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Age group 0 to 5 years

Developmental screening

Early childhood development sets the trajectory for physical health and cognitive, emotional and behavioural wellbeing through childhood, adolescence and into adulthood.

Developmental health screening is an important mechanism to identify and manage any issues early to ensure children have the best possible chance for positive life outcomes.

Overview and areas of concern

Children in WA can access five child health checks between birth and two years, plus the School Entry Health Assessment in the first year of school attendance.

Screening programs of this nature generally have three key goals: early detection of developmental and health problems; health promotion to families; and identification of children who may need more support.1

For information on the School Entry Health Assessment refer to the Developmental screening indicator in the 6 to 11 age group.

Data overview

Almost all eligible WA children in the Perth metropolitan area (99.6%) received the 0 to 14-day child health check in 2017–18.

In 2017–18, between 80.9 per cent and 91.3 per cent of Perth metropolitan children with a completed Ages and Stages Questionnaires® (ASQ) were developmentally on track in all ASQ domains at four months of age. A high proportion (86.8%) of Perth metropolitan children with a completed ASQ were on track in the gross motor domain at age two years.

Areas of concern

While attendance at early child health checks is high, a low proportion of eligible children in the Perth metropolitan area received the 12-month child health check (53.0%) and the two-year child health check (28.9%) in 2017–18.

Proportion of children receiving child health checks in metropolitan Perth by age, in per cent, WA, July 2017 to June 2018

Source: Custom report provided by the Child and Adolescent Community Health Service to the Commissioner for Children and Young People WA [unpublished]

There is a lack of consistent and comprehensive data on attendance at child health checks for children in regional and remote WA. In particular, there is limited data on whether Aboriginal children are attending child health checks in the same proportion as non-Aboriginal children.

No data was available from the Department of Communities on whether the 1,229 children in care in WA under five years of age (at 30 June 2018)2 received health and developmental checks or have been assessed for developmental issues.

Other measures

Immunisation is often considered a key measure of child wellbeing. Immunisation has not been selected as a measure in the Indicators of wellbeing. This is not because immunisation is not important – it is critical for children’s wellbeing – however, immunisation rates for WA’s children and young people are adequately monitored through various data sites, and policy settings are firm.

For information on immunisation rates in WA refer to the AIHW Healthy Community Indicators website which reports interactively on immunisation rates for regions across Australia.

Ear and hearing health is also an important measure of child wellbeing, as hearing loss can affect the development of speech, language and learning. Ear disease and associated hearing loss are particularly prevalent among Aboriginal and Torres Strait Islander children.3 The reasons for this are complex and include experiences of poverty and environmental factors such as lack of community infrastructure, access to clean drinking water and access to appropriate and quality services.4 Hearing loss, particularly undiagnosed hearing loss, can have long lasting impacts on children’s wellbeing including school truancy, behavioural issues and social isolation.5,6

Ear health is not specifically included as one of the measures within the Indicators of wellbeing. The child health and development checks are the primary mechanism for identifying issues with ear and hearing health, therefore if children are attending the full complement of health checks, issues with their hearing should be identified.

Children will have the best chance to have healthy hearing when any issues are identified early and follow-up services are provided to support their families to ensure optimal ear health. It is also important that underlying environmental issues that impact on ear and hearing health for children are addressed at the community level.

The Australian Institute of Health and Welfare (AIHW) publishes data on Ear Health as part of the Aboriginal and Torres Strait Islander Health Performance Framework.

For further information on ear health, refer to the WA Child Ear Health Strategy 2017–2021 and the Australian Indigenous HealthInfoNet Ear Health.

Endnotes

  1. McLean K et al 2014, Screening and surveillance in early childhood health: Rapid review of evidence for effectiveness and efficiency of models; Murdoch Children Research Institute.
  2. Department of Communities 2019, Child Protection Activity Performance Report 2017–18, WA Government p. 17.
  3. Australian Institute of Health and Welfare 2018, Australia’s Health 2018 - 6.4 Ear health and hearing loss among Indigenous children, AIHW.
  4. WA Department of Health and Department of Aboriginal Affairs, WA Child Ear Health Strategy 2017–2021, WA Government.
  5. Burns J and Thomson N 2013, Review of ear health and hearing among Indigenous Australians, Australian Indigenous HealthBulletin, Vol 13 No 4.
  6. Australian Institute of Health and Welfare 2018, Australia’s Health 2018 - 6.4 Ear health and hearing loss among Indigenous children, AIHW.
Measure: Health and developmental checks

Optimising a child’s chance to have a healthy and productive life requires a holistic approach which includes a safe and nurturing home and community environment, access to appropriate health and family services and early identification of risk factors and developmental issues.1,2 Health and development screening is a key component used within Australia to assist in early identification of health and developmental issues.

This measure uses data from the WA Department of Health to report on the proportion of children receiving age appropriate child health and development checks.

Child development health checks are a critical service that provide an entry point to other child health services; when they are not performed, developmental and health problems may not be detected and intervention may be delayed. As children get older the developmental pathways initiated in early childhood become more difficult to change.3 Therefore, intervention when children are young is the most effective time to make a difference.

WA Health offers regular free health and development checks to children between birth and school entry. For data on school entry health screenings refer to the Developmental screening indicator for children aged 6 to 11 years.

Health services for children and young people in the Perth metropolitan area4 are delivered by the Child and Adolescent Community Health Service, while health services in regional and remote WA are delivered by the WA Country Health Service.

In 2010, the WA Auditor General reviewed the WA Department of Health’s universal health check system and found that many children were missing out on checks.5 In 2014, the Auditor General performed a follow-up review and found that while the Department had increased the number of health checks being performed, they were still not keeping up with the growth in demand.

