EVOLUTION OF DEVELOPMENTAL PAEDIATRICS IN HONG KONG : A N OVERVIEW

HONG KONG PAEDIATRIC SOCIETY
E D U C A T I O N B U L L E T I N
ISSN 1028-6497
MARCH 2006
Editors: Dr. Sam SP LAU
Vol. 13 No. 1
Drs. KL Kwok, Karen L Kwong, TF Leung, KY Wong
EVOLUTION OF DEVELOPMENTAL PAEDIATRICS IN
HONG KONG: AN OVERVIEW
Dr. Chok Wan CHAN
President, Hong Kong Society of Child Neurology and Developmental Paediatrics
Developmental Paediatrics, an established paediatric
After much hard work in the following months on planning
subspecialty professionally, is designated to promote
the study and submitting the plans to various sponsors,
normal child development, to identify children with
Professor Field was delighted by the generosity of the
developmental needs, and to provide optimum environment
Nuffield Foundation of England who donated enough
for all children to attain their highest potentials. The
money for the first 3 years and, after which, the Social
subspecialty comprises of three major components:
Welfare Lotteries' Fund of Hong Kong Government
Developmental Screening (Surveillance) in a Community,
sponsored the subsequent 5 years. Terms of reference were
Comprehensive Developmental Assessment and Neuro-
to study the growth and development of Chinese children
Rehabilitation. The subspecialty evolved in Hong Kong
with particular reference to their social environment. To
over the past five decades and can be classified into the
carry out this study, the Medical and Health Department
Incubation Stage and the Maturation Stage according to
generously provided accommodation on half a floor in
the chronological development of events.
the Jockey Club Polyclinic in Yaumatei, Kowloon, where
the first "Child Development Centre" was established.
Incubation Stage
Budding
Germination
At this time there were no Child Developmental
This started when Dr. Flora Baber came to Hong Kong
Assessment Clinics in Hong Kong, Dr. Baber recruited
from Uganda (East Africa) in November 1962 and went
and trained a Chinese medical officer, Dr Wong Yuk Sau,
to meet Professor C Elaine Field in her tiny office in Queen
and 4 nursing staff via meetings designated to discuss
Mary Hospital. Professor Field had just arrived in Hong
methods and procedure for assessing child growth and
Kong 6 months earlier as first holder of the chair of
development of Hong Kong children. The aim was to
Paediatrics in the University of Hong Kong. In view that
recruit a random sample of all babies born in Kwong Wah
there were no standards of growth and development for
and Queen Elizabeth Hospitals over a period of 6 weeks
Chinese infants and pre-school children, the two pioneers
with the objectives to include a representative sample of
were keen to promote a longitudinal study on growth and
the population of Hong Kong. Six months before the study
development of Hong Kong children. The problems then
commenced Dr. Baber recruited 50 newborn babies from
were funding, venue and resources. The Professor of
the same hospitals to act as controls (prototype), and to
Anatomy, Professor KSF Chang and his staff were engaged
try out the procedures on the babies and questionnaire on
in anthropometric, cross-sectional studies of Chinese
the mothers to ensure that both were acceptable.
school children at the time except that younger children
were not included.
The design of the main study was to have a cohort of
"regular attenders" of at least 500 babies, examined as
Whilst working in the Medical Research Council's Infantile
soon as possible after their births. 782 babies were
Malnutrition Research Unit in Kampala, Uganda from
recruited between the end of February and beginning of
1950-61, Dr. Flora Baber had been studying the
April 1967. From this cohort after 3 years, Dr. Baber
development of African babies with Dr. Marcelle Geber,
selected 542 "regular attenders", who were seen
a French child psychiatrist, who found that African babies
approximately every month in their first year; every 3
from rural homes, brought up in the traditional way (i.e.
