (Blair and Hall 2006Blair M. Hall D.M.B. From health surveillance to health promotion: The changing focus in preventive Children’s Services.Archives of Diseases of Childhood. 2006; 91: 730-735Crossref PubMed Scopus (45) Google Scholar). These precursors or psychosocial risk factors include parental depression, poverty, limited parental education, housing instability, absence of social support, and a parenting style characterized by minimal verbal mediation (e.g., only talking to infants when they cry, issuing mostly commands, and not talking about things children notice) (Aylward 1992Aylward G.P. The relationship between environmental risk and developmental outcome.Journal of Developmental and Behavioral Pediatrics. 1992; 13: 222-229Crossref PubMed Scopus (104) Google Scholar, Sameroff et al 1987Sameroff A.J. Seifer R. Barocas R. Zax M. Greenspan S. Intelligence quotient scores of 4-year-old children: Social-environmental risk factors.Pediatrics. 1987; 79: 343-350PubMed Google Scholar). Efforts to ameliorate or reduce risk factors broaden conventional notions of early intervention services to include parent education, quality day care and preschool programs, special education, Head Start, social services, parenting classes, housing assistance, and mental health treatment.The process of information gathering within a surveillance model is multidimensional and involves eliciting and addressing parents’ concerns, monitoring developmental/behavioral emotional progress, screening for development problems periodically, measuring and promoting resilience factors, and addressing risk factors. Although the process of surveillance may seem overwhelming, if viewed as a multi-step process with varying foci at each well-child visit, it is readily doable and very effective. Surveillance is a longitudinal process designed to help clinicians focus on the “big picture” or context of children’s lives. Unlike screening that can only detect existing delays, however subtle, surveillance embraces identification and intervention into the precursors of problems in order to potentially prevent them (Blair and Hall 2006Blair M. Hall D.M.B. From health surveillance to health promotion: The changing focus in preventive Children’s Services.Archives of Diseases of Childhood. 2006; 91: 730-735Crossref PubMed Scopus (45) Google Scholar). These precursors or psychosocial risk factors include parental depression, poverty, limited parental education, housing instability, absence of social support, and a parenting style characterized by minimal verbal mediation (e.g., only talking to infants when they cry, issuing mostly commands, and not talking about things children notice) (Aylward 1992Aylward G.P. The relationship between environmental risk and developmental outcome.Journal of Developmental and Behavioral Ped
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