RETHINKING UNIVERSAL AND TARGETED SERVICES

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CENTRE FOR COMMUNITY CHILD HEALTH
RETHINKING UNIVERSAL AND TARGETED SERVICES
CCCH Working Paper 2
Tim Moore
Senior Research Fellow
August 2008
Preferred citation:
Moore, T.G. (2008). Rethinking universal and targeted services. CCCH Working
Paper 2 (August 2008). Parkville, Victoria: Centre for Community Child Health.
Introduction
In supporting young children and their families, we need to use the available
resources in ways that are both effective (that achieve the outcomes we are seeking)
and efficient (that do so with least amount of effort and cost). Among other things,
this involves knowing what combination and balance of universal and additional or
targeted services are needed and how these should be deployed.
One of the key ways in which human services vary is according to their aims or target
groups. Three forms of services that are usually distinguished are universal, targeted
and treatment services, and defined as follows:
• Universal services are available to the whole of the population and are designed
to promote positive functioning and thereby decrease the likelihood of specific
disorders developing.
• Targeted services are available to selected groups or individuals who are known
to be at risk of developing a particular health or developmental problem, and are
designed to reduce the incidence of the problem developing.
• Treatment services are available to individuals or families who have an
established condition or problem and are designed to minimise the negative
impact of the condition or problem.
This paper seeks to rethink these forms of service and the relationship between
them. It proposes an alternative relationship, a tiered system of universal, secondary
and tertiary services that are more closely integrated than the existing universal,
targeted and treatment services, and that are designed to strengthen the capacity of
the universal services to be truly inclusive and to cater more effectively for the
diverse needs of all children and families.
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Why is this issue important?
There are a number of reasons why we need to rethink the way that we provide
services to young children and their families.
The first concerns the impact of recent social and demographic changes. Over the
last two or three decades, families and family circumstances have changed to such
an extent that the service system that worked well when society was more
homogeneous and the demands on families were fewer is no longer adequate
(Richardson, 2005; Richardson and Prior, 2005a; Stanley, Prior and Richardson,
2005; Zubrick, Silburn and Prior, 2005). One indication that all is not well is that we
are seeing worsening or unacceptably poor health and well-being outcomes among
young people (Keating and Hertzman, 1999; Rutter, 2002; Sawyer, 2004; Stanley,
Prior and Richardson, 2005). These poor outcomes all have associated costs that are
a significant drain on public resources and undermine national productivity and
prosperity (Kids First Foundation, 2003; Heckman, 2006).
A second cause of concern is the growth in the numbers of those who are socially
excluded: despite overall growth in prosperity, the gap between the rich and the poor
has widened, with the result that there are children and families who do not or cannot
easily access the services they need (Hertzman, 2002a; Richardson, 2005;
Wilkinson, 2005). This has negative consequences for their long-term health,
achievements and well-being (Hertzman, 2002a; Shonkoff and Phillips, 2000). ‘Social
gradient’ effects are evident in the distribution of these poor outcomes: the more
socioeconomically disadvantaged families are, the more likely it is that they and their
children will be experiencing problems (Brooks-Gunn, Duncan and Britto, 1999;
Keating and Hertzman, 1999; Marmot, 2004; Offord, 2001). These gradient effects
are evident at birth (in the form of low birth weight and other birth complications) and
apply to all aspects of children’s development. The gradients do not seem to be
reduced by schooling (which may even reinforce disparities rather than reduce them),
and they continue through the adolescent years. The gradients exist along the entire
income distribution, with those in deep poverty faring worst but poor outcomes still
being evident among those in the highest income brackets (Brooks-Gunn, Duncan
and Britto, 1999).
Third, the service system is also having difficulty coping with the overall demand.