months in their 2nd & 3rd years; every 6 months in their
breast fed and personally nursed by their mothers), were
4th & 5th years and annually thereafter for statistical
significantly more advanced in their motor development,
analysis. This was efficiently carried out by two prominent
in comparison with babies in urban areas, from well-to-
consultant statisticians, the late Mr. WZ Billewicz and
do families who were artificially fed and left in their cots
Professor AM Thomson in the MRC's Reproduction and
between feeds. At the time the difference between the types
Growth Unit, Newcastle-upon-Tyne in England.
of f eeding was not appreciated. Her method of
developmental assessment was that of Drs O Brunet and
Unfortunately the time scale corresponded with the onset
I Lezine. This same method was being contemporarily used
of the cultural revolution in China. Repercussions were
by 8 different centers in Europe, Scandinavia and West
felt in Hong Kong, when at one point there was no public
Africa in collaborative studies of child development.
transport in Kowloon. Recognising the difficulties for
Professor Field and Dr. Baber decided to use this method
many of the families in coming to the clinic, Dr. Baber
of assessment for Chinese babies as it had no cultural bias.
and her Team offered them "Home Assessments"
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H.K. PAEDIATRIC SOCIETY EDUCATION BULLETIN
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(Outreach Service as what we call nowadays). A maximum
Implementation and Outcome
of 260 of these were carried out approximately every
Dr. Baber recalled as many as possible on or around their
3 months for 5 years, when traffic congestion forced the
15th birthday and 228 children attended the follow-ups.
Team to abandon these in favour of annual visits to the
Although the majority of parents of the original cohort
clinic for all the remaining children.
had less than primary or no education, the aspirations of
both girls and boys at 15 years was impressive. Encouraged
At the onset of the study in 1967 Hong Kong was severely
by their parents & grandparents to do their best in studying
overcrowded, mainly by refugees from China, in spite of
at school, many of these children were ambitious to excel
the considerable fall in the birth rate promoted by the
and improve their own and their families' fortunes. The
Family Planning Association. The majority of these
physical growth of both sexes showed evidence of a
families were living in cramped, overcrowded conditions
significant secular trend.
in tenement buildings; old style resettlement "H" blocks;
squatter huts and roof-top dwellings.
Maturation Stage
Growing
Developmental Paediatrics in Hong Kong: The Early
Naturally, one of the major objectives of the Child
Days
Development Study was to find out effect of these
At the beginning of this study, there was no evidence of
environmental conditions on the development of Hong
any interest in developmental paediatrics in Hong Kong.
Kong children and the following significant observations
As in so many other countries it is a "Cinderella" specialty,
were made during the follow-up.
lacking the drama and challenge of acute clinical & surgical
paediatrics, it was considered to be dull & unattractive.
Initially, for the first 3 months, Dr. Baber found the young
But in the early years of the study, there was upheaval of
babies, were co-operative (before they recognized
interest internationally in developmental screening tests
strangers!) and relatively well-nourished, particularly those
for young children and importance of early detection of
who were breast fed. But as they grew older towards
abnormalities amenable to treatment.
toddlerhood they became inhibited and uncooperative,
particularly the girls. These children were seldom taken
It was the custom in the 1960's in Hong Kong, for families
outside their dark, crowded and ill-ventilated homes except
to keep children with obvious developmental defects
to go to market. (Television had not arrived yet!) The Team
confined to their homes away from the public eye, cared
was alarmed at their loss of weight between 4-6 months
for by an elderly relative or in some cases abandoned
which corresponded with a high incidence of infection and
altogether, as the staff of Po Leung Kuk children's home
the weaning period, when many babies were offered a bowl
would testify. After a home visit, on one occasion the Team
of watery congee as a substitute for milk. Baber and Field
met a distressed mother who asked Dr. Baber to "test" her
published their first book "Growing Up in Hong Kong" to
5-year-old daughter, who had just been rejected by
draw attention to this problem. The weight loss in these
3 schools; "Because she cannot speak properly", her mother
babies was compounded by a seasonal effect. It was most
said and added: "I know she is not stupid!" The child was
marked in the height of summer and there was an attempt
later assessed and found to be highly intelligent with
to "catch up" in the cooler winter months.