During 2017–18 a revised service model for child health checks was implemented across the State.6 Some of the key changes were:

  • An updated Universal child health check schedule (0–14 days, eight weeks, four months, 12 months, two years and school entry)
  • Adopting a more flexible service delivery approach through drop-in sessions or Universal Plus contacts offered to families where additional support is required.

Drop-in sessions are offered at child health centres and other community locations, providing parents and carers with an opportunity for a brief clinical discussion with their child health nurse without the need for an appointment. During 2017–18, drop-in sessions were offered at more than 80 locations across Perth each week.7

Universal Plus contacts are generally provided to families who require additional support and may be provided face-to-face or by telephone.

Child health checks delivered in metropolitan Perth,* in number and per cent, WA, July 2017 to June 2018

Contact type

Eligible children
(Number)

Children
completing Universal
check
(Number)

Children
completing
Universal Plus or
Drop-in check** (Number)

Total
(Number)

Percentage
of eligible
children seen (%)

0–14 days

27,008

26,593

316

26,909

99.6

8 weeks

27,154

23,316

1,245

24,561

90.5

4 months

27,370

21,628

3,159

24,787

90.6

12 months

27,886

11,843

2,932

14,775

53.0

2 years

28,415

7,077

1,128

8,205

28.9

Universal Plus

34,227

Drop-in

36,961

Source: Custom report provided by the Child and Adolescent Community Health service from Child Development Information System and contracted service database to the Commissioner for Children and Young People [unpublished]

* Data includes only those child health checks of mothers with a residential address in the Perth metropolitan area. Mothers from regional or remote WA who attend child health checks in Perth are not included in this data – where possible they are recorded against regional/remote child health checks. In 2017–18 there were only 45 children who resided in outer regional and remote WA who had their child health checks in the metropolitan area.

** Number reflects only those children who did not complete a Universal contact, but did attend an individual, face to face Universal Plus or drop-in Contact with the child health nurse coinciding with the Universal contact point.

There is a significant reduction in the number of eligible children attending child health checks as they age. This is of concern as some developmental issues are only able to be identified at the 12-month and two-year checks.

During 2017–18, approximately nine per cent of child health checks at the Universal contact points were accessed through the alternative formats of drop-in or Universal Plus. Many families also attended drop-in sessions or completed Universal Plus checks which did not coincide with the Universal contacts timeframe, these contacts accounted for 42 per cent of all contacts with Child Health Nurses during 2017–18.8

The recent changes in the service model limit the ability to directly compare the proportion of children receiving age specific health and development checks over time.

Comparison of proportion of children seen at Universal contact points under different child health check models, metropolitan Perth, in per cent, at 30 June 2013 and 30 June 2018

Current model

2018
%

Equivalent in
previous model

2013
%

0–14 days

99.6

0–10 days

38.0*

11–21 days

45.0*

22+ days

6.0*

8 weeks

90.5

6 to 8 weeks

87.0

4 months

90.6

3 to 4 months

71.0

8 months

53.0

12 months

53.0

18 months

34.0

2 years

28.9

3 years

19.0

Source: Custom reports provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

* Children would generally attend only one of the three postnatal checks available in 2013 as the first of the six child health checks.

Note: With the introduction of the new model which includes drop-in sessions not necessarily aligned with the Universal contact points, the data for 2018 will underrepresent the proportion of children attending child health checks.

Edition Two of the State of Western Australia’s Children and Young people – 2014 reported that only 38 per cent of eligible newborns aged 0 to 10 days and 45 per cent of newborns aged 11 to 21 days received a child health and development check in the three months to 30 June 2013. Consequently, there appears to have been a substantive increase in the number of children aged 0 to 14 days-old who have received the appropriate health check in the Perth metropolitan area.

A greater proportion of infants aged around eight weeks and four months have received a child health and development check than in 2013.

There has been no improvement in the attendance at checks for older infants. In the three months to 30 June 2013, 53 per cent of eight month-old children received a health and development check,9 compared to 53 per cent of children at 12 months of age at 30 June 2018.

Only 28.9 per cent of young children attended the two-year check, which is significantly lower than the 34 per cent attending the 18-month check in 2013. Although, it is possible that children who missed these checks attended a drop-in session.

Child health checks in regional and remote WA are managed by the WA Country Health Service (WACHS).

Child health checks delivered in regional and remote WA, in number and per cent, WA, July 2017 to June 2018

Contact type

Eligible children
(Number)

Children
completing
Universal check
(Number)

Percentage
of eligible
children seen
(%)

0–14 days

6,542

4,894

74.8

8 weeks

6,584

4,838

73.5

4 months

6,671

4,657

69.8

12 months

6,915

4,135

59.8

2 years

7,062

3,085

43.7

Source: Custom report provided by the WA Country Health Service to the Commissioner for Children and Young People [unpublished]

Note: Data was captured in multiple systems across WACHS sites which relied on replication of data, increasing the risk of data integrity problems. The implementation of a single clinical information system across WACHS in July 2019 is expected to significantly improve data integrity.

Data is collected across the state on the provision of checks under the enhanced schedule (i.e. contacts outside of the Universal schedule timeframes). However, due to a variety of disparate systems (replaced with a single system in July 2019) it was not possible to centrally report this data. WACHS also does not have access to data regarding child health checks provided by some alternative services, such as Aboriginal Community Controlled Health Services.10 For these reasons the above data most likely under-represents the number of regional and remote children who receive a child health and development check.