Many specialist services have waiting lists, and these create referral bottlenecks. As
a result, there are many children not receiving the additional help they need. This
suggests that specialist services are underfunded. However, given the range of
specialist services in this position (health, mental health, disability, special education,
family support, parenting, child protection etc.), the cost of trying to eliminate waiting
lists by increasing funding to all specialist services in their current forms would be
prohibitive (Fonagy, 2001; Sawyer, Arney, Baghurst, Clark, Graetz, Kosky,
Nurcombe, Patton, Prior, Raphael, Rey, Whaites and Zubrick, 2000). Instead,
specialist services need to review how best to utilise their expertise so as to meet the
needs of the greatest number of people and reduce the need for the most intensive
forms of specialist help. (It should be noted that this is not an argument for not
increasing funding for specialist services: it is a question of whether additional
funding should be used to increase the capacity of existing forms of specialist
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service, or should be used to diversify the forms of support that specialist services
provide so as to deploy their expertise more effectively.)
What does the research tell us?
Evidence of problems with the current service system
The service system is having difficulty providing support to all families who are
eligible, and waiting lists are increasingly common, particularly for specialist services
of various kinds (Fonagy, 2001). For instance, in the mental health field, it has been
estimated that as many as 75% of children and families experiencing difficulties do
not receive the help they require (Cox, 1993; Flisher, Kramer, Grosser, Algeria, Bird,
Bourdon, Goodman, Greenwald, Horwitz, Moore, Narrow and Hoven, 1997; Sawyer
et al, 2000; Sayal, 2006).
How this occurs has been explored by Sayal (2006) who identified four stages of
help-seeking and shows how each of these can act as filters to prevent children
being referred for specialist help. The four stages are:
– Parental perception of problems. Following parental awareness of child
symptoms, parental perception of problems is the key initial step in the help-
seeking process.
– Use of primary care services. Although children with mental health problems or
disorders are regular attenders within primary care and most parents
acknowledge that it is appropriate to discuss concerns about psychosocial issues
in this setting, few children are presented with mental health symptoms even if
their parents have such concerns.
– Recognition within primary care. Subsequently, less than half of children with
disorders are recognised in primary care.
– Referral to or use of specialist health services. Amongst recognised children,
about half are referred to specialist services.
Overall, up to one-third of children with disorders receive services for mental health
problems. Sayal concludes that, as there are inequities in patterns of service use, a
greater emphasis on developing resources at population and primary care levels is
required. Barriers involving parental perceptions and expression of concerns within
consultations should be minimised at these levels.
Another problem with the current service system is that many forms of service are
treatment-oriented (Prilleltensky and Nelson, 2000). This means they are can only
help those who meet specified criteria (health, educational, disability, welfare)
indicating that they have a level of need that justifies a specialist form of intervention.
Services are therefore unable to respond to the emerging needs and problems of
children and families, and thus miss opportunities to reduce the numbers needing
intensive help (Tolan and Dodge, 2006). Moreover, by the time they are eligible for
specialist help, the problems experienced by these families are likely to have become
so well-established and serious that they are resistant to change and very costly to
remediate in terms both of time and resources (Fonagy, 2001). Responding early to
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problems as they emerge is more efficient and cost-effective than waiting until they
meet particular eligibility criteria.
There is also evidence that it is often those with the greatest need that are least likely
to be able to access available services (Fonagy, 1996; 2001; Offord, 1987; Watson,
White, Taplin and Huntsman, 2005). On the basis of a review of the evidence for the
efficacy of different forms of early intervention, Watson, White, Taplin and Huntsman
(2005) conclude that there is often a low take-up of opportunities to participate in
programs, as well as a high attrition rate among program participants and staff
providing the services. This is particularly apparent amongst the most vulnerable
families for whom the programs are often intended.
Even universal services have difficulties engaging and retaining all families. To do
this effectively, universal services need to be inclusive, that is, willing and able to
cater for the needs of all children and families. Australian studies (Carbone, Fraser,
Ramburuth and Nelms, 2004; Walker, 2004) suggest that universal early childhood
services are not as accessible or inclusive as they need to be. For instance, in a
study of usage of antenatal and universal early childhood services in Victoria,
Carbone, Fraser, Ramburuth and Nelms (2004) found that the majority of children
and parents make good use of these services, but there was a small but significant
minority of families that underuse some or all of these services. This was most
apparent in disadvantaged neighbourhoods and in vulnerable families. Often it
appeared that retaining the families on service was more of a problem than access:
most parents make contact with services, but some might then cease attendance,
attend infrequently, or not become fully involved in the services’ activities. Both these
studies found that there were many barriers to access: some reflect family
circumstances, some relate to resources, while others reflect systemic problems.
