Two-year child development check

What is the Healthy Child Programme?

As part of the Healthy Child Programme (HCP) in the UK, children have a health and development review at the age of 2-2.5 years.¹ This is carried out by the health visitor. It may be done in the child's home, the baby clinic, the children's centre or the child's nursery.

This may now be an integrated review, combining what was previously an Early Years Foundation Stage (EYFS) 2-year progress review (carried out by childcare providers), with the 2.5-year HCP review.²

In England, the responsibility for these early reviews was transferred from NHS England to local authorities in 2015.³

This article covers the HCP two-year development check in England. The review is identical in principle in the rest of the UK but the specifics and terminology are available as follows:

• Northern Ireland: health and development review at 2-2.5 years, a home visit by health visitors as part of the Healthy Child, Healthy Future programme of 2010.⁴

• Scotland: 27- to 30-month child health review guidance 2012, as part of the Scottish Child Health Programme published in 2005.^{5 6}

• Wales: 27-month check as part of the Healthy Child Wales Programme (0-7 years) published in 2016.⁷

Aims of the Healthy Child Programme

The two-year review aims to optimise child development and emotional well-being and reduce inequalities in outcome - specifically:⁸

• Improvement in emotional and social well-being.

• Improvement in learning and speech and language development.

• Early detection of, and action to address:

  • Developmental delay.

  • Ill health.

  • Growth impairment.

• High immunisation rates and reduction in rates of preventable disease.

• Prevention of obesity.

• Promotion of health-enhancing behaviours such as active play and well-balanced diet.

• Early detection of psychosocial issues and action to address them:

  • Poor parenting.

  • Disruptive family relationships and domestic violence.

  • Mental health issues.

  • Substance misuse.

• Provide information and advice about:

  • Dental care.

  • Accident prevention.

  • Sleep management.

  • Toilet training.

  • Behavioural management.

The process⁸

It is crucial to engage the parent(s) or carers and to discuss their views and concerns. Parents who voice concerns about their child's development are usually right.⁹ Parents or carers must feel the process is useful, that their concerns have been listened to and addressed and that advice they have received is relevant and helpful. Invitations to the two-week check can be sent by letter, email, text or birthday card. Communication should be culturally appropriate; both parents should be encouraged to be involved where relevant and possible. Appointment times and venues must be flexible to enable a high response rate. Agreement of a shared agenda at the start, prioritising discussion of parental concerns and open-ended questions may all be helpful at the start of the appointment.

It may be helpful to offer a validated parental questionnaire to elicit concerns in advance of the appointment, to be discussed at the check. Appropriate questionnaires to use are the Parental Evaluation of Development Status (PEDS) or the Ages and Stages Questionnaire (ASQ).^{10 11} From April 2015, NHS England mandated use of a standard questionnaire and specified ASQ-3 should be used; in addition, from October 2016 the ASQ:SE-2 (ASQ for social and emotional development) should be used.² Resources for a British form of the questionnaire have been funded and made available for health visitors to use.

This health and development check is designed to be flexible and non-prescriptive so it can be adapted to the needs and priorities of the locality and individual.

Assessment of development^{8 11}

Under the EYFS monitoring, progress is assessed in the following areas at age 2 years by a childcare provider, and a written summary provided for the parent(s) and/or carers:¹²

• Communication and language.

• Physical development.

• Personal, social and emotional development.

• Literacy.

• Numeracy.

• Understanding the world.

• Creativity (expressive art and design).

This overlaps with the review which forms part of the HCP delivered by the health visiting team. At the 2- to 2.5-year review, development is assessed by answers on the ASQ-3 and by health visitors' observations. There are different forms to correspond to the appropriate age at which the questionnaire is being applied. If a significant delay is suspected, and this has not already been addressed then the appropriate referral should be made. If global developmental delay is suspected then investigation in secondary care may include genetic testing.¹³ Assessment includes the following areas but will vary slightly with exact age.

Gross motor skills

• Walking and running without falling.

• Ability to walk up or down at least two steps.

• Jumping.

• Kicking a ball.

