The Child Development Program: A Multidisciplinary Integrated Team

The Montreal Children’s Hospital’s (MCH) Child Development Program provides a unique coordinated continuum of care for the three percent of children who have developmental delays. This program is part of the MCH Developmental and Behavioural Pediatric Services and the division of General Pediatrics, and integrates multidisciplinary teams that evaluate and diagnose special needs children. “We do the triage, coordinating the appropriate clinical consults and sharing of data,” says Program Director, Dr. Emmett Francoeur. “Some of the children have complicated medical backgrounds. Our goal is to present a clear and unified diagnosis and treatment approach for the family.”

The program also serves as an entry point for families who are not only seeking diagnosis but also trying to better understand their child’s complex issues and impairments. “We spend a lot of time and effort on communication and information transfer to parents,” says program member Dr. Shuvo Ghosh. “We want them to know what is going on with their child.”

The Child Development Program was established by Dr. Ron Barr more than 25 years ago. Dr. Barr’s vision was to integrate the necessary disciplines and to encourage movement away from silo thinking. “Previous to this program children would go to different specialists on different days, generating independent reports and confusion,” says Dr. Francoeur. “Now, there is a consolidated clinical process, a summary report is generated and clear feedback is relayed.” One of the strengths of the program is the expertise of its many professionals. Clinic coordinator Kimberly Reynolds organizes interdisciplinary teams that collaborate closely to determine the next steps for the child, including appointments with specialists in speech and language therapy, occupational therapy, psychiatry, neurology, psychology, and audiology. Often when a child is being evaluated, team members observe the process in an adjacent room. “The inter-disciplinary team is the foundation and strength of our work with these children,” says Dr. Francoeur. “We want to make sure we don’t miss anything.”

To best meet the needs of patients, the Child Development Program has divided its services into four main clinics, which address distinct clinical issues. Although these are separate services, many patients overlap between clinics.

The Developmental Progress Clinic

The Developmental Progress Clinic treats pre-school-age children; many do not have a clear impairment. The great majority of children are referred because of language difficulties; this tends to occur between the ages of two and three. “The children who are typically referred to this clinic are not severely delayed,” says Dr. Francoeur, “This may be a reason why parents hesitate to seek advice, and as a result, the child’s future development may be affected.”

“However, in some cases, the impairment is quite severe,” adds Dr. Ghosh. “This causes difficulties for integrating them into the community and enabling them to catch up with their peers.”

The most common diagnosis of this clinic is Global Developmental Delay, a somewhat ambiguous disorder that can affect motor, social and language function.

“This is an umbrella term,” says Dr. Ghosh. “It somewhat defines these children, but is not yet sufficient. One of the tasks we are undertaking is to come to a consensus within the medical community for the diagnostic criteria of Global Developmental Delay.”

Once the Developmental Progress Clinic has evaluated a child, the team determines the best interventional strategy, which is suggested to the family physician or pediatrician. “It is important that families have a physician manager in the community who can follow their child after being assessed in our clinic,” says Dr. Francoeur. “Our job is to be as clear as possible about what’s going on and what the child needs. Only then can appropriate resources be allocated.”

Learning Clinic

The Learning Clinic is for children aged six to 11 years who are failing academically and whose problems cannot be sufficiently assessed by their school. They may present with emotional and behavioural problems, or disruptive disorders. Often these children have worked their way through the school system, starting with interventions at the class level and counseling sessions with the school psychologist, before they end up at the Learning Clinic. “Eventually, parents become frustrated with the lack of communication and understanding from the school,” says Dr. Francoeur. “This is when they turn to their physician who then seeks advice from us. Many of these children have complex issues, which are best evaluated in a tertiary care system.”

The Learning Clinic’s role is to develop treatment strategies and to initiate a continuum of care when school failure is the issue. The clinic is sometimes involved with identifying and starting treatment for children with Attention Deficit Hyperactivity Disorder (ADHD). The clinic physicians follow the progress of these children until they adjust to their treatment regimes.

Developmental-Behavioural Assessment and Continuity Clinic

The Developmental-Behavioural Assessment and Continuity Clinic provides service to the entire pediatric population. “This clinic covers issues not touched by other clinics,” says Dr. Ghosh, director of the Developmental-Behavioural Assessment and Continuity Clinic.

The clinic has three areas of focus for evaluation and follow-up:

  • elimination disorders: bed wetting, encopresis, enuresis, soiling, and difficult toilet training issues;
  • sleeping: problems that are behavioural in nature, sleep hygiene, setting routines, night terrors, and co-sleeping issues, and;
  • gender issues: concerns about gender identity, gender variance and gender-specific behaviours.

Although it is preferable that parents ask their physician to refer them to this clinic, in some cases this is not necessary. Parents seeking advice which does not require close physician follow-up, such as coping with intermittent bed-wetting or gender-related questions, are encouraged to contact the clinic directly.

Feeding Program

The Feeding Program includes the Failure to Thrive / Feeding Disorders Clinic and the Swallowing and Dysphagia Clinic. The Failure to Thrive / Feeding Disorders Clinic is run by psychologist Dr. Maria Ramsay, and remains unique in Canada, with psychologists, pediatricians and nutritionists working together. Dr. Ramsay developed the clinic to treat children who have issues related to feeding. These may be due to difficulties due to food refusal, poor appetite or with the feeding process. Referred children are often identified because they are at or below the third percentile on growth curves. According to Dr. Ghosh, although there is no specific age range for this clinic, most referrals come from birth to the age of six. Additionally, children with swallowing problems are referred to the Swallowing and Dysphagia Clinic, where occupational therapists evaluate oral motor functioning.

Valuable contribution to other programs

The Child Development Program, which treats more than 1,500 children annually, has been a catalyst for setting up other multidisciplinary working teams to provide quality, comprehensive care. These programs, which include the Autism Spectrum Disorders Program and the ADHD Program, have been developed in response to patient demand and account for more than 1,000 patient visits per year.

The greatest achievement for Drs. Francoeur and Ghosh has been the encouragement and support of their colleagues, a testimony that the “silo days” are a thing of the past. “We are motivated by the enthusiasm of our team members,” says Dr. Francoeur. “There is mutual satisfaction in working together.”

by Christine Zeindler