profound hearing impairment. Dr. Baber referred her to
the school for the deaf, which was in its infancy stage. The
The difficulty facing the Team, as the children grew older
child grew and developed well thereafter. Nowadays, it is
from 3-5 years and beyond, was to find appropriate
totally unacceptable if a child's hearing loss should be
developmental tests that were not culturally biased. In the
missed by the age of five years old because there are good
end they chose the Wechsler Pre-School & Primary Scale
surveillance systems in the community to ensure early
of Intelligence as it has an equal number of Verbal &
identification such as the newborn hearing screening tests,
Performance Tests. The latter proved to be popular with
The Developmental Screening Test in the Community, the
the children. In their fourth & fifth years many of the
health education on Early Warning Signs for Hearing
children were still inhibited, particularly in answering
Impairment to parents and the public, and close vigilance of
verbal tests. For this reason the Team could only use the
Pre-School & Primary school teachers who will recognize
results for 6-year-old children.
the problem and take appropriate action accordingly.
As the terms of reference for the Survey Team were to
There were also speech problems in several children in
study the effect of the social environment on the
the survey. Fortunately the Assessment Team had an
development of our children, the nurses asked the mothers
excellent speech therapist sharing the same floor. Only
about the child's health, new additions to the family, the
one of 6 referred children attended for treatment more than
care of the child, including sleeping arrangements, and
once. The mothers failed to appreciate the importance of
discipline at home and school at each clinic visit. In the
regular attendance for therapy to ensure optimum results
first few years, migration of families was the norm, when
to be achieved. When one child reached primary school
difficulties with neighbours living in such close proximity,
age, her mother returned hoping for an "immediate cure"
sharing cooking, washing and toilet facilities created
as the teacher had rejected the child as she "could not
problems. By the fifth year, in 1972, many of the families
understand him".
had moved out of their ill-ventilated, cramped quarters to
much improved self-contained flats in both private and
Whilst the Team was preparing for the study, Professor
public housing. The effect of these social changes,
Field was concerned with the lack of facilities for ongoing
accompanied by a dramatic rise in the family income of
treatment for children with cerebral palsy of all grades. In
all social groups was self-evident, not only in the more
the early days severely affected children were kept at home
outgoing behaviour of the children, but in their "catch up"
away from the public eye. Naturally their deformities grew
growth. By the time of their last visit to the Clinic, around
worse as the authorities did not appreciate their mobility
their ninth birthday, there was evidence of a significant
problems. Frequently the families had to accept a home
secular trend in their growth in all parameters, especially
higher than ground level where there were no lifts. As the
in the boys.
children grew older their difficulties increased. They
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H.K. PAEDIATRIC SOCIETY EDUCATION BULLETIN
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received no physiotherapy. The result was spastic and
Kong onto the world map of child health in that it is one of
functionless limbs. The Duchess of Kent Children's
the few screening tests to be launched on community basis
Hospital in Sandy Bay, Hong Kong Island, had very good
and that it is the ONLY test given free of charge to all
physiotherapists in those days, but transport difficulties
babies at preschool age globally. It remains one of the
were formidable. The solution was a residential school for
great achievements jointly hosted by local paediatricians
these children, as well as the training of more physiotherapists
and the Hong Kong Government.
& occupational therapists in special day schools around
the territory for which the Spastic Children's Association
Developmental Assessment Service in Hong Kong
of Hong Kong was founded. The British National Spastics
When the first Child Assessment Service was first
Association, (now called "SCOPE") gave a generous
inaugurated, the Arran Street Child Assessment Centre had
donation; enough to start a small school for 11 out of 30
only 2 doctors seconded from a paediatric unit of the Queen
children assessed, in premises kindly loaned by the Boys
Elizabeth Hospital. In addition to providing clinical service,
& Girls' Club. The chief publicity organizer, Mrs Li Fook
the assessment centre undertook teaching of medical
Shu was able to stage a premiere film show of "Thomas a-
students and postgraduate training of doctors in paediatrics.