Fine motor skills

• Ability to make a stack of seven or more blocks.

• Ability to thread beads or pasta on a string.

• Imitating a drawing of a line.

• Ability to use a turning motion for doorknobs, lids, wind-up toys.

• Ability to turn switches on and off.

• Ability to turn pages in a book.

Problem solving

• Pretend play.

• Knowing where items are kept and putting them away in the right places.

• Recognition of own image in mirror.

• Ability to work out a way of getting something out of reach.

• Ability to copy lining up four objects in a row.

• Picture recognition.

Personal-social

• Copying gestures.

• Ability to use cutlery.

• Appropriate play with common toys.

• Ability to put on a coat without help.

• Calling themselves "I" or "me".

Communication

• Following instructions (eg, "get your book" or "close the door".

• Vocabulary: ability to name items/animals in a picture or parts of the body. Words such as "mine", "you", "me".

• Understanding instructions given without gestures/pointing.

• Ability to make sentences of 3-4 words.

• Intelligible to familiar adults.

Hearing and vision

• Parental concerns.

• Family history of problems.

Priority topics⁸

The HCP identifies the following topics as priorities at the two-year check.

Healthy lifestyle

This focuses on the prevention of obesity and on nutrition and active play. Nearly a third of children in year 6 are currently overweight or obese, leading to huge potential health and economic costs later in life.¹⁴ The two-year review is an excellent opportunity to discuss and establish lifelong healthy eating habits and encourage physical activity. This should be within the context of the whole family's eating and activity patterns. Parents and siblings are role models, and meals should ideally be taken within the family group. Specific information and advice about a healthy balanced diet should be shared and should be culturally appropriate and relevant. Vitamin drops containing vitamins A, C and D should be given to all children up to the age of 5 years.

Weight and height may be recorded on the growth charts in the child's 'red book'. Body mass index charts can be used for overweight or obese children. Referral for growth problems or interventions for obesity may be considered where appropriate.

Immunisation

Immunisation status is checked at the two-year review and followed up if not complete. Advice is given about the forthcoming schedule of further vaccination and its importance.

Personal, social and emotional development

This gives an opportunity for the parents to discuss temper tantrums and other behavioural problems, sleep issues and toilet training. By this age most toddlers are out of nappies in the daytime and using a potty or toilet. Issues such as parenting, involvement of the father, parental relationships and secure attachments can be discussed.

Speech, language and communication

Normally by this age a child can understand more complex instructions, has a range of 200 words or more, uses two- or three-word phrases, and can be understood by those who know them well. Where this is not the case referral to audiology or speech and language therapy may be appropriate.

Injury prevention

Most injuries at this age occur at home as a result of scalds, burns, falls or accidental poisoning, and this is an opportunity to raise awareness and prevent such incidents. Examples of areas to discuss include:

• Locked cupboards for medicines, cleaning products. etc.

• Stair-gates.

• Covers for electric plugs.

• Covers for sharp corners.

• Smoke alarms.

Tools⁸

The Department of Health's 2009 guidance on the two-year review advises that if there are concerns, a formal assessment using validated tools should be used. Which is appropriate in each circumstance may vary between locality and individuals. The recommended tools are not needed in every child but support professional judgement where used. Validated recommended tools include:

• UK World Health Organization (WHO) growth charts (to chart weight and height accurately in order not to miss problems such as obesity).

• Ages and Stages Questionnaire (ASQ) (for general development).

• Schedule of Growing Skills II (SOGS II) (for general development).

• Parents' Evaluation of Developmental Status (PEDS) (for general development).

• Sure Start Speech and Language Measure or the Communicative Development Inventory (CDI) (for speech and language assessment).

• Social and Communication Questionnaire (SCQ) (autistic spectrum disorders).

• The Modified Checklist for Autism in Toddlers (M-CHAT).

• Ages and Stages Questionnaire: Social and Emotional (ASQ:SE).

• Achenbach Child behaviour checklist.

• Brief Infant Toddler Social Emotional Assessment (BITSEA).

• Strengths and Difficulties Questionnaire.

• HOME inventory (for parenting style observation).