Nevertheless, the data suggests that a greater proportion of children in metropolitan Perth attend the earlier child health checks than in regional and remote WA. This is consistent with the Auditor General’s finding in Universal Child Health Checks 2010 report that the metropolitan services prioritise the early checks at the expense of the later ones, while some regional locations were actively promoting the later checks.11

Proportion of eligible children attending child health checks by Universal contact by metropolitan and regional and remote WA, in per cent, WA, July 2017 to June 2018

Contact type

Perth
metropolitan

Regional and
remote WA

0–14 days

99.6

74.8

8 weeks

90.5

73.5

4 months

90.6

69.8

12 months

53.0

59.8

2 years

28.9

43.7

Source: Custom reports provided by the Child and Adolescent Health Service and WA Country Health Service to the Commissioner for Children and Young People [unpublished]

Proportion of eligible children attending child health checks by Universal contact by metropolitan and regional and remote WA, in per cent, WA, July 2017 to June 2018

Source: Custom reports provided by the Child and Adolescent Community Health service and WA Country Health Service to the Commissioner for Children and Young People [unpublished]

In July 2019, the WA Country Health Service implemented a single clinical information system which will improve data integrity.

There is also significant variation in attendance across WA regions.

Proportion of eligible children attending child health checks delivered in regional and remote WA by region, in per cent, WA, July 2017 to June 2018

Kimberley

Pilbara

Mid West

Goldfields

Wheatbelt

South West

Great Southern

Total

0–14 days

86.2

32.5

69.3

92.0

75.2

80.6

81.4

74.8

8 weeks

69.1

56.3

63.1

81.0

80.5

78.6

80.6

73.5

4 months

68.9

49.6

67.5

64.2

80.8

77.3

72.9

69.8

12 months

60.1

42.5

55.6

68.9

75.1

55.4

72.8

59.8

2 years

50.7

19.9

34.0

47.6

66.4

44.6

43.7

43.7

Source: Custom report provided by the WA Country Health Service to the Commissioner for Children and Young People [unpublished]

Note: Data was previously captured in multiple systems across WACHS sites which relied on replication of data, increasing the risk of data integrity problems. The implementation of a single clinical information system across WACHS in July 2019 will improve data integrity.

Proportion of eligible children attending child health checks delivered in regional and remote WA by region, in per cent, WA, July 2017 to June 2018

Source: Custom report provided by the WA Country Health Service to the Commissioner for Children and Young People [unpublished]

The number of children receiving child health checks from the WA Country Health Services in the Pilbara region is significantly lower than in other regions.

The WA Country Health Service note that the Pilbara region experienced significant staffing shortages in the 2017–18 financial year, which impacted the provision of universal child health services. They state that a range of strategies to improve accessibility were implemented, including virtual child health consultations (using videoconferencing technology) and engagement of contracted providers to deliver services.

Furthermore, a higher proportion of children in regional and remote locations attend Aboriginal Community Controlled Health Services (ACCHS) for child health checks. ACCHS are often funded by the Commonwealth government and are not required to share data with the WA Country Health Service.

There is a lack of consistent and comprehensive data on attendance at child health checks for all children in regional and remote WA. This means it is difficult to determine whether children in specific locations or specific cohorts of children (such as Aboriginal or culturally and linguistically diverse children) are missing out on child health checks.

Furthermore, there is limited information available on whether children recommended for referral have received appropriate services for any issues identified.

In the 2018 calendar year, 14 per cent of children in the Perth metropolitan area receiving a child health check were referred to other services.12

Referrals in the Perth metropolitan area are tracked electronically within the Child Development Information System (CDIS). The CDIS also records if referrals are declined by the parent/carer, which provides the child health nurse with an opportunity to take further action, where appropriate.

The CDIS record enables community health nurses to monitor individual outcomes following a referral to Child Development Services (CDS). These can be centrally reported and monitored. Where children are referred to external health care providers (including GPs and medical specialists) outcomes data cannot be centrally monitored. In 2018, 16 per cent of referrals from metropolitan child health services were to external providers.13

In 2010 the Auditor General noted that child health checks were the main referral point to CDS. The Auditor General also noted that CDS have historically had significant waitlists for therapy and treatment of identified developmental delays.14 In 2016–17 the Child and Adolescent Community Health Service redesigned the Perth metropolitan CDS. In that year, waiting times for CDS allied health services were approximately three to five months, which represented a 50 per cent reduction in comparison with 2015–16.15 In 2017–18 median waiting times were between one and six months.16

While data is captured across regional and remote WA on child health referrals, this data was not able to be collated due to disparate systems. This is expected to improve with the recently completed implementation of a single data collection system across the WA Country Health Service.

