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DARSHAK SANGHAVI

A crash course to help at-risk toddlers

IMAGINE if we allowed teenagers to operate automobiles without driver's education. Or if we let people dive into a pool without any prior swimming classes. Yet today many routinely engage in an activity of equal importance - and greater complexity - with little societal commitment to proper preparation: being a parent of a child with developmental problems. Unfortunately, the state has cut what little money was available.

Pediatricians in Massachusetts are looking harder than ever for early social and developmental problems in young children - yet increasingly are able to do less and less about them. Stemming from the 2005 class action lawsuit Rosie D. v. Romney, pediatricians now must screen all children on Medicaid for developmental problems, such as language delays, during routine visits. When problems are suspected, children are referred to the state's Early Intervention Program, and the doctor's job is largely complete.

The majority of children's developmental delays and parental education in the state get handled not by doctors, nurses, or hospitals, but by Early Intervention. Roughly 30,000 Massachusetts children each year qualify for continuing services. After an initial home-based assessment by a developmental specialist, Early Intervention coordinates regular parental education, occupational or speech therapy, social work, and other family support.

An avalanche of data supports EI's effectiveness. In 2007, 1,387 toddlers with moderate to severe developmental problems graduated to normal pre-schools, saving the state over $20 million in special education costs. The Early Intervention Collaborative Study showed that children in the program make strong gains in multiple developmental areas, and the Carolina Abecedarian Project showed such gains in mental, verbal, and math skills persisted until 21 years of age.

Now 7, my son Jake is an EI graduate who had a speech delay as a toddler. Though I'm a Harvard-trained pediatrician and medical subspecialist, I had little practical parenting know-how. Every few weeks, a young woman named Lisa visited our house to help us learn to enrich Jake's language skills. "Let's go out" was replaced by "Let's drive to the store to buy some vegetables," as my wife and I introduced more words in context. We offered more choices ("Do you want to hold Daddy's left or right hand to cross the street?") and began, for example, to run constant verbal commentary on our cooking or shopping when Jake was with us. In addition, Lisa pointed out useful discipline tactics and recommended books and resources on parenting.

We essentially had a crash course on toddler language and behavior - and within two years Jake had met all his milestones.

Clearly, not all children do so well. But research from sociologist Annette Lareau of the University of Maryland shows that such parenting skills often translate to later cultural and social advantages - and thankfully, our family gained some of them from Early Intervention. With a little push in the right place, a child veering from the path of normal development was steadied.

Unfortunately like many other state services, Early Intervention is facing budget cuts. Before January, children with more than 25 percent delays in language or other skills qualified for services. Now they must be 30 percent delayed - a change estimated to cut services for 3,000 at-risk children and save about $1.1 million. In essence, the standards for normal development in toddlers have been lowered, and further gerrymandering is possible. What was once cause for concern is now repackaged as normal, to cut costs.

Today, researchers understand that certain social and emotional stresses can harm molecules called telomeres in the brains of at-risk toddlers, which may explain why nurturing these children is critical. In our state, pediatricians now identify these children before the damage is irreversible. And decades of research have shown that for these babies' brains, an ounce of prevention from Early Intervention buys more than a pound of cure. What a shame that we now understand so much, yet may end up choosing to do too little.

Darshak Sanghavi is the chief of pediatric cardiology at UMass Medical School and author of "A Map of the Child: A Pediatrician's Tour of the Body."  

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