Becket", which was attended by the Governor and elites
Assessment tools and parent education packages suitable
of Hong Kong. It raised a substantial amount of money, as
for local use were also developed. By May 2005, there
well as publicity for the work of the Association. Soon
were a total of 8 assessment centres in Hong Kong, 7 of
afterwards an American philanthropist visited Hong Kong
which being run by the Department of Health of the Hong
looking for a suitable project to support. He gave enough
Kong SAR Government under Consultant Paediatrician
funds for the residential school "the JF Kennedy Centre"
Dr. Catherine CC Lam and the other one at Sandy Bay by
to be built. Since then the Spastic Children's Association
the Department of Child and Adolescent Medicine of The
has been running special day schools around the territory.
University of Hong Kong under Professor Virginia Wong.
By then the public was more aware of the problems of
such children and fewer of them were needlessly confined
Scope of developmental paediatrics also grew in response
to their homes untreated.
to society‘s demands for quality of survival and to growth
of current medical knowledge. In addition to the traditional
Evolution of Developmental Paediatrics in Hong Kong:
(more physical) aspects of development, the child’s
Recent Development
psychological and social development also received due
The importance of developmental paediatrics in the
attention. The "holistic" approach was further pursued by
rehabilitation of children with disabilities was established
including consultations by visiting specialists (such as
in 1977 when the Hong Kong Government, upon the advice
ophthalmologists, clinical geneticists), joint consultative
of Professor K S Holt (Director of Wolfson Centre, Institute
clinics (with paediatric neurologists, paediatric psychiatrists,
of Child Health, University of London), implemented the
orthopaedic surgeons, ENT specialists) as well as by
White Paper on Comprehensive Observation Scheme for
increasing liaison with other clinical units and the plethora
early identification of children with developmental delays.
of rehabilitation services in Hong Kong. Rehabilitation of
This is a monumental milestone for Developmental Paediatrics
the child with special developmental needs (formerly known
in Hong Kong because this is the year the Medical and
as chronic disabilities), while still based on child development
Health Department of the Hong Kong Government
principles, shifted from dependence on professionals to the
inaugurated two major events in Hong Kong: Universal
empowering of parents. To this aim, toy and parent resource
Developmental Screening Tests for all Preschool Children
libraries were set up, parent support and parent self-support
in Hong Kong at the Maternal Child Health Centres free
groups were conducted, and parents were given guidance
of charge under the then Principal Medical Officer Dr.
through seminars, workshops and telephone consultations
Betty Eo-Yang, and the grand opening of the first
with good rapport.
multidisciplinary Child Assessment Centre at Arran Street
to provide developmental assessment for children with
It is most unfortunate that the good liaison and cooperation
developmental problems. Dr. Lillian Ko was the first
between assessment centres and hospital paediatric units
Consultant-in-Charge of the Centre and succeeded by Dr.
suffered a serious setback when in 1989 the Medical and
Rose Mak for another 18 years with outstanding
Health Department was bifurcated into the Department of
achievements. Dr. Catherine CC Lam is currently
Health (to which the seven government assessment centres
Consultant-in-Charge of Child Assessment Service and has
belong) and the Hospital Authority (to which the other
significantly revamped the Service to meet challenges and
assessment centre and hospital paediatric units belong).
needs of the Hong Kong community in the 21st century.