Endnotes

  1. Australian Health Ministers Advisory Council 2011, National Framework for Universal Child and Family Health Services, Australian Government.
  2. Moore TG et al 2017, The First 1000 Days: An Evidence Paper – Summary, Centre for Community Child Health, Murdoch Children’s Research Institute.
  3. Centre for Community Child Health 2018, Policy Brief: The First Thousand Days – Our Greatest Opportunity, Murdoch Children’s Research Institute.
  4. A number of outer metropolitan area post codes classified as Inner Regional (ABS Remoteness Index) fall within the Child and Adolescent Community Health Service (CAHS) Community Health catchment. These include Bullsbrook, Childlow, Chittering, Gidgegannup, Jarrahdale, Two Rocks and Waroona. Services provided to children and families living in these areas are included in the above. All other metropolitan postal codes are classified as Major Cities.
  5. Office of the Auditor General WA 2010, Universal Child Health Checks, Report 11, November 2010.
  6. This redesign was in response to the WA Metropolitan Birth to School Entry Universal Health Service Delivery Model Review (the Review) completed by Professor Karen Edmond, Consultant Paediatrician and Public Health Physician.
  7. Information provided to the Commissioner for Children and Young People by the Department of Health Child and Adolescent Community Health service [unpublished].
  8. Information provided to the Commissioner for Children and Young People by the Department of Health Child and Adolescent Community Health service [unpublished].
  9. Commissioner for Children and Young People WA, The State of Western Australia’s Children and Young People – Edition Two, p. 70.
  10. These services are often funded by the Commonwealth government and WACHS does not have visibility of their attendance data.
  11. Office of the Auditor General WA 2010, Universal Child Health Checks, Report 11, November 2010, pp. 19, 24.
  12. Information provided to the Commissioner for Children and Young People by the Department of Health Child and Adolescent Community Health service [unpublished].
  13. Information provided to the Commissioner for Children and Young People by the Department of Health Child and Adolescent Community Health service [unpublished].
  14. Office of the Auditor General WA 2010, Universal Child Health Checks, Report 11, November 2010, p. 14–15.
  15. Child and Adolescent Health Service 2017, 2016–17 Annual Report, WA Department of Health.
  16. Ibid.
Measure: Identified developmental delays

Screening for developmental issues in infants and young children is critical to detect and subsequently manage any identified issues. Research suggests that up to 15 per cent of children under the age of five years may have difficulties in more than one area of development.1

The Ages and Stages Questionnaires® (ASQ) is a developmental screening and monitoring system designed to identify infants and young children in need of further assessment. The ASQ provides developmental information in five key domains: communication, gross motor skills, fine motor skills, problem solving and personal/social skills.2 Social-emotional health is administered via the Ages and Stages Questionnaire®: Social-Emotional, Second Edition (ASQ:SE2).3

The ASQ has been validated against a number of standard measures and shown to be administratively simple and flexible, low cost and suitable for diverse populations.4

In WA the ASQ is the primary child developmental screening tool used by community health nurses. Since July 2017, the ASQ has been universally offered to parents at the four-month, 12-month and two-year child health checks.5

Parents complete the ASQ relevant for their child’s age. The resulting score will categorise the child into ‘on track’, ‘requiring monitoring’ or ‘requiring referral’ for each domain. Children suspected of having a developmental delay will then be referred to other services. It should be noted that the ASQ does not provide a diagnosis, it is a tool for referral.

Data on the completion and results of the ASQ at the population level is not publicly reported. The following data has been provided to the Commissioner for Children and Young People WA by the Child and Adolescent Community Health Service.

As with the child health checks, not all eligible children are assessed through the ASQ or ASQ-SE. During 2017–18 a total of 36,348 ASQs were completed for 31,767 children and 29,959 ASQ-SEs were completed for 27,076 metropolitan Perth children.6

At the 12-month check, this represents only 36 per cent of all eligible children in metropolitan Perth with a completed ASQ-3 and 33 per cent with a completed ASQ:SE2.

Proportion of eligible children with a completed ASQ and/or ASQ-SE by Aboriginal status and age, in per cent, metropolitan Perth, July 2017 to June 2018

ASQ-3
(unique clients with one or more ASQ3 completed by child health check)

ASQ:SE2
(unique clients with one or more ASQ:SE2 completed by child health check)

All

Aboriginal

Non-Aboriginal

All

Aboriginal

Non-Aboriginal

4 months

58.0

33.0

59.0

48.0

25.0

49.0

12 months

36.0

22.0

36.0

33.0

19.0

34.0

2 years

23.0

23.0

23.0

19.0

17.0

19.0

Source: Custom report provided by WA Department of Health, Child and Adolescent Health Services (CAHS) to the Commissioner for Children and Young People WA [unpublished]

Consistent with the child health checks, the proportion of eligible children with a completed ASQ/ASQ-SE2 decreases significantly with age for both Aboriginal and non-Aboriginal children.

Furthermore, not all children who attend child health checks have a completed ASQ/ASQ-SE2.

Proportion of children attending a child health check with a completed ASQ and/or ASQ-SE by Aboriginal status and age, in per cent, metropolitan Perth, July 2017 to June 2018

ASQ-3
(unique clients with one or more ASQ3 completed by child health check)

ASQ:SE2
(unique clients with one or more ASQ:SE2 completed by child health check)

All

Aboriginal

Non-Aboriginal

All

Aboriginal

Non-Aboriginal

4 months

64.0

51.0

64.0

53.0

38.0

53.0

12 months

67.0

54.0

67.0

63.0

47.0

63.0

2 years

80.0

73.0

81.0

65.0

54.0

65.0

Source: Custom report provided by WA Department of Health, Child and Adolescent Health Services (CAHS) to the Commissioner for Children and Young People WA [unpublished]

The proportion of Aboriginal children with a completed ASQ/ASQ-SE2 while attending a child health check was consistently lower than for non-Aboriginal children.

Outcomes for children from the ASQ and ASQ-SE2 are tracked. However, as noted above this does not report on outcomes for all children in the Perth Metropolitan area.

It is likely that the data is not representative as those not attending child health checks and being assessed under the ASQ/ASQ-SE2 may have different characteristics from those that do attend and are assessed.

