Targeting toddlers’ communication difficulties at the Swedish child health services – a public health perspective

Communication is fundamental for human interaction. Communication difficulties have a negative impact on children’s learning, relations, and quality of life and are regarded as a public health problem. The Swedish child health services have a possibility to prevent communication difficulties and their consequences for the individual through universal interventions and identification of affected children. This thesis investigates interventions at the levels of universal prevention, identification, and indicated intervention for children with communication difficulties. Study I explored associations between family and child health centre characteristics and exposure to a universal preventive communication intervention. Questionnaires answered by 2326 mothers and 2077 fathers were analysed. Few parents reported that they had been exposed to the intervention. Positive associations were seen to high socioeconomic status and if the child was of low age at the start of the intervention or was oldest among siblings. Study II described the study design employed to investigate the identification and effects of an indicated intervention. Study III used a mixed-methods design to explore child health service nurses’ experiences and sense of competence when using the Infant-Toddler Checklist (ITC) at the 18-month health visit. The nurses considered the ITC to be a beneficial tool both in communicating with families and in identifying children with communication difficulties. The ITC seemed to enhance nurses’ and parents’ awareness of the child’s communication. In study IV, the psychometric properties of the ITC were analysed using data on 679 children. A sensitivity of 86% and specificity of 59% were found. These measures improved when combining the ITC with the child health service nurses’ informal developmental surveillance. Study V explored parents’ perceptions of the intervention ComAlong Toddler, consisting of five group sessions and two individual home visits. The parental intervention focused on responsive communication, enhanced milieu teaching and augmentative and alternative communication. Qualitative content analysis showed that parents appreciated the intervention and used the strategies taught. Parents described benefits of the combination of home visits and group sessions with peer learning through video recorded home assignments. In conclusion, the thesis shows that the ITC can be implemented in the child health services as the method identifies children with communication difficulties and seems to have preventive capabilities. ComAlong Toddler may help parents to implement communication-enhancing strategies with their children. When universal interventions are delivered through the child health services, implementation and distribution need to be carefully planned and carried out so that they reach all children