What this shows is that the existing system does not do a good job of catering for the
needs of the most vulnerable families. Yet these families are often the ones who,
because of the poor outcomes they and their children eventually present, will need
intensive support and intervention later on, taking up a disproportionate amount of
professional time and resources. Universal, targeted and specialist services all have
problems reaching and retaining these vulnerable families.
Evidence of efficacy of different service models
There is evidence of that each of the three forms of service discussed here –
universal, targeted and treatment – can be effective (Homel, 2005; Loxley,
Toumbourou, Stockwell, Haines, Scott, Godfrey, Waters, Patton, Fordham, Gray,
Marshall, Ryder, Saggers, Sanci and Williams, 2004). It is also clear that each
approach has its strengths and weaknesses (Barnet, Brown and Shore, 2004;
Fonagy, 2001; Gilham, 2003; Homel, 2005; Offord, Kraemer, Kazdin, Jensen,
Harrington and Gardner, 1999).
Treatment services. The great virtue of treatment programs is that they have the
capacity to tackle the most difficult and chronic conditions and, some of the time at
least, make a difference. There is evidence that treatment programs for a wide range
of problems (including health, mental health, drug abuse, crime, family interventions,
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disability) can be effective (eg. Farrington, 2002; Fonagy, Target, Cottrell, Phillips and
Kurtz, 2002; Guralnick, 1997, 1998; Loxley et al., 2004).
However, these interventions are not without their problems. The most commonly
cited problem is that, by the time they become eligible for treatment services,
people’s problems are often so severely entrenched that they are difficult to shift
(Fonagy, 2001). This reduces the efficiency of such services. For instance, even
those mental health interventions with the best evidence base (pharmacotherapy,
psychotherapy) are far less than 100% effective, possibly because they are used so
late in the evolution of the disorder (Fonagy, 2001). Moreover, even highly effective
mental health treatment services rarely make a serious impact on the population
prevalence of the disorder (Fonagy, 2001).
Another problem is the cost. Treatment needs to be intensive and tailored for
individual families to be at all effective, which makes such services costly in terms of
time, effort and money. A related issue is the difficulty in providing adequate
coverage of populations and ensure that everyone has easy access to these
services.
Another problem with treatment services is that they stigmatise the families they aim
to help, which tends to make them ambivalent or even hostile to the service. This
leads to many needy families dropping out of service, or never approaching them in
the first place. Thus, these interventions may inadvertently increase inequalities
rather than decreasing them, because it is the most socially excluded who are least
likely to benefit from the intervention (Fonagy, 2001).
Targeted services. Targeted services have the capacity to provide intervention
before symptoms or disorders are well-established, which is particularly important in
conditions where results of treatment are disappointing or treatment services over-
stretched. There is strong evidence that targeted programs can be effective in
improving the lives of children and families (Karoly, Greenwood, Everingham, Houbé,
Kilburn, Rydell, Sanders and Chiesa, 1998; Karoly, Kilburn and Cannon, 2005;
Shonkoff and Phillips, 2000; Williams, Toumbourou, McDonald, Jones and Moore,
2005).
As with treatment services, the targeted approach has some disadvantages. If the
selection of targeted individuals or areas can be done accurately, targeted
approaches can be an efficient way of preventing later problems. However, there are
often difficulties with screening, as screening procedures fail to identify many of the
individuals who ultimately develop the problem (Gilham, 2003). Even when risks are
relatively easy to identify, the developmental pathways to subsequent poor health
and developmental outcomes are complex and poorly understood (Cowen, 2000;
Blair and Stanley, 2002), and therefore it can be unclear what form the targeted
service should take in order to be effective. Prevention programs are only effective if
they are able to influence key risk and protective factors that have a causal
relationship with the problems being addressed, that is, that they have a strong
conceptual framework built on a solid empirical base which describes the relationship
between risk and protective factors, and relevant problems (Giesen, Searle and
Sawyer, 2007).