Proportion of children in range of outcomes of ASQ across all domains at 4 months, 12 months and 2 years, in per cent, metropolitan Perth, July 2017 to June 2018

Percentage on track

Percentage requiring monitoring

Percentage requiring referral

4 months

80.9 - 91.3

6.4 - 15.7

1.9 - 3.4

12 months

75.9 - 86.8

9.0 - 12.2

3.5 - 11.9

2 years

76.8 - 86.8

8.3 - 14.3

4.8 - 12.8

The above table reports on the range of outcomes for Perth-based children assessed under the ASQ in each domain at four months, 12 months and two years. There is some variation across domains. In particular, at the four-month check the proportions of children on track for each domain were above 85 per cent, except for fine motor (80.9%) and social emotional (83.2%). At the 12‑month check the proportions of children on track for each domain were above 80 per cent, except for gross motor skills (75.9%).

Proportion of children 'on track' based on ASQ by age and domain, in per cent, metropolitan Perth, July 2017 to June 2018

Communication

Gross motor

Fine motor

Problem solving

Personal social

Social emotional

4 months

90.6

89.9

80.9

91.3

89.4

83.2

12 months

86.6

75.9

86.8

84.0

84.9

85.8

2 years

78.2

86.8

83.9

84.8

76.8

82.1

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

Proportion of children 'on track' based on ASQ by age and domain, in per cent, metropolitan Perth, July 2017 to June 2018

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

While many Aboriginal children are doing well, multiple and complex disadvantage linked to intergenerational trauma means that Aboriginal children are more likely to be developmentally at risk.

Proportion of children in the 'refer' zone based on ASQ by age and Aboriginal status, in per cent, metropolitan Perth, July 2017 to June 2018

Communication

Gross motor

Fine motor

Problem solving

Personal social

Social emotional

4 months

Aboriginal

2.2

4.3

3.2

2.4

3.0

2.9

Non-Aboriginal

1.8

2.2

3.4

2.3

2.4

3.0

12 months

Aboriginal

7.4

8.3

5.7

7.4

5.7

8.5

Non-Aboriginal

3.4

12.0

3.7

6.0

4.2

5.2

2 years

Aboriginal

19.6

7.1

7.9

12.1

13.8

16.2

Non-Aboriginal

12.5

4.7

5.4

6.6

8.7

9.3

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

Proportion of children in the 'refer' zone based on ASQ at 4 months and 2 years by Aboriginal status, in per cent, metropolitan Perth, July 2017 to June 2018

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

At age four months there was little significant difference between Aboriginal and non-Aboriginal children across domains. At age two years, the proportion of Aboriginal children identified in the refer zone was significantly higher than non-Aboriginal children on communication, problem solving and social emotional domains.

The ASQ data is also available by gender. As with the AEDC data (refer Indicator Readiness for learning) male children are more likely to be at risk of developmental issues across most domains than female children.

Proportion of children in the 'refer' zone based on ASQ by age and gender, in per cent, metropolitan Perth, July 2017 to June 2018

Communication

Gross motor

Fine motor

Problem solving

Personal social

Social emotional

4 months

Male

1.5

2.4

3.3

2.2

2.3

3.1

Female

2.2

2.1

3.6

2.4

2.5

3.0

12 months

Male

4.7

11.5

4.4

7.0

5.7

6.6

Female

2.1

12.4

2.9

5.0

2.6

3.7

2 years

Male

18.1

5.7

7.4

9.6

13.1

13.1

Female

6.0

3.7

3.1

3.3

3.4

5.1

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

Proportion of children in the 'refer' zone based on ASQ at 4 months and 2 years by gender, in per cent, metropolitan Perth, July 2017 to June 2018

Source: Custom report provided by the Child and Adolescent Community Health service to the Commissioner for Children and Young People [unpublished]

At age 12 months, the proportion of male children recommended for referral or monitoring was much higher than female children on the communication, problem solving and personal-social domains. Male children were also more likely to be identified for referral on the fine motor and social-emotional domains.

At age two years, the proportion of male children recommended for referral or monitoring was much higher than female children on all domains.

The reason for differences between the development of male and female children is complex and often contested.7 There is evidence to suggest that male children mature at a slower rate and may develop language and communication skills later than female children.8,9 There is also some evidence to suggest that social interactions start to influence differences at an early age.10

No data was available on completion rates or results of the Ages and Stages Questionnaires® for children in regional and remote WA.

One preventable condition that impacts an unknown number of WA children is Fetal Alcohol Spectrum Disorders (FASD) which is a ‘hidden’ disability, and easily confused with disobedience or conditions such as ADHD.11 FASD is an umbrella term which covers a range of possible birth defects and/or developmental disabilities that can be caused by exposure to alcohol prior to birth. It has a significant impact on mental health and increases the likelihood of social and emotional behavioural issues throughout life.12,13

In 2017, a Telethon Kids Institute research team found that 89 per cent of young people in WA’s Banksia Hill Detention Centre had at least one form of severe neurodevelopmental impairment, while 36 per cent were found to have FASD. Only two of the young people with FASD had been diagnosed prior to participation in the study.14

The Royal Australian College of Physicians note that it is highly likely there is substantial under-diagnosis of FASD more broadly due to a lack of awareness by clinicians and a fear of stigmatising families and children.15 

This highlights the importance of early identification of developmental issues through health and developmental checks, particularly for vulnerable children.