Such a severance, brought about by short-sighted and
inexperienced bureaucrats, hampered significantly the close
Universal Developmental Screening Tests in a Community
communication and coordination between the two closely-
From the results of the Ad-hoc Longitudinal Developmental
linked components of the service essential for the proper
Study by Field and Baber, a screening test based on the
functioning of the subspecialty of developmental paediatrics.
format of the Denver Developmental Screening test (of
History will bear witness to the detrimental effect on the
Frankenberg et al) for the first 3 years was compiled with
optimum development of the subspecialty created by such
the format modified to correspond with "the Woodside
misguided administration change without consultation of the
System" of JH Barber of Glasgow. This system, designed
profession!
by Chan, Baber and Hutchison from the Department of
Paediatrics, The University of Hong Kong and known as
The Hong Kong Society of Child Neurology and
the "Hong Kong Developmental Screening System", was
Developmental Paediatrics
launched officially in Hong Kong in 1982 for use in all
The Hong Kong Society of Child Neurology and
Maternal and Child Health Centres. More than 100,000
Developmental Paediatrics started as an "interest group"
children received these screening tests annually over the
in 1992 and officially inaugurated in April 1994 with the
past twenty-five years. Analysis of screening data yielded
objectives to promote the standard of practice and
encouraging results and successful outcome achieving the
professional image of the two subspecialties of child
ultimate objectives of early identification of children with
neurology (CN) and developmental paediatrics (DP), to
developmental delays! The Test successfully put Hong
provide assistance to and cooperate with other medical
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H.K. PAEDIATRIC SOCIETY EDUCATION BULLETIN
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professionals, and to act as advocates for children suffering
Centre (ASCAC) of CAS from 1978 to 1982, in children
from diseases related to the subspecialties of CN and DP.
aged 0-11 years with an average of 650 referrals per year,
mental retardation was the most common disability
Since its inauguration ten years ago, the Society has made
occurring in 56.9%, while cerebral palsy occurred in 18.
significant contributions to the subspecialties of child
7%, severe-profound hearing loss in 6.4%, autism in 2.6%
neurology and developmental paediatrics via its regular
and blindness in 1.4%. In addition, there were 16.2% with
scientific activities and public lectures by guest speakers
specific speech disorders. 65% of children referred were
(and thereby also providing excellent opportunities for
between 1-4 years, with 88% under 6 years. These revealed
continuing medical education). The Society strove to
the state of assessment and placement needs for children
establish a central registry for local diseases within the
who had severe unmet developmental needs at that time.
subspecialties and endeavour to promote collaborative
From 1995, the categories of disabilities in the White Paper
research efforts among clinical units. It created joint
on Rehabilitation were revised to also include autism,
consultative clinic conferences for discussing clinical
speech impairment and visual disabilities, while learning
problems, reviewed current practice and standards for the
difficulties and later maladjustment were excluded. During
two subspecialties in Hong Kong, published Brainchild
this period, less visible developmental disorders have
(Society's official professional publication) and
become increasing recognized. While these conditions may
Manuals on Child Neurology and Developmental
not affect the individual in all aspects of basic activities of
Paediatrics respectively, as well as provided advice and
living, they cause serious disablement and exclusion from
recommendations to the Hong Kong College of
participation in important areas of development, including
Paediatricians regarding both basic and higher training
learning and social participation. These include
within our subspecialties. In addition to such heavy
developmental dyslexia (within the SLD group of
engagements in professional affairs, the Society has been
disorders), attention deficit disorders, and the fuller
proactive in realizing its role as child advocate. Its effort
spectrum of autistic spectrum disorders. In 2004, 6439
and achievements on "Myoblast Transplant in Duchenne
children were referred for assessment. 75% of these were
Muscular Dystrophy", "Rights and Welfare for Children
under 6 years. Their diagnoses showed a significantly
with Specific Learning Disabilities (SLD) and
different profile: mental retardation was seen in 8.4%,
"Iodinization of Table Salts in Hong Kong" all bear
borderline developmental delay in another 17.7%, language
permanent testimony of the Society's dedications.