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There is another problem with a risk-based approach to targeting: not all those who
are identified as being at risk will develop problems. By their very nature, risk factors
only indicate an increased likelihood of problems emerging, and many or most of
those in a risk group will not develop problems. Thus, risk factors lack sufficient
specificity and sensitivity to be useful in predicting poor outcomes; there are no risk
factors that always lead to poor outcomes, ie. that have 100% specificity and 100%
sensitivity. Hence, although targeted programs are potentially efficient if the targeting
is accurate, if it is not, then those children who are misidentified will be unnecessarily
labeled or stigmatized, while some who are in need of help will not be detected
(Offord, 2001). The use of risk assessment procedures is particularly problematic in
sensitive areas such as child protection (Goddard, Saunders, Stanley and Tucci,
1999). This is partly because risk assessment involves a professional judgment of
what might happen in the future rather than a parental report of what has happened
or is happening now.
Targeted programs have lower costs than treatment services, and should produce
higher returns per dollar invested than universal programs (Karoly and Bigelow,
2005). However, they are more expensive than universal programs because of the
administrative costs of determining eligibility and addressing changes in eligibility
over time. Like treatment services, targeted services can stigmatise the families they
aim to help, which leads to many needy families dropping out of service, or never
approaching them in the first place.
Another key issue is that, although the concentration of those who would benefit from
particular interventions may be highest in targeted populations, the absolute number
of individuals who develop a disorder may actually be higher in low-risk groups who
do not receive the intervention (Offord, 2001; Offord, Kraemer, Kazdin, Jensen, and
Harrington, 1998). This reduces the efficiency of the targeted approach. Evidence of
this in the Australian context comes from a study of child social exclusion resulting
from poverty in Booroondara, one of Melbourne’s wealthiest municipalities (Stanley,
Mestan and Ng, 2007). This estimated that 12 % of children in Booroondara
(representing about 4500 children under the age of 15) were living in poverty.
Although 12% of children living in poverty is much lower than the regions in
Melbourne where disadvantage is concentrated (at rates above 25%), the number of
children involved may outweigh the sum of people living in poverty in regions where
disadvantage is concentrated. Moreover, because Boroondara is largely an affluent
area, it does not have some of the supportive infrastructure of other areas where
poverty is concentrated. Paradoxically, such families are more at risk in wealthy
municipalities because of their isolation and the lack of appropriate support services.
This example highlights a problem with ‘place-based’ targeting initiatives. Such
initiatives provide resources for specific communities and works with them to address
particular local issues, such as crime, amenities, neighbourhood appearance, or
social cohesion. This approach is popular with governments (eg. the Neighbourhood
Renewal initiative adopted by the Victorian Government to address aspects of social
exclusion). However, these place-based initiatives will not help those disadvantaged
people living in other areas, nor can they deal with the problems of scattered poverty
in areas of higher relative wealth. Scattered poverty can be more difficult to address
because the disadvantage is more covert.
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Universal services. Because of the difficulties associated with targeted and
treatment approaches, universal services have a number of features to recommend
them. Since the interventions are offered to all children and populations, there is no
labelling or stigmatisation involved, and therefore they are likely to be more effective
at identifying and reaching all targeted children. Moreover, universal programs are
particularly beneficial for the most disadvantaged children (Barnett, Brown and
Shore, 2004; Karoly, Kilburn and Cannon, 2005; Melhuish, 2003). Although
successful universal interventions typically have very small effects for the average
participant, such effects can add up to large benefits for society (Offord, Kraemer,
Kazdin, Jensen, and Harrington, 1998).
There is evidence that universal programs can be effective. In a review of mental
health interventions, Greenberg, Domitrovich and Bumbarger (1999) found that such
programs produced positive outcomes in either specific symptoms of
psychopathology or commonly accepted risk factors associated with
psychopathology. Further evidence comes from a Canadian study (Peters, Petrunka
and Arnold, 2003) that evaluated a community-based, universal project designed to
prevent emotional and behavioral problems and promote general development in
young children. The project also sought to improve family and neighbourhood
characteristics, to link effectively with existing services, and to involve local residents
in project development and implementation. Long-term follow up showed that the
program led to significant improvements in children's and parents' social-emotional
functioning and physical health, parenting behaviours, and neighbourhood and
school characteristics. An Australian study, the Gatehouse Project, has shown that a
school-wide prevention strategy designed to promote social inclusion and
commitment to education was effective in reducing student health risk behaviours
and improving their emotional well-being (Patton, Bond, Carlin, Thomas, Butler,
Glover, Catalano and Bowes, 2006). The study provides support for prevention
strategies in schools that move beyond health education to promoting positive social
environments.