Endnotes

  1. Oberklaid F and Drever K 2011, Is my child normal? Milestones and red flags for referral, Australian Family Physician, Vol 40, No 9, September 2011.
  2. The ASQ is a tool for individual screening of children two years and under. This is in contrast to the Australian Early Development Census, which covers similar domains, however is a tool to provide policy makers and communities with information on children’s developmental outcomes at the community level. The AEDC is not used for individual screening or referral of children.  
  3. Feeney-Kettler KA 2010, Screening Young Children’s Risk for Mental Health Problems: A Review of Four Measures, Assessment for Effective Intervention, Vol 35, No 4.
  4. Yoong T et al 2015, Is the Australian Developmental Screening Test (ADST) a useful step following the completion of the Ages and Stages Questionnaire (ASQ) on the pathway to diagnostic assessment for young children?, Australian Journal of Child and Family Health Nursing, Vol 12, No 1.
  5. Community Health services in WA use the Ages and Stages Questionnaires®, Third Edition (ASQ-3), the Ages and Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2) and in some country health services ASQ TRAK is used. Source: WA Department of Health: Community Health Manual – Ages and Stages Questionnaire.
  6. Email correspondence from WA Department of Health, Child and Adolescent Health Services (CAHS) to the Commissioner for Children and Young People WA
  7. Kinnell A et al 2013, Boys and girls in South Australia: A comparison of gender differences from the early years to adulthood, Fraser Mustard Centre, Department for Education and Child Development and Telethon Kids Institute.
  8. Etchell A et al 2018, A systematic literature review of sex differences in childhood language and brain development, Neuropsychologia, Vol 114, pp. 19–31.
  9. Brinkman SA et al 2012, Jurisdictional, socioeconomic and gender inequalities in child health and development: analysis of a national census of 5-year-olds in Australia, BMJ Open, Vol 2, No 5.
  10. Kinnell A et al 2013, Boys and girls in South Australia: A comparison of gender differences from the early years to adulthood, Fraser Mustard Centre, Department for Education and Child Development and Telethon Kids Institute, p. 28.
  11. McLean S and McDougall S 2014, Fetal alcohol spectrum disorders: Current issues in awareness, prevention and intervention, CFCA Paper No 20, Child Family Community Australia (CFCA).
  12. Brown J et al 2018, Fetal Alcohol spectrum disorder (FASD): A beginner’s guide for mental health professionals, Journal of Neurological Clinical Neuroscience, Vol 2, No 1.
  13. Pei J et al 2011, Mental health issues in fetal alcohol spectrum disorder, Journal Of Mental Health, Vol 20, No 5, pp. 438–448.
  14. Bower C et al 2017, Fetal alcohol spectrum disorder and youth justice: a prevalence study amount young people sentenced to detention in Western Australia, BMJ Open, Vol 8, No 2.
  15. Royal Australian College of Physicians 2018, RACP Submission: Consultation on the Australian Draft National Alcohol Strategy 2018-2026, p. 19.
Children in care

There is limited data available on the number of WA children in care aged 0 to five years who have received an initial medical examination or ongoing health assessment, or who have identified developmental issues.

At 30 June 2018 there were 1,229 WA children in care aged between 0 and four years, more than half of whom (58.0%) were Aboriginal.1

Children in care are more likely than the general population to have poor physical, mental and developmental health.2 Experts recommend that for the best optimal care, all children entering care should have a comprehensive assessment of their health within 30 days of placement.3

Standard five of the National Standards for Children in out-of-home care states that children and young people should have their physical, developmental, psychosocial and mental health needs assessed and attended to in a timely way.4

The WA Department of Communities casework practice manual requires that all children entering the WA out-of-home care system receive an initial medical examination by a general practitioner or other health professional within 20 days, and that they have an ongoing annual health assessment.5 The health provider is nominated by the Department of Communities and can include an Aboriginal Medical Service, general practitioner or a community health nurse. The Department of Health (Child and Adolescent Community Health Service) monitors the health and development assessments of children in care conducted by metropolitan community health nurses.

In 2016, the WA Department of Child Protection (now Department of Communities) published the Outcomes Framework for Children in Out-of-Home Care 2015–16 Baseline Indicator Report. The outcomes framework identified two indicators related to reviewing the physical health of children in out-of-home care.

The first indicator was the ‘proportion of children who had an initial medical examination when entering out-of-home care’. In 2015, 53.1 per cent of children entering out-of-home care had an initial medical examination.6

The second indicator was the ‘proportion of children who have had an annual health check of their physical development.’ In this report they noted that there were limitations in data accuracy which prevented reporting on this indicator in 2015–16; however, data would be reported in 2016–17.7

No more recent data has been reported by the Department of Communities as at publication date.

The low proportion of children provided with an initial medical examination in 2015 and lack of publicly available data on whether all children in care are receiving these essential checks needs to be urgently addressed.

The Pathways of Care Longitudinal Study (POCLS) is a longitudinal study on out-of-home care which examines the developmental wellbeing of children and young people aged 0 to 17 years in NSW.8 To measure the children’s development the research team used the ASQ-3 for children from nine to 66 months of age.

Preliminary findings from this study show that more than 80 per cent of the children were generally developing normally. However, Aboriginal children aged three to five years tended to show higher atypical development across all domains.9 In the area of socio-emotional wellbeing, the study showed behavioural problems for all children increasing with age from 17 per cent among 12 to 35 month-olds to 47 per cent among 12 to 17 year-olds.10 Children in residential care appeared to experience poorer wellbeing outcomes than other placement types, such as kinship care.11

Endnotes

  1. Department of Communities 2019, Child Protection Activity Performance Report 2017–18, WA Government p. 17.
  2. Royal Australasian College of Physicians (RACP) 2006, Health of children in “out-of-home” care, RACP.
  3. Ibid.
  4. Department of Social Services 2011, An outline of the National Standards for out-of-home care, Australian Government.
  5. Department of Child Protection and Family Support (Communities), Casework Practice Manual: Healthcare Planning, WA Government.
  6. Department for Child Protection and Family Support 2016, Outcomes Framework for Children in Out-of-Home Care 2015–16 Baseline Indicator Report, p. 5.
  7. Ibid, p. 10.
  8. Australian Institute of Family Studies, Chapin Hall Center for Children University of Chicago and New South Wales Department of Family and Community Services 2015, Pathways of Care Longitudinal Study: Outcomes of children and young people in Out-of-Home care in NSW Wave 1 baseline statistical report, NSW Department of Family and Community Services.
  9. Ibid, p. 113.
  10. Ibid, p. 123.
  11. Ibid, p. 124.
Children with disability

Early childhood health and development checks can often identify children with potential disability or developmental issues. A child who presents with possible disability through this process will be referred to Child Development Services for assessment.