and speech delay and disorders in 30.2%, specific learning
Throughout these years, the Society worked as one
disabilities in 12.1%, attention problems and disorders in
functional unit, and has the unique feature whereby
10.2%, and autistic spectrum disorders in 8.8%. Traditional
activities served to bridge the gap between paediatricians
serious and visible impairments were found in 0.6% with
practising within institutions and in the private sector:
cerebral palsy, 0.2% with blindness and 0.6% with
a most cost-effective way to utilize local manpower and
significant hearing impairment.
resources establishing good prototypes for harmonious
collaboration and cooperation between the two sectors in
Secular changes observed can be ascribed to a number of
Hong Kong. The Society is very proud of its progress and
medical, educational and societal factors. Improvement
achievements and is confident that, with determination and
in prevention of disabling conditions, including through
dedication, new horizons will be reached for Child
improved prenatal diagnosis, antenatal and perinatal care,
Neurology and Developmental Paediatrics in Hong Kong!
effective immunization programmes, injury prevention,
early treatment of illnesses such as cataract and infections,
Developmental Paediatrics Today: Some Local Statistics
have led to progressive decrease in serious disabilities.
in Hong Kong
Increased public awareness of developmental problems
From the experience of Child Assessment Service of the
and raised expectations by parents and the public have
Department of Health of the Hong Kong SAR Government
brought forth children with less severe intellectual and
(7 assessment centres out of total of 8 within the SAR),
behavioural problems. Improvement in professional
the number of new cases of children aged between 0 to 12
understanding of conditions such as specific learning
years requiring developmental assessment rose from 2374
disabilities, attention deficit disorders and high function
in 1994 to 6439 in 2004. This increase is witnessed against
autistic spectrum disorders have allowed earlier and more
the background of a fall in the number of children aged
accurate diagnosis and effective management.
0 to 15 years from 1.2 million to 1.04 million during these
10 years. A Central Registry for Rehabilitation (CRR) of
As citizens of a developed city, Hong Kong's children
Hong Kong was established in 1982 to collect and compile
should be provided with the highest standards of health
information on people with disabilities in Hong Kong
care. Maximizing their development in physical, intellectual
through relevant government departments and non-
and emotional domains is the duty not only of the parents,
governmental organizations with a view to providing
but also of those taking care of them, and of course of
statistics on disability to Government and NGOs for the
paediatricians who are their guardians and advocates.
planning and delivery of rehabilitation services and
research purposes. Registration with the CRR is on a
Link List:
voluntary basis and is known to have serious problems
1)
Department of Health/HKSAR Government:
with under reporting. 6542 children 0-14 years old
www.dh.gov.hk
a) Child Assessment Service: Tel 2246 6633
registered with disabilities in 2004, representing 0.63%
b) Family Health Service: Tel 2961 8855
of the population of this age range, significantly lower
2)
The University of Hong Kong: Duchess of Kent Child
than rates quoted for developmental problems today.
Assessment Centre, Tel: 2974 0331
Categories of disabilities in the 1980's and early 1990's
3)
Social Welfare Department/HKSAR Government: www.
included mental handicap, physical handicap, hearing
info.gov.hk/swd, Tel: 2343 2255
4)
Education & Manpower Bureau (EMB) /HKSAR
impairment, visual impairment, mental illness,
Government: http://serc.emb.gov.hk, Tel: 28910088
maladjustment and learning difficulties (referring to a
5)
Hospital Authority: www.ha.org.hk, Tel: 2300 6555
mixed group of children with education difficulties due to
6)
Heep Hong Society: www.heephong.org,
low intelligence, specific learning difficulties and transient
Tel: 2776 3111
factors that lead to underachievement in school). These
7)
Overseas: www.med.umich.edu/1libr/yourchild/devdel.htm
categories largely reflected disabilities that were recognized
To obtain the list of references please contact author at
by and visible to the public. At Arran Street Child Assessment
M-10, Hennessy Centre, 555 Hennessy Road, Hong Kong
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