There is also evidence that high-quality preschool programs lead to significant
improvements in children's early language, literacy and mathematical development,
regardless of ethnic background or economic circumstances (Barnett, Lamy and
Jung, 2005; Committee on Economic Development, 2006; Gormley, Gayer, Phillips
and Dawson, 2005; Henry, Henderson, Ponder, Gordon, Mashburn and Rickman,
2003; Schulman and Barnett, 2005; Waldfogel, 2006). On the basis of this evidence,
there has been a groundswell of opinion in the US in favour of providing universal
preschool programs (Barnett, Brown and Shore, 2004; Committee on Economic
Development, 2006; Karoly and Bigelow, 2005; Schulman and Barnett, 2005).
In addition, there is the evidence that interventions during the early years can be cost
effective (Heckman, 2000, 2006; Heckman and Masterov, 2004; Karoly, Greenwood,
Everingham, Houbé, Kilburn, Rydell, Sanders and Chiesa, 1998; Karoly, Kilburn and
Cannon, 2005; Lynch, 2004; Rolnick and Grunewald, 2003). Universal preschool
programs in particular have been shown to be cost effective (Bellfield, 2004; Calman
and Tarr-Whelan, 2005; Committee on Economic Development, 2006; Lynch, 2004;
Karoly and Bigelow, 2004).
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Implementing an effective universal approach can be challenging. One problem is the
difficulty of ensuring the high quality of service needed for such services to be
effective (Barnett, Brown and Shore, 2004; Melhuish, 2003). Expanding universal
options takes time, and patience is required to build capacity while maintaining or
improving quality (Barnett, Brown and Shore, 2004). Another challenge is matching
services to needs: universal programs that do not match the needs of families or are
not delivered in ways that are easily accessible are not likely to be effective (Scott,
O'Connor and Futh, 2006).
Then there is the challenge is ensuring that universal services are truly inclusive and
able to meet the needs of all children and families, including those with additional
needs. Providing universal services does not mean providing uniform services
(Carbone, Fraser, Ramburuth and Nelms, 2004; Committee on Economic
Development, 2006). Some children and families who are at risk or have additional
needs will require additional services (such as more intensive instruction, parent
education, home visits, or access to health care services) (Barnett, Brown and Shore,
2004). This means that strengthening universal services must be coupled with the
development of an efficient tiered system of targeted and treatment services.
What are the implications of this research for policy and programs?
Four major themes emerge from this evidence:
• the need to shift from treatment and targeted services to a universal prevention
approach
• the need to develop an integrated tiered system of universal, targeted and
specialist services
• the need to shift from a risk-based approach to targeting children and families in
need to a response-based approach
• the need to develop better ways of engaging and retaining the most vulnerable
families
The first major theme emerging from this evidence is that there needs to be a shift
from treatment and targeted services to universal prevention approaches (Albee and
Gullota, 1997; Coie, Watt, West, Hawkins, Arsanow, Markman, Ramey, Shure and
Long, 1993; Cowen, 2000; Fonagy, 2001; Homel, 2005; Prilleltensky, Peirson and
Nelson, 2001; Richardson and Prior, 2005; Sanders, Cann and Markie-Dadds, 2003;
Schorr, 1991; Winkworth, 2003). As noted by Robson, Silburn and the Aboriginal
Suicide Prevention Steering Committee, Western Australia (2002), a number of
adverse outcomes – including family violence, alcohol and substance abuse, juvenile
and adult crime, sexual abuse of children and women, mental health problems and
suicide – are known to develop along similar causal pathways. The fact that these
diverse problems arise from exposure to a common set of risk factors ‘clearly
indicates the need for significant new investment in broadly based primary
prevention’ (p. 5). On the other hand, there is evidence that adopting several positive
health behaviours has a cumulative effect in reducing mortality (Khaw, Wareham,
Bingham, Welch, Luben and Day, 2008).