The Australian Bureau of Statistics Disability, Ageing and Carers data collection reports that approximately 5,100 WA children (3.0%) aged 0 to four years have a reported disability.1,2

The types of disability that affect children vary somewhat with age. Of young children aged 0 to four years who had a disability, almost two-thirds (63%) had a sensory (e.g. sight and hearing) or speech disability. Older children were more likely than younger children to have an intellectual disability. This is likely to be partly due to the lack of formal intellectual testing in very young children.3

There is no data available on health and developmental screening of WA children aged 0 to five years with disability.

Endnotes

  1. ABS uses the following definition of disability: ‘In the context of health experience, the International Classification of Functioning, Disability and Health (ICFDH) defines disability as an umbrella term for impairments, activity limitations and participation restrictions… In this survey, a person has a disability if they report they have a limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts everyday activities.’ Australian Bureau of Statistics 2016, Disability, Ageing and Carers, Australia, 2015, Glossary.
  2. Estimate is to be to be used with caution as it has a relative standard error of between 25 and 50 per cent. Australian Bureau of Statistics 2016, Disability, Ageing and Carers, Australia, 2015: Western Australia, Table 1.1 Persons with disability, by age and sex, 2012 and 2015 estimate, and Table 1.3 Persons with disability, by age and sex, 2012 and 2015, proportion of persons.
  3. Australian Bureau of Statistics 2012, Australian Social Trends, June 2012, Children with a disability, ABS.
Policy implications

Early childhood is the most effective time to intervene in the health, development and wellbeing of children and has the greatest potential to prevent or lessen problems in later childhood, adolescence and adulthood.

Child health checks and developmental screening through the Ages and Stages Questionnaires® (ASQ) are key mechanisms to improve child health outcomes through early identification of developmental issues. The primary policy objective is to ensure all WA children receive child health checks and are screened through the ASQ.

In 2010, the WA Auditor General reviewed the WA Department of Health’s universal health check system and found that many children were missing out on checks.1 In 2014, the Auditor General performed a follow-up review and found that while the Department had increased the number of health checks being performed, they were still not keeping up with the growth in demand.2

Recommendations from the Auditor General’s 2014 report included extending access to child health centres through more flexible opening hours, sending appointment reminders to parents and possibly implementing an online booking system.3

The Child and Adolescent Health Service in metropolitan Perth and the WA Country Health Service have implemented changes to provide a more flexible approach. In metropolitan Perth this has meant the addition of drop-in sessions as an alternative to the Universal checks. In regional and remote locations the updated schedule has also been implemented, however services are historically more informal with higher rates of drop-in contacts and visits between Universal checks.

Service availability and accessibility is a key issue in remote and regional locations. In the Pilbara a lower proportion of children are attending child health checks due to a lack of available services. The WA Country Health Service has implemented changes with the aim of improving availability, the effectiveness of these changes will be monitored in future data updates for this measure.

While most children in WA are receiving the initial child health check after birth, many children are not receiving the later child health checks, particularly the 12-month and two-year checks. These checks are critical to identify developmental issues related to speech and language and children who miss these checks are at risk of not being ready for school.4

The Child and Adolescent Health Service in metropolitan Perth are implementing strategies to improve attendance at the later universal child health checks, including a communication and awareness raising campaign, identification and targeted follow-up of ‘at-risk’ children, outreach programs and a range of ICT initiatives.

Attendance at the 12-month and two-year checks will be closely monitored to determine whether the strategies being implemented are working.

Attending child developmental health checks is only a first step – if a child is identified as having a potential health or developmental issue it is critical that they are referred for further diagnosis and, if necessary, they receive appropriate treatment and services.

Ages and Stages questionnaires®

The results of the Ages and Stages Questionnaires® (ASQ) in metropolitan Perth show that many children in Perth are ‘on track’ developmentally. However, a significant proportion of parents are not completing the ASQ for their children.

Additionally, of those children with ASQ results, a relatively high proportion are identified as possibly having a developmental delay and are recommended for either monitoring or referral. For example, in 2018, 21.8 per cent and 17.9 per cent of Perth metropolitan children aged two years were recommended for monitoring or referral in the communication domain and the social and emotional domain, respectively.

Some experts note that tools such as the ASQ miss a large number of children with mild to moderate developmental issues and may incorrectly identify children whose development is normal.5 They recommend a broader approach to developmental reviews by integrating surveillance into primary health care, so that every encounter a health professional has with a child is an opportunity to consider their developmental progress. Thus, general practitioners, not only child health professionals, need to have a good understanding of normal child development and should review developmental progress at each contact.6 

Aboriginal children are at a higher risk of experiencing developmental issues in childhood and into adulthood.7 Yet, evidence suggests that universal mainstream child health services are under-used by many within the Aboriginal population.8 This is consistent with the data reported in this section for child health checks and the ASQ developmental checks where Aboriginal children were less likely to attend health and developmental checks across WA.

