Child First – Work Together (CF-WT)
Rajanagarindra Institute of Child Development

The Problem

The Rajanagarindra Institute of Child Development (RICD) is an Institute under the supervision of the Department of Mental Health and The Ministry of Public Health. The RICD is located in northern Thailand. It is responsible for providing treatment and rehabilitation for children with delayed development. The number of children with delayed development who came for treatment at the RICD, increased year by year, from 22,576 patients in 2007 to 35,153 patients in 2011.

The World Health Organization reported that every year more than 200 million children aged from birth to 5 years are still neglected and cannot develop to reach their potential. From the survey done by the Department of Health, Thailand, in the year 1999, 2004, and 2007, it was found that 28.3%, 28.0%, and 32.3% of Thai children respectively had delayed development. In the year 2007, it is estimated that there were 1,269,483 Thai children who needed to promote their development, and 209,393 of these children were in the northern part of Thailand. However, 57.20% of children with delayed development had no chance to access screening services from health care facilities.

Before the project started, Thailand health care services focused only on giving vaccination to prevent communicable diseases, but the health personnel had little knowledge and skills on screening or assessing child development. Another problem was that the screening and assessment tools for child development were imported from western countries with no specific focus for Thai children’s development. So the tools often gave incorrect results and led to improper treatment. Other problems were the lack of skilled health personnel, too many patients at the health care facilities that led to limited treatment time, and the referral system for children with delayed development was not effective.

Treating and rehabilitating children with delayed development needed cooperation from parents in the long term. Looking after children with delayed development caused many problems to the family, such as high expenses, loss of daily payments when the parents have to bring the child to see the doctor; some families have to leave their jobs in order to look after their child full time. Many parents feel stressed, discouraged, tired, worried, and also have interpersonal problems with other family members.

Therefore, if the children with delayed development can be identified as early as possible, they will be treated properly and will not become a burden to their family, if not, they will become chronically disabled and need more time for treatment, which means the family will have to spend more time and money, and it is also results in a loss of the children’s opportunity to develop their potential and the loss of human resources to develop the country in the future as well.

Solution and Key Benefits

 What is the initiative about? (the solution)
The project’s name is “Child First – Work together” or CF-WT. It began by enhancing awareness of health personnel; the personnel who work with children, such as nursery care takers, kindergarten teachers and parents, on how important to screen or assess child development and promote their development properly since early childhood.

Then the RICD developed screening and assessment tools on child development named “Thai Development Skills Inventory for Children from Birth to Five Years – TDSI”. The TDSI was developed for three different target groups that were, 70 item tools for parents, village health volunteers, nursery care takers, kindergarten teachers and health personnel at the well baby clinic of the sub-district health promotion hospitals; 286 item tools for general medical doctors, nurses at baby clinics of the community (district) hospitals and the general (provincial) hospitals; and 654 item tools for medical doctors, nurses, special personnel on child development at baby clinic of the central or special hospitals respectively.

The norm for normal Thai children’s development was found through research study. Many materials and the manual on child development promotion were developed. The training courses on how to screen and assess child development and how to promote child development were also developed. Knowledge and information on this issue were distributed by a website and through a variety of media. So the general public, health personnel, personnel that work with children and parents can access these issues easily. For the minority group who cannot understand the Thai language, village health volunteers will advise them.

After the development of the screening tools, materials, and training courses, the RICD integrated them into the public health service system, including, the Department of Health, other health care facilities both public and private sectors, and community facilities. Many public health personnel and personnel that work with children were trained to use the screening and assessment tools, and how to promote child development effectively. Thus, they are certain to provide services to their clients. Parents can now bring their children to the health care facilities near their home; they can save a lot of money and time for transportation. And the delayed development children can be promoted to reach their potential at an early stage, and they are not a burden on their families as before. It is estimated that the government can save 1,217,980,074 Thai Baht (around US$39,289,679.81) treating delayed development children in 2007.

In conclusion, delayed development children can get the most benefit from this project. They can develop their high potential and not to become a burden on their families. Their parents also be happier and live an easier life because their children can help themselves much more than before. The personnel that work with children have more confidence to screen, assess, and help the children because they were trained in professional skills. Then the country will have active human resources to develop the country in the future.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The RICD’s multidisciplinary team, who are medical doctors, nurses, dentists, educators, activity therapists, occupational therapists, psychologists, and speech therapists; together with many university technical staff, began to develop screening and assessment tools with the cooperation on data collection from medical and public health personnel in 50 hospitals across Thailand. The National Research Council of Thailand supported the project budget.

The RICD’s team developed human resources, communication channels, services systems, and networks. The RICD’s team worked closely with parents’ clubs, village health volunteers, local administrative authorities at a sub-district level, nursery care takers, kindergarten teachers, primary school teachers, special disabilities school teachers, hospital staff, philanthropic foundations, provincial public health offices, the Department of Mental Health (DMH), and the Department of Health (DH), Ministry of Public Health. The DMH, the National Research Council of Thailand and the Thai National Health Security Office supported the budget for this part of the project.

The RICD’s team cooperated with the DMH, and DH developed the tools to use in the public health system. The DMH supported the budget. Later, the tools were expanded to use in public health facilities all over Thailand.

The RICD’s team, the local administrative authorities at sub-district level, and university staff worked together to screen, assess, and promote child development in other public facilities outside the public health system, such as child development centers and received budgetary support from the Thai Health Promotion Foundation.

The RICD’s team cooperated with health supervisors of the Ministry of Public Health, hospital staff, and the DH developed an online database system. The Center for surveillance and care for the risk group of children on Oxygen Deficiency at birth (Lanna Birth Asphyxia Center – L-BAC) was established to follow up this group of children aged from birth to 5 years. Screening and assessment tools were used and this project was launched in the northern part of Thailand and will be expanded nationwide at a later date.

The RICD’s team cooperated with schools that provide the opportunity for the delayed development children to study with normal children to promote child development in school. The RICD’s team trained the delayed development children to prepare them before going to school.

The RICD’s team also worked with local administrative authorities at sub-district level, special schools for disabled persons, clubs, foundations, Interact Center – USA, to develop disabled people by using drama-therapy.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
In 2009, the RICD developed the TDSI. In 2010, the RICD conducted a research study to find the norm of normal Thai child development in Chiangmai Province where the RICD is located.

In 2011, the RICD expanded this research study in all provinces of Thailand. After that there was an evaluation on the effectiveness of the manual for parents and health personnel on promoting child development. The RICD also developed materials, computer programs, and a website for screening and assessing child development as well. The parents, health personnel, nursery caretakers and kindergarten teachers were educated and trained on this issue.

The strategy used in this project is called TMC-CSP together with 2F 1N as driver, motivator, and behavior changer, as below:

TMC-CSP stands for:
T is an abbreviation for Tools that are standard, safe, interesting, up to date, easily to use, and can access by everybody.
M is an abbreviation for Man who are empowered on knowledge, attitude, and skills. They are students, general public, personnel who work with children, and experts.

C is an abbreviation for Communication through various channels, such as, printed media, radio programs, TV programs, internet, online radio, Face book, web-site, conferences, journals’ articles, VDO conferences, VDO presentation, E-book, computer program that can be downloaded to mobile phones and tablets, etc. which are up to date and can access by everybody.

C is an abbreviation for Cooperation in every issue, such as, human resources, places, materials, budget, and management, among various group of people, such as, parents, village health volunteers, nursery care takers, kindergarten teachers, personnel from local administrative authorities, health personnel in the hospitals and health care facilities, provincial public health offices, National Health Security Office, foundations, and international organizations.

S is an abbreviation for System that are screening and assessment system, early intervention system, referral system, treatment and rehabilitation system, data and information report system that connect among public health services system, other services system, and community to cover all children groups; normal group, risk group, and delayed development group; in every area of the country.

P is an abbreviation for Policy that support this project to expand widely by providing manpower, budget, equipments, and technologies. Bottom-up policy can solve the local problems and can sustain the project in the long run.

2F 1 N
F is an abbreviation for Fraternity
F is an abbreviation for Friendship
N is an abbreviation for Network

The RICD works as the coordinator among these groups of people, provides them knowledge, tools, and materials, then support them to work together and help each other solve child development problems.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
There were 3 key development and implementation steps as follows:

Tools development
In 2009, RICD did a research study to develop the TDSI.Later, in 2010, the norm for Thai normal children development was developed in Chiangmai Province where the RICD is located. Then in 2011, the norm for Thai normal children was developed at a national level. At the same time, the manuals for parents and health personnel for screening, assessment, and promoting child development were developed in a variety of forms such as printed media, electronic media, VDO presentation, computer program, and websites.
In 2012, RICD did a research study to evaluate the effectiveness of the manual.

Human resources development
Before 2002, training courses and printed media did human resource development. The trainers were the experts in this area.

From 2002–2010, training courses, printed media, and VDO presentation did human resource development. The trainers were the experts or trainees from former courses.

From 2011 to the present, human resource development was done by training courses, printed media, VDO presentation, e-books, and computer programs both online and offline. The trainers were experts and the trainees from former courses. The general public can self-learn by accessing the materials mentioned above.

Communication, cooperation, system, and policy advocacy development
Before 2002, communication was delivered through printed media, radio programs, and meetings. The RICD also cooperated with health stations, hospitals, provincial public health offices, the Department of Health and foundations.

From 2002 to 2009, there were more channels for communication, such as conferences, online radio, etc. RICD cooperated with more target groups such as, parents groups, village health volunteers, community leaders, local administrative authorities, childcare centers, kindergartens, schools, DH, the National Health Security Office, the Ministry of Social Development and Human Security and international organizations.

From 2011 to 2012, more communication channels were developed such as, internet, Facebook, web-sites, journal articles, VDO conference, e-book and computer programs that can be downloaded to mobile phone and tablets. Communication was in Thai and English. The Minister of Public Health was invited to participate in this program and help develop the policy on child development at a national level.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
There were 3 main obstacles and the RICD can overcome them as follows:

The first main obstacle was the lack of awareness among parents and concerned health personnel of the importance of finding children with delayed development as soon as possible in order to treat and promote their development properly and help them learn to help themselves and not be a burden on their family. This obstacle can be overcome by educating parents and health personnel on child development, together with information about the situation, problems and impact that may occur if the children’s problems cannot be solved in early childhood, also informing them about the benefits they will get if the children with delayed development are found as early as possible. When they knew exactly what would happen to the children with delayed development, they had more awareness of this problem.
The second obstacle was the lack of acceptant, cooperation, and trust from parents and health personnel. RICD had to overcome this obstacle by developing good and sincere interaction, fraternity, friendship, and creating a co-operation network with them through frequent meetings and various kinds of communication channels. It was found that two-way communication with reliable information that can be proved by scientific research and development that can make parents and health personnel accept and cooperate in this project and develop a good relationship with RICD staff.
The last obstacle was the lack of formal connection between medical and public health service systems and other organizations outside the Ministry of Public Health that are responsible for children’s quality of life and education, such as local administrative authorities, child care centers, nurseries, schools, NGOs, foundations, etc. Each of these organizations have their own policies, missions, objectives, budget and they work in their own style. However, RICD tried to approach and integrate its work with these organizations by encouraging them to focus on the common and ultimate goal that is “healthy children”.
All the major obstacles can be overcome with a proactive approach, two-way communication, regular meetings, accurate information, repeated practice, good personal relationships, persuasion and devotion to the betterment of our children’s development.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
RICD received financial support from three main organizations.

The first one was the Department of Mental Health (DMH). The DMH supported the budget for RICD to print the tools, publish printed media, and train health personnel, other personnel that work with children and parents.

The second organization was the National Research Council that provided budget for doing a research study on TDSI and for developing a website

The third organization was the Thai Health Promotion Foundation that supported training childcare takers and publishing media to use in the Child Development Centers.

There were many organizations involved in this project, such as, hospitals under the Ministry of Public Health, Child Care Centers under the Ministry of Interior, kindergartens under the Ministry of Education, and nurseries under the local administrative authorities. There were also many groups of people involved in this project, such as the DMH’s personnel, health personnel, teachers, childcare takers, and parents. All of these people can help screen, assess, and promote child development in their settings and support this project until it’s goal is achieved.

The key benefits from this project were as follows:

From 2002 – 2006 there were 11,065, 14,328, 16,456, 15,805, and 21,304 delayed development children respectively who were treated at the RICD. After the research project was launched, the number of children increased from 22,576 children in 2007 to 35,153 children in 2011. This is due to the effective result of the TDSI developed by RICD and the good cooperation among concerned personnel who were involved in this project.

From 2011 – 2012, there were 3,447 nurses being trained on how to screen, assess, and promote child development. In 2011, parents were trained to screen and promote their children development 35,153 times. From the parents’ evaluation, it was found that 83.13% of these parents could train their children at home very well. From 2008 – 2011, it was found that 75% (2008) to 87% (2011) of children, who were discharged from the RICD had better development. The number of patients at the RICD decreased because parents can bring their children to get treatment at the health facilities near their home and many of them can promote their children development at home.After the delayed development children were trained at the RICD, they will be sent to study at normal schools.

From 2006 to 2010, 3,695 (2006) and 14,542 (2010) children were trained at the RICD before going to school. Before the project started, around 50% of these children were sent back for more training at the RICD. However, after the project had been launched, only one child had been sent back to the RICD. This number shows how effective this project is.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
This project can be sustainable and transferable by many factors.

Firstly, with love and care from parents with delayed development children, they agree and are happy to become involved with screening, assessing, and promoting children’ development. The health personnel and other personnel that work with children are aware of the importance of child development and are happy to be empowered by the RICD project.

Secondly, the screening, assessment tools and other materials are easy to use, and can be accessed by everybody easily. So it is convenient for parents and other personnel to use whenever they want.

Thirdly, the Ministry of Public Health, Thailand, has launched a project to screen, assess, and promote children’s development on the auspicious occasion of H.M. Queen Sirikit’s 80th Birthday Anniversary in 2012. The goal of this project is to screen at least 400,000 children all over the country on their development. There are more than 10,000 baby clinics in general hospitals that are involved, 400,000 copies of the manual on child rearing have been distributed to parents to use to promote their children’s development.

Fourthly, the Ministry of Public Health, Thailand realized the importance of child development, and initiated a policy to provide child development services in every baby clinic in all hospitals nationwide. The Department of Mental Health, the Department of Health, and the Thai Health Promotion Foundation cooperated to promote activities in all child development centers, kindergartens, and hospitals in the country and empower all the personnel to be able to screen, assess, and promote child development properly and effectively.

Lastly, the Lanna Birth Asphyxia Center (L-BAC) was established. This Center is responsible for surveillance and following up children with L-BAC or oxygen deficiency at birth. This center will follow up these children from birth to five years of age and use screening and assessment tools developed by the RICD.
At present, the training courses developed by the RICD are widely used by many organizations that work with children and the materials developed by the RICD have been translated from Thai into English in order to provide an opportunity for other ASEAN countries to use for the benefit of their children.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The main impacts of this project are on children, parents, and our country. Firstly, Thai children were screened and assessed on child development by TDSI since early childhood. When children with delayed development are identified, health personnel and their parents support them. They can study in school with other normal students and can develop like other students. After finishing school, they will find a job and can take care of themselves. In the future, this group of children will not be a burden on their family as before.
Secondly, parents of delayed development children began to realize that it was their responsibility to observe and screen their own children on child development from early childhood. After being empowered by the training course, they were confident to promote their children by themselves. Now, they do not totally depend on health personnel, but they can work together to promote their child development. They also felt relieved when their children can help themselves in school and in daily life. Parents also saved a lot of money and time looking after their children. They had more money and more time to spend with other family members that help develop better relationships and happiness in the family.
Lastly, our country can save a lot of money providing treatment and rehabilitation for delayed development children. Before the project started, children with delayed development could not be easily found during early childhood. This group of children often had chronic disabilities and needed more finance for treatment and more time for rehabilitation. However, when the TDSI was developed and many personnel and parents are trained to use it to screen and assess children since early childhood. Children with delayed development were identified earlier. Thus, the cost of treatment and rehabilitation and the lost of productivity from this group of children was decreased.
The main lessons learned from this project are the emphasis on interpersonal relationships, and parent and community involvement. When the project first started, official contact was made between the RICD and other concerned organizations. It was found that official contacts didn’t work well, unofficial personal relationships worked much better. Improved co-operation came from personal rather than official contact. For parents and community involvement, we found that if we had to do a project like this again, we would invite parents, community leaders, care takers, and kindergarten teachers to become involved in the project from they beginning, in order to plan, work and evaluate the project with us, because all these people are key success factors in the project. If they feel that they are the owner of the project, they will do their best to make the project successful. They are in the community, so it is convenient for them to promote child development in the long run. They can do better than us, as we are a small institute and located far away from rural communities.

Contact Information

Institution Name:   Rajanagarindra Institute of Child Development
Institution Type:   Government Agency  
Contact Person:   Saowalak Langkaphin
Title:   Associate medical Technologist R&D unit  
Telephone/ Fax:   + (66) 53-890238, + (66) 815682994/ + (66) 53-121-
Institution's / Project's Website:
Address:   196 Moo 10 , Chiang Mai-Fang Rd. Tambon Don Kaew
Postal Code:   50180
City:   Mae Rim
State/Province:   Chiang Mai
Country:   Thailand

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