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There have been calls for a universal service approach across a wide range of
services, including preschool services (Barnet, Brown and Shore, 2004), child
protection services (Barlow and Stewart-Brown, 2003; Sanders, Cann and Markie-
Dadds, 2003; Winkworth, 2002), mental health services (Park, 2003), health services
(Tolan and Dodge, 2005), and disability services (Blair and Stanley, 2002). For
instance, Sanders, Cann and Markie-Dadds (2003) argue that, to reduce the
prevalence of child maltreatment, we need to adopt a population-level approach,
creating community-wide support structures to support positive parenting. Blair and
Stanley (2002) argue that the evidence regarding effective prevention strategies for
disabilities or other conditions suggests that ‘simple, low-cost, universal measures
implemented early in the pathway may be more effective, but less visible, means of
prevention than relatively expensive medical interventions selectively implemented
late in the causal path’ (p. 184). Similarly, on the basis of the cumulative research
evidence, Robson, Silburn and the Aboriginal Suicide Prevention Steering
Committee, Western Australia (2002) suggest that interventions are most effective
when they are ‘preventive, comprehensive and integrated across communities and
across the life-span’ (p. 5).
The argument for the adoption of a universal prevention approach to service delivery
has been most clearly stated by Richardson and Prior (2005):
‘Targeted policies and services to meet the special needs of children with
chronic problems, or who face difficult circumstances, will always be required.
However, such services will continue to consume an ever increasing
proportion of public expenditure on social and other human services unless
there is a substantial repositioning of policy from its current focus on remedial
and treatment services towards increased investment in universal prevention
for all children -- particularly in the early years. Without such investment, we
are likely to see a continuation of the present trends of increasing inequality
and localised concentration of an adverse outcomes for children and youth,
including vulnerability to emotional and behavioural problems, substance use
and abuse, alienation from school, and disengagement from or rejection of
civic and social values and hopes for the future.’ (p. 318)
The second major theme is the need to develop an integrated, tiered system of
universal, secondary and specialist services. The evidence suggests that existing
service systems may be too dependent upon scarce specialist expertise. For
instance, it has been argued that, in the current mental health service system, there
tends to be an over-reliance on out-of-home and out-of-community treatment options
and an overemphasis on traditional psychotherapeutic interventions (Huang, Stroul,
Friedman, Mrazek, Friesen, Pires and Mayberg, 2005). To counteract this tendency,
we should be seeking to incorporate interventions for more vulnerable children and
families into existing early childhood and family support services (Knitzer and
Kreader, 2004).
To do this, the capacity of universal services to cater for the needs of a broad range
of children and families will have to be strengthened. This will involve several
strategies, including training of primary care workers (Sayal, 2006), increased
support from specialist services (NHS Health Advisory Service, 1995), and the use of
inclusive practices and strategies (such as the natural learning opportunities
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approach used with young children who have developmental disabilities)(Dunst,
Hamby, Trivette, Raab and Bruder, 2000; Hanft and Pilkington, 2000; Noonan and
McCormick, 2005). However, the main strategy needed is to create a more integrated
system of universal, targeted and treatment services, and to deploy the expertise of
specialists more broadly.
As the evidence has shown, clinical, targeted, and universal programs all have
advantages and disadvantages - one type of program alone will never be sufficient to
meet all the needs of all young children and families. What is needed is a tiered
approach to service delivery (NHS Health Advisory Service, 1995; Statham, 1997)
incorporating all three approaches and built upon a strong base of universal services.
To help distinguish this new tiered approach from the existing system, it is proposed
that the three levels of service be designated universal, secondary and tertiary. All
three would have a prevention focus (Simeonsson, 1991; Statham, 1997): universal
services directed to whole populations aim to strengthen capacity and reduce the
incidence of developmental and other problems; secondary services directed to
individuals or groups with emerging problems aim to reduce the numbers who
develop significant problems; and tertiary services directed to those who have
identified problems aim to reduce the sequelae or complications of the condition.
As shown in Figure 1, in the existing system, targeted and treatment services are
mostly located separately from universal services, there are referral ‘bottlenecks’ that
result in delays in help being provided, and the communication between services
tends to be one way. Figure 2 shows how, in an integrated system, secondary and
tertiary services would have outreach bases co-located with universal services, would
provide consultant support for children who have emerging problems, and would
work collaboratively with universal service providers.
The third major theme involves the need to shift from a risk-based approach to
targeting children and families in need to a response-based approach. Because risk-
based targeting can be inefficient, missing some of those in need and including many
who do not need intervention, it should not be the sole basis on which targeting is
conducted, but should be combined with (or replaced by) a response-based
approach. This involves providing support in response to emerging child and family
problems rather than attempting to predict ahead of time which children and families
might need help.
These two approaches differ in the nature of the relationship between professionals
and parents: a risk-based approach involves judgments made by professionals about
family needs whereas a response-based approach involves a partnership between
parents and professional in which the professionals seek to identify and respond to
parental concerns. A partnership approach is to be preferred both for philosophical
and practical reasons (American Academy of Pediatrics, 2003; Glascoe and Dworkin,
1995; Squires, 1996). Monitoring and surveillance tools based upon parental
identification of children’s problems have been developed, such as the Parents’
Evaluation of Developmental Status (PEDS) (Glascoe, 1997, 1998). These have
been demonstrated to be as efficient and cost effective as professionally
administered tools (Glascoe, Foster and Wolraich, 1997; Squires, 1996; Wright and
Oberklaid, 2004).
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The fourth major theme is the need to develop ways of engaging and retaining
contact with the most marginalised and vulnerable children and families. The service
system needs to become more equitable and inclusive (Carbone, Fraser, Ramburuth
and Nelms, 2004; Hertzman, 2002b, Offord, 2001).
What can we do?
• Seek to ensure that the general community is supportive of all families
(Long and Hoghughi, 2004; Offord, 2001; Stanley, Prior and Richardson, 2005).
The key element of a comprehensive strategy to deliver services for children is
the presence of what Offord (2001) calls a civic community. Among other things,
this means a community where all children have the right of full participation in
community life, and where everyone accepts responsibility for what happens to
children.
• Shift from targeted and treatment approaches to a universal prevention
approach (Coie, Watt, West, Hawkins, Arsanow, Markman, Ramey, Shure and
Long, 1993; Cowen, 2000; Fonagy, 2001; Prilleltensky, Peirson and Nelson,
2001). This would serve to increase both the effectiveness and efficiency of
investments in early childhood services (Barnett, Brown and Shore, 2004;
Hertzman, 2002b; Waldfogel, 2004, 2006; Watson, White, Taplin and Huntsman,
2005). Building the capacity of universal services without compromising the
quality of secondary and tertiary services will take time and patience (Barnett,
Brown and Shore, 2004). It will also require that specialist professionals receive
training in consultation (Buysse and Wesley, 2004) and coaching skills (Hanft,
Rush and Shelden, 2004) to ensure that they are able to share their expertise with
universal services providers effectively.
• Promote greater integration of universal and specialist support services
(Fonagy, 2001; Hertzman, 2002b; Knitzer, 2000; Knitzer and Lefkowitz, 2006;
Sawyer et al, 2000). As Fonagy (2001) states, ‘It is now generally recognized that
the promotion of early intervention will not take place without extensive
integrations at various levels of the social care system.’ This would include
providing greater support for and access to short-term intervention in primary care
settings (Tolan and Dodge, 2005).
• Ensure that there is an efficient and effective tiered system of universal,
secondary and tertiary services capable of meeting the needs of all children
and families (NHS Health Advisory Service, 1995; Offord, 2001). Strategies to
achieve this include specialist services providing support to universal services in
the form of training and consultation; secondary and tertiary services establishing
outreach services in universal service settings; and developing more effective and
efficient screening and referral pathways for children and families who need more
specialised help.
• Promote more effective ways of identifying emerging child and family
problems. Train staff in the use of tools such as Parents’ Evaluation of
Developmental Status (PEDS) (Glascoe, 1997, 1998) and develop matching tools
to identify parenting and family concerns.
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• Explore ways of varying eligibility requirements to allow specialist services
to respond to emerging child and family needs, and not wait until problems
become so entrenched and severe that they are finally eligible for service (Tolan
and Dodge, 2005). This could involve a version of the response-to-intervention
model being used in the special education field in the US (Fuchs and Fuchs,
2005; National Association of State Directors of Special Education, 2005) and
now being trialed in early childhood settings (Coleman, Buysse and Neitzel,
2006).
• Increase the range of universal services available to all children, including
high quality preschool programs (Barnett, Brown and Shore, 2004; Richardson
and Prior, 2005b; Schulman and Barnett, 2005).
• Explore ways of making universal services more inclusive. This could involve
ensuring that such services are affordable, well publicised, and geographically
accessible; providing outreach and support with transport; providing a family-
friendly and culturally inclusive physical environment; employing skilled and
responsive staff working from a family-centred, culturally sensitive perspective;
promoting social connectedness through informal supports; and establishing
strong reciprocal links with other relevant services (both universal and
specialist)(Carbone, Fraser, Ramburuth and Nelms, 2004).
• Make special efforts to reach the marginalised groups who make poor use
of services, universal or otherwise (Carbone, Fraser, Ramburuth and Nelms,
2004). Ways of making universal services more acceptable to vulnerable families
have been identified by Carbone, Fraser, Ramburuth and Nelms (2004), Ghate
and Hazel (2002), Hogue, Johnson-Leckrone and Liddle (1999), and Weeks
(2004). For instance, Carbone et al suggest that, since it is highly unlikely a
service will have no vulnerable children and parents among its potential clients,
every service needs to make the service attractive to families, rather than waiting
to change once they arrive. Among the most critical factors is workers’ ability to
establish positive, non-judgmental relationships with all children and parents, and
to proactively engage and sensitively follow-up vulnerable children and parents
who are at risk of ‘dropping out’. Weeks (2004) stresses the importance of the
physical environment in service delivery, and identifies ways of creating services
that are comfortable, safe, friendly and attractive for people who are facing family
difficulties in attending.
This Working Paper is an expanded and updated version of the following CCCH
Policy Brief published in 2006:
Centre for Community Child Health (2006): Services for children and families: An
integrated approach. CCCH Policy Brief 4. Parkville, Victoria: Centre for
Community Child Health, Royal Children’s Hospital.
http://www.rch.org.au/ccch/pub/index.cfm?doc_id=10475
12

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21

CONTACT DETAILS
Dr. Tim Moore
Senior Research Fellow
Centre for Community Child Health,
Murdoch Childrens Research Centre,
Royal Children’s Hospital, Flemington Road,
Parkville, Victoria, Australia 3052
Phone: +61·3·9345 5040
Fax: +61·3·9345 5900
Email: tim.moore@mcri.edu.au
Websites: www.rch.org.au/ccch
www.ecconnections.com.au
Working papers / WP2 - Rethinking universal and targeted services revised
28.8.08
22

Figure 1
TRADITIONAL SYSTEM
Figure 2
INTEGRATED SYSTEM
MAINSTREAM SERVICES
TARGETED SERVICES
TREATMENT
SERVICES
MAINSTREAM SERVICES
TARGETED
SERVICES
TREATMENT
SERVICES
• Specialist services are usually
located separately from
mainstream services
• Children have to meet certain
criteria to be eligible for specialist
services.
• There are more children needing
support than the specialist services
are able to accept, resulting in
referral bottlenecks and some
children not receiving help at all.
• Information tends to flow one way
only – from the mainstream
services to the specialist – and
collaboration between specialist
and mainstream services is limited
•
Specialist services have outreach
bases co-located with mainstream
and other specialist services
• Specialist services provide at least
some support in family and early
childhood settings
•
Specialist services work directly
with some ‘eligible’ children, and
provide consultant support for all
others
• Specialist services also provide
consultant support to mainstream
services on a broad range of child
and family issues
• Information flows both ways
between mainstream and specialist
services – they collaborate as
equal partners
23