Health in early childhood is a critical determinant of risk of chronic diseases over the lifetime.9 Life expectancy at birth for Aboriginal people in Australia in 2010–2012 was 69.1 years for men and 73.7 years for women. This is in contrast with 79.7 years for non-Aboriginal men and 83.1 years for non-Aboriginal women.10 he leading causes of higher mortality for Aboriginal people were chronic diseases including circulatory disease, cancer, diabetes and respiratory disease.11

Socio-economic disadvantage, including parental income levels, education and access to health services have a significant influence on health in childhood.12 The data supports this finding, as Aboriginal peoples living in the most disadvantaged areas - a higher proportion of whom are living in remote Australia - have the lowest life expectancy.13

A critical component of improving Aboriginal people’s health and wellbeing over the longer term is to ensure Aboriginal children are assessed for health and development issues and where necessary referred to high quality, culturally safe services as early as possible.

Research highlights that Aboriginal mothers continue to have negative experiences with some health services, in part due to a lack of cultural awareness on the part of the service providers.14,15 is essential that health services focus on improving their engagement with Aboriginal families and in particular, implementing culturally safe practices.16,17,18

To that end, the Child and Adolescent Community Health service has noted that some metropolitan Aboriginal health team nurses and health workers are involved in a University of Western Australia pilot test of ASQ3-TRAK, a modified version of the ASQ3 which has been adapted to be more culturally appropriate for Aboriginal children.

Data gaps

While attending child health checks is critical, it is also essential to ensure that children receive appropriate services for any issues identified. Referral and outcomes data for each child is captured in the Perth metropolitan area through the Child Development Information System (CDIS) and this is used by the child health nurse for follow-up as required. In regional and remote WA, referral data is captured on individual child health referrals, however this data was not able to be collated due to disparate systems. This is expected to improve with the recently completed implementation of a single data collection system across the WA Country Health Service.

There is a lack of consistent and comprehensive data on attendance at child health checks for all children across regional and remote WA. In particular, the data for children in regional and remote areas does not include attendance at alternative services, such as Aboriginal Community Controlled Health Services. This means it is difficult to determine whether children in specific locations or specific cohorts of children (e.g. Aboriginal children) are missing out on child health checks.

While the Ages and Stages Questionnaires® (ASQ) is administered in regional and remote WA, there is no data on completion or the results of the ASQ for children in regional and remote WA.

These issues are expected to improve with the recent implementation of a single data collection system across the WA Country Health Service.

The limited data being collected and reported on the physical health of WA children in care is of concern. That 53.1 per cent of children entering out-of-home care had an initial medical examination in 2015 and the lack of publicly available data needs to be urgently addressed.

Children in care are more likely than the general population to have poor physical, mental and developmental health,19 it is therefore essential that they receive appropriate health and developmental checks on entry into care and on a regular basis thereafter.

Endnotes

  1. Office of the Auditor General WA 2010, Universal Child Health Checks, Report 11, November 2010.
  2. Ibid, p. 14.
  3. Office of the Auditor General WA 2014, Universal Child Health Checks Follow-up, Report 10, June 2014.
  4. Office of the Auditor General WA 2010, Universal Child Health Checks, Report 11, November 2010, p. 20.
  5. Oberklaid F and Drever K 2011, Is my child normal? Milestones and red flags for referral, Australian Family Physician, Vol 40, No 9, September 2011.
  6. Ibid.
  7. Wise S 2013, Improving the early life outcomes of Indigenous children: implementing early childhood development at the local level, Closing the Gap Clearing House, Australian Institute of Health and Welfare (AIHW).
  8. WA Department of Health, Child and Adolescent Health Service 2018, Community Health Manual: Aboriginal Child Health, WA Government.
  9. Campbell F et al 2014, Early Childhood Investments Substantially Boost Adult Health, Science, Vol. 343, No. 6178, pp. 1478–1485.
  10. Australian Bureau of Statistics 2013, 3302.0.55.003 - Life Tables for Aboriginal and Torres Strait Islander Australians, 2010–2012.
  11. Department of Prime Minister and Cabinet 2018, Closing the Gap: Prime Minister’s Report 2018, Australian Government, p. 105.
  12. Australian Institute of Health and Welfare (AIHW) 2017, Australia’s Health 2016: 4.2 Social determinants of Indigenous health, AIHW.
  13. Australian Bureau of Statistics (ABS) 2018, 3302.0 Life Tables for Aboriginal and Torres Strait Islander Australians, 2015–2017, ABS.
  14. Brown et al 2016, Aboriginal and Torres Strait Islander women's experiences accessing standard hospital care for birth in South Australia – A phenomenological study, Women and Birth, Vol 29 No 4.
  15. Bar-Zeev et al 2014, Factors affecting the quality of antenatal care provided to remote dwelling Aboriginal women in northern Australia, Midwifery, Vol 30.
  16. Wilson G 2009, What do Aboriginal Women Think is Good Antental Care? Consultation Report, Central Australian Aboriginal Congress Inc. and Cooperative Research Centre for Aboriginal Health,
  17. Telethon Institute for Child Health Research 2009, Overview and Summary Report of Antenatal Services Audit for Aboriginal Women and Assessment of Aboriginal Content in Health Education in Western Australia.
  18. Australian Health Ministers’ Advisory Council 2017, National Aboriginal and Torres Strait Islander Health Standing Committee 2015, Cultural Respect Framework 2016 – 2026 for Aboriginal and Torres Strait Islander Health: A National Approach to Building a Culturally Respectful Health System, Australian Health Ministers Advisory Council.
  19. Royal Australasian College of Physicians (RACP) 2006, Health of children in “out-of-home” care, RACP.
Further resources

For more information on early childhood health and development screening refer to the following resources: