Health Needs and Use of Services Among Children with Developmental Disabilities - United States, 2014-2018.

Developmental delays, disorders, or disabilities (DDs) manifest in infancy and childhood and can limit a person's function throughout life* (1-3). To guide strategies to optimize health for U.S. children with DDs, CDC analyzed data from 44,299 participants in the 2014-2018 National Health Interview Survey (NHIS). Parents reported on 10 DDs,† functional abilities, health needs, and use of services. Among the approximately one in six (17.3%) U.S. children and adolescents aged 3-17 years (hereafter children) with one or more DDs, 5.7% had limited ability to move or play, 4.7% needed help with personal care, 4.6% needed special equipment, and 2.4% received home health care, compared with ≤1% for each of these measures among children without DDs. Children with DDs were two to seven times as likely as those without DDs to have taken prescription medication for ≥3 months (41.6% versus 8.4%), seen a mental health professional (30.6% versus 4.5%), a medical specialist (26.0% versus 12.4%), or a special therapist, such as a physical, occupational, or speech therapist, (25.0% versus 4.5%) during the past year, and 18 times as likely to have received special education or early intervention services (EIS) (41.9% versus 2.4%). These percentages varied by type of disability and by sociodemographic subgroup. DDs are common, and children with DDs often need substantial health care and services. Policies and programs that promote early identification of children with developmental delays and facilitate increased access to intervention services can improve health and reduce the need for services later in life.§ Sociodemographic inequities merit further investigation to guide public health action and ensure early and equitable access to needed care and services.

Prevalence and predictors of expulsion in home-based child care settings.

This study explored the prevalence of expulsion in home-based child care (HBCC) settings using a nationally representative sample of HBCC providers from the National Survey of Early Care and Education. In addition to prevalence, enrollment and provider characteristics that predicted expulsion were examined. Although there is increasing awareness of the prevalence of early childhood suspension and expulsion in early care and education settings and the negative effects it has on children's development, few studies have included or focused on HBCC, where many children receive care. This study highlights that many home-based providers, especially listed providers, report that they expelled at least one child within the last year. Significant predictors of expulsion emerged, including enrollment characteristics such as caring for children with disabilities, enrolling more children, and caring for children unrelated to the provider. Provider characteristics, including years of experience, provider education, and provider age, also predicted provider report of expulsion. These results provide insight as to possible strategies that may be effective in reducing expulsion rates in this caregiving context.

Este estudio exploró la prevalencia de expulsión en escenarios de cuidado infantil con base en el hogar usando una muestra nacionalmente representativa de proveedores de cuidado infantil con base en el hogar de la Encuesta Nacional de Cuidado y Educación Temprana. Además de la prevalencia, se examinaron el número de inscripciones y las características del proveedor que predecían la expulsión. A pesar de que aumenta el conocimiento acerca de la prevalencia de la suspensión y expulsión en la temprana niñez en escenarios de cuidado y educación temprana y de los efectos negativos que la misma tiene en el desarrollo de los niños, pocos estudios han incluido o se han enfocado en el cuidado infantil con base en el hogar, donde muchos niños reciben el cuidado. Este estudio subraya el hecho de que muchos proveedores con base en el hogar, especialmente proveedores que son parte de una lista, reportan que ellos expulsaron por lo menos un niño dentro del último año. Surgieron significativos factores de predicción de la expulsión, incluyendo características de la inscripción tales como el cuidar a niños con discapacidades, el inscribir a más niños y el cuidar a niños que no están relacionados con el proveedor. Las características del proveedor, incluyendo los años de experiencia, la educación del proveedor y la edad del proveedor, también predijeron el reporte del proveedor sobre la expulsión. Estos resultados aportan una percepción en cuanto a las posibles estrategias que pudieran ser efectivas para reducir el porcentaje de expulsión en este contexto de prestación de cuidado.

Cette étude a exploré la prévalence de l'expulsion dans les contextes de crèches à domicile / familiales en utilisant une échantillon représentatif de l'Inventaire national américain des crèches et des institutions éducatives appelé National Survey of Early Care and Education. En plus de la prévalence, l'admission et les caractéristiques de l'assistante maternelle prédisant l'expulsion ont été examinées. Bien qu'il y ait une prise de conscience de la prévalence de la suspension et de l'expulsion de la petite enfance dans les contextes de modes de garde de l'enfant ainsi que des effets négatifs que celles-ci peuvent avoir sur le développement de l'enfant, peu d'études ont porté sur les soins en crèches familiales, où beaucoup d'enfants sont accueillis. Cette étude met en évidence le fait que bien des crèches familiales, et surtout celles qui apparaissent sur les listes de crèches, signalent avoir renvoyé au moins un enfant en une année. Des facteurs de prédiction importants ont émergé, y compris les caractéristiques de l'inscription et de l'admission comme le fait de prendre soin d'enfants handicapés, le fait d'accepter plus d'enfants, et le fait de prendre soin de plus d'enfants sans lien avec la crèche. Les compte rendus d'expulsion montrent que les caractéristiques de l'assistante maternelle, y compris les années d'expérience, l'éducation, et l'âge étaient également des facteurs de prédiction d'expulsion. Ces résultats donnent une idée de stratégies possibles qui peuvent s'avérer efficaces pour la réduction des taux d'expulsion dans ce contexte de mode de soin.

Race/ethnicity, human capital, and the selection of young children into early childhood education.

Mexican-origin families face complex ethnic and immigration-based barriers to enrollment in early childhood education programs. As such, reducing barriers to enrollment for this population requires a better understanding of how Mexican-origin families work with, against, or around both general and group-specific constraints on educational opportunities. Using the Early Childhood Longitudinal Study-Birth Cohort, this study tailored broad social theory to the experience of Mexican-origin families to examine associations between human capital considerations and early childhood education enrollment within this population. Results supported the hypothesis that human capital considerations would be associated with early childhood care and education and provide limited evidence for the expectation that this link would be stronger for Mexican-origin families.

Causal Learning Across Culture and Socioeconomic Status.

Extensive research has explored the ability of young children to learn about the causal structure of the world from patterns of evidence. These studies, however, have been conducted with middle-class samples from North America and Europe. In the present study, low-income Peruvian 4- and 5-year-olds and adults, low-income U.S. 4- and 5-year-olds in Head Start programs, and middle-class children from the United States participated in a causal learning task (N = 435). Consistent with previous studies, children learned both specific causal relations and more abstract causal principles across culture and socioeconomic status (SES). The Peruvian children and adults generally performed like middle-class U.S. children and adults, but the low-SES U.S. children showed some differences.

How Does Context Relate to Nutrition Promotion and Mealtime Practice in Early Care and Education Settings? A Qualitative Exploration.

BACKGROUND: Early childhood educators have the potential to influence children's dietary outcomes through daily interactions. However, existing research suggests that educator practices are often suboptimal. Previous research has often focused on individual characteristics that affect practices. There is less study of contextual influences of practices of early childhood educators. OBJECTIVE: The purpose of this study was to understand and describe contextual factors evident in narratives of early childhood educators influencing mealtime and nutrition promotion practices. We use the Promoting Action on Research Implementation in Health Services framework to consider how contextual factors related to practices of early childhood educators. DESIGN: This cross-sectional, qualitative study collected data through in-depth interviews with early childhood educators. Analyses of the data reflected a factist perspective and semantic approach to complete thematic content analysis of in-depth interviews. PARTICIPANTS: The study used a stratified purposive sampling approach to recruit 28 educators to balance across educator role, agency type (Head Start vs state-funded), and obesity prevalence in the community. Early childhood educators were mostly lead teachers (62%), between the ages of 30 and 49 (82.1%), and white (75%) or African American (14.3%). RESULTS: The coders identified three primary themes: Mealtime Structures, Resources, and Classroom/Center Atmosphere. Mealtime Structures associated with detrimental practices included cafeteria meals with rigid schedules. Mealtime Structures associated with evidence-based practices (EBPs) included classroom meal service. Resources associated with detrimental practices included limited funding. Resources associated with EBPs included meals paid for early childhood educators and classroom food experiences. Classroom/Center Atmosphere factors associated with detrimental practices included poor food offerings and policies that conflicted (eg, allowing children to bring in outside foods). Classroom/Center Atmosphere factors associated with EBPs included clarity around meal service rules and healthy, appealing food offerings. CONCLUSIONS: This study highlighted that it may be difficult for an early childhood educator to adopt and maintain EBPs in certain contexts.

[One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention]. / One size fits all? Die Eignung von Risikoscreenings zur Prognose der Inanspruchnahme von Angeboten der Frühen Hilfen.

One Size Fits All? Using Psychosocial Risk Assessments to Predict Service Use in Early Intervention and Prevention Early intervention and prevention services offer a variety of programs. At the same time, program participants differ widely in their service use. This study aims at investigating the prognostic validity of psychosocial risk assessments in predicting the participants' service use. The psychosocial risk assessment "Heidelberg Stress Scale" is used to predict aspects of service use (dosage, attrition, intervention content, working relationship). Service use data of N = 1.514 participants of a home-visiting program will be analyzed via Machine-Learning-Algorithms. Dosage and intervention content can be predicted with psychosocial risk assessments. The classification strength is small. Global and continuous risk scales have a prognostic advantage over single categorical risk items. Financial burden has a significant influence on every aspect of service use. Psychosocial risk assessments provide additional information that can support intervention planning. Yet, these instruments should be supplemented by additional diagnostic information.

Limited access to special education services for school-aged children with developmental delay.

BACKGROUND: Current policy in Oregon limits eligibility of children diagnosed with developmental delay for school-based services. Due to eligibility definitions, children with developmental delay may face additional barriers transitioning from early intervention/early childhood special education into school-based special education services. AIMS: Examine the relationship between enrollment in school-based special education programs given a change in primary disability diagnosis. METHODS: Logistic regression models were fit for children who enrolled in early intervention/early childhood special education services with a primary disability diagnosis of developmental delay and changed primary disability diagnosis before third grade (n=5076). RESULTS: Odds of enrollment in future special education were greater in children with a change in primary disability diagnosis after the age of five in comparison to children that had a change in primary disability diagnosis before the age of five, while adjusting for demographic characteristics (adjusted odds ratio: 2.37, 95% CI 1.92, 2.92). CONCLUSION: Results suggest that children who are diagnosed with a developmental delay and exit early childhood special education due to maximum age of eligibility are more likely to enroll in special education compared to children without a gap in service access. IMPLICATIONS: Gaps in service access during early development are associated with the need for supportive services later on in life.

Head Start Oral Health Assessment.

PURPOSE: A Head Start program located in Paterson, New Jersey considered establishing a school-based dental clinic to address unmet oral health needs such as access to care and the need for restorative treatment. The purpose of this study was to establish the oral health status of Head Start children, their treatment needs, and parents' interest and willingness to utilize a school-based dental clinic. DESCRIPTION: School-based dental care has been used to address access to care issues, particularly among children who live in underserved areas. A 21 item survey was used to correlate the results of an oral exam performed on the Head Start children and the parents' preferences, beliefs and access patterns. Fisher's exact test and Chi squared test were used to study the association among variable with significance levels set at 0.05. Assessment The oral exam revealed a high caries rate amongst all of the children. Parental responses indicated strong support for the establishment of a school-based clinic and identified the need for further parental education. Having a regular source of care was found to be unrelated to treatment needs. CONCLUSION: Further education of the parents regarding the child's oral health is critical to the success and viability of this school-based clinic.

Factors Affecting Early Services for Children Who Are Hard of Hearing.

PURPOSE: To describe factors affecting early intervention (EI) for children who are hard of hearing, we analyzed (a) service setting(s) and the relationship of setting to families' frequency of participation, and (b) provider preparation, caseload composition, and experience in relation to comfort with skills that support spoken language for children who are deaf and hard of hearing (CDHH). METHOD: Participants included 122 EI professionals who completed an online questionnaire annually and 131 parents who participated in annual telephone interviews. RESULTS: Most families received EI in the home. Family participation in this setting was significantly higher than in services provided elsewhere. EI professionals were primarily teachers of CDHH or speech-language pathologists. Caseload composition was correlated moderately to strongly with most provider comfort levels. Level of preparation to support spoken language weakly to moderately correlated with provider comfort with 18 specific skills. CONCLUSIONS: Results suggest family involvement is highest when EI is home-based, which supports the need for EI in the home whenever possible. Access to hands-on experience with this population, reflected in a high percentage of CDHH on providers' current caseloads, contributed to professional comfort. Specialized preparation made a modest contribution to comfort level.

The relationship between treatment attendance, adherence, and outcome in a caregiver-mediated intervention for low-resourced families of young children with autism spectrum disorder.

Rates of participation in intervention research have not been extensively studied within autism spectrum disorder. Such research is important given the benefit of early intervention on long-term prognosis for children with autism spectrum disorder. The goals of this study were to examine how family demographic factors predicted treatment attendance and adherence in a caregiver-mediated randomized controlled trial targeting core deficits of autism spectrum disorder, and whether treatment attendance and adherence predicted outcome. In all, 147 caregiver-child dyads from a low-resourced population were randomized to in-home caregiver-mediated module or group-based caregiver education module treatment. Treatment attendance, adherence, and outcome (time spent in joint engagement) were the primary outcome variables. The majority of families who entered treatment (N = 87) maintained good attendance. Attendance was significantly predicted by socioeconomic status, site, and treatment condition. Families in caregiver-mediated module reported lower levels of treatment adherence, which was significantly predicted by site, condition, caregiver stress, and child nonverbal intelligence quotient. Dyads in caregiver-mediated module had significantly longer interactions of joint engagement, which was significantly predicted by an interaction between treatment attendance and condition. Overall, the results from this study stress the importance of considering demographic variables in research design when considering barriers to treatment attendance and adherence.

Variation in Educational Services Receipt Among US Children With Developmental Conditions.

OBJECTIVE: To examine the relationship between ease of access to needed community-based services (ease of access) and educational services receipt, and variation in educational services receipt by sociodemographic and need factors among a nationally representative sample of children with autism spectrum disorder (ASD), developmental delay (DD), and/or intellectual disability (ID). METHODS: Data from the 2009-2010 National Survey of Children with Special Health Care Needs were linked to the 2011 Survey of Pathways to Diagnosis and Services on a sample of 3502 US children aged 6 to 17 years with ASD, DD, and/or ID. Descriptive statistics, chi-square tests, and multivariable logistic regression models were used to determine associations of educational services receipt with ease of access and sociodemographic and need factors. RESULTS: Among children with developmental conditions, nearly half (49.7%) lacked easy access to services, and 16.9% did not have an individualized education program (IEP). Among children with an IEP, those with ease of access were more likely to have an IEP that addressed parent concerns about the child's development and education than those unable to easily access services (adjusted odds ratio 2.77; 95% confidence interval 1.71-4.49). Need factors, including functional limitations status, care coordination need, developmental condition type, and early intervention receipt, were significantly associated with educational services receipt. CONCLUSIONS: Cross-systems initiatives facilitating service access remain important to ensuring the developmental needs of children with ASD, DD, and/or ID are met. Increased interprofessional collaboration promoting quality educational services receipt for children diagnosed with developmental conditions may further reduce disparities.

Youth engagement with an emerging Irish mental health early intervention programme (Jigsaw): participant characteristics and implications for service delivery.

BACKGROUND/AIMS: The transition to adulthood represents a critical period which influences mental health problems, but access to and utilisation of mental health services by young people is poor. Jigsaw is a response to the challenge of transforming how young people access mental health support and attain positive outcomes. This article presents an overview of the characteristics of young people engaging with this service. METHOD: Data about young people who engage with Jigsaw are captured through an online system designed to record salient clinical, case management, service delivery, and outcome information. Participant characteristics are summarised to portray the young people who engaged with the service for the first time during 2013 (N = 2420). RESULTS: The majority of young people engaging with Jigsaw were female, aged 15-17 years, and were referred by their parents. Over half were in full-time education, although many 21-25-year-olds were unemployed. Young people presented with a range of difficulties which varied by age and gender. They reported high levels of distress, with age and gender having a significant impact on their well-being. CONCLUSIONS: This study provides emerging evidence to support the need for an early intervention component within the system of mental health care.

The Incredible Years Parent-Toddler Programme and parental language: a randomised controlled trial.

BACKGROUND: Parental language is associated with children's later language development. Parenting programmes, based on social learning theory, enhance a range of parenting behaviours, yet there is limited evidence for their effect on parental language. AIM: To assess the benefits of a behavioural-based parenting programme, which features components of language and communication, to enhance parental language. METHOD: Parents of toddlers, aged 12 to 36 months, were recruited from eight Flying Start early intervention centres across Wales. Participants were randomised 2:1 either to a parenting programme (n = 60) or to a wait-list control group (n = 29). Researchers were blind to participant allocation throughout the trial. Fifteen-minute video-recorded observations of parents and children interacting during free-play, both at a pre-intervention and at 6-month follow-up, provided the data for the study. Five observed measures of parental language were assessed; quantity and variety, encouraging, critical, child-led and parent led interactions. INTERVENTION: The Incredible Years Parent-Toddler Programme (IYPTP) is a 12-week group-based behavioural intervention that teaches effective relationship and behavioural management skills including social, emotional and persistence coaching to enable parents to better support their children's development. RESULTS: Of 89 dyads that completed pre-intervention assessments 81 (54 intervention and 27 control) met the criteria for the current study. Intention to treat analysis indicated that child-led language interactions significantly benefited from the intervention [regression coefficient (B) = -1.44, 95% confidence intervals (CI) = -2.59 to -0.29, P = 0.015, effect size (ES) = 0.47] and a positive trend for encouraging language in favour of the intervention sample was evident. Per-protocol sample analysis replicated these findings with encouraging language reaching statistical significance (B = 1.07, 95% CI = 0.11 to 2.03, P = 0.03, ES = 0.52). No further benefits were evident. CONCLUSIONS: The IYPTP has limited evidence as an effective programme for enhancing some aspects of parental language.

Effects of simulated interventions to improve school entry academic skills on socioeconomic inequalities in educational achievement.

Randomized controlled trial evidence shows that interventions before age 5 can improve skills necessary for educational success; the effect of these interventions on socioeconomic inequalities is unknown. Using trial effect estimates, and marginal structural models with data from the Avon Longitudinal Study of Parents and Children (n = 11,764, imputed), simulated effects of plausible interventions to improve school entry academic skills on socioeconomic inequality in educational achievement at age 16 were examined. Progressive universal interventions (i.e., more intense intervention for those with greater need) to improve school entry academic skills could raise population levels of educational achievement by 5% and reduce absolute socioeconomic inequality in poor educational achievement by 15%.

Who benefits most from Head Start? Using latent class moderation to examine differential treatment effects.

Head Start (HS) is the largest federally funded preschool program for disadvantaged children. Research has shown relatively small impacts on cognitive and social skills; therefore, some have questioned its effectiveness. Using data from the Head Start Impact Study (3-year-old cohort; N = 2,449), latent class analysis was used to (a) identify subgroups of children defined by baseline characteristics of their home environment and caregiver and (b) test whether the effects of HS on cognitive, and behavioral and relationship skills over 2 years differed across subgroups. The results suggest that the effectiveness of HS varies quite substantially. For some children there appears to be a significant, and in some cases, long-term, positive impact. For others there is little to no effect.

Classifying infants and toddlers with developmental vulnerability: who is most likely to receive early intervention?

BACKGROUND: Infants and toddlers with developmental difficulties represent a heterogeneous group who often receives early intervention (EI). Notable population heterogeneity exists and complicates unmet need and effectiveness research. However, a mix of relatively homogeneous clinically policy relevant 'subgroups' may create the apparent heterogeneity. To date, methodological challenges have impeded identifying these potential groups and their policy-relevance. METHODS: From the 2005-2006 National Survey of Children with Special Health Care Needs, we derived a sample (n = 965) of infants and toddlers with parent-reported developmental difficulties. We used latent class analysis (LCA) to identify subgroups of developmental vulnerability based upon functional, social and biological characteristics that would make children eligible for EI. Mixture modelling estimated the likelihood of each subgroup receiving parent-reported EI, controlling for race/ethnicity, child's age, and state of residence. RESULTS: LCA identified four distinct subgroups of developmental vulnerability: developmental disability (Group 1), mild developmental delay (Group 2), socially at risk with behaviour problems (Group 3), and socially at risk with functional vision difficulties (Group 4). Black, non-Hispanic children are significantly more likely than their white counterparts to be in Group 3 (ß = 1.52, P = 0.001) or group 4 (ß = 1.83, P < 0.001). Compared with children with a mild developmental delay (Group 2), children in group 1 (ß = -0.61, P < 0.001), group 3 (ß = -0.47, P = 0.001) and group 4 (ß = -0.38, P = 0.009) are significantly less likely to receive EI. CONCLUSIONS: Racial and ethnic differences exist with regard to membership in developmental vulnerability subgroups. Observed inconsistencies in access to EI suggest the need for improved surveillance, referral and outreach.

Restricting state part C eligibility policy is associated with lower early intervention utilization.

To examine if state differences in early intervention (EI) utilization can be explained by recent restrictions on EI state eligibility policy. The sample (n = 923), derived from the 2009/10 National Survey of Children with Special Health Care Needs, included CSHCN who were ages 0-3 with a developmental delay or disability that affected their function. Multi-level logistic modeling was used to describe state differences in EI utilization and to determine if narrower state eligibility policy explained these differences. EI utilization ranged from 6 to 87 % across states. Having a severe condition (ß = 0.99, SE = 0.28) and a usual source of care (ß = 0.01, SE = 0.001) was associated with higher odds of utilizing EI. Compared to a diagnosed disability, having a developmental delay (ß = -0.61, SE = 0.20) was associated with lower odds of utilizing EI. Living in a state with narrow and narrower state eligibility policy (ß = -0.18, SE = 0.06) was significantly associated with lower odds of EI utilization, and this effect was strongest for children with the most severe functional impairments. Significant state variation in EI rates exists that can be explained, in part, by the restrictiveness of state eligibility criteria. Children with the most severe functional impairments appear to be least likely to utilize EI in states with the most restrictive eligibility policies.

Risk determinants in early intervention use during the first postnatal year in children born very preterm.

BACKGROUND: Early interventions (EI) are recognised for their potential risk-reduction capacity. Although developmental delay is common in children born very preterm reports continue to suggest poor uptake of EI services. This study examined the risk determinants of EI in Australian children born less than 32 weeks gestation during the first year of life. METHODS: As part of a multi-centre-randomised-trial, 195 children were prospectively studied during their first year of life and EI use, type of follow-up, perinatal, social and parental psychosocial risk factors were collected using questionnaires. Child neurodevelopmental disability-status was assessed at 12-months (cerebral palsy, blind, deaf, developmental quotient 1 standard deviation (SD) below mean). The associations between EI and variables were examined using Pearson's chi-squared test (χ2) and regression techniques. RESULTS: A total of 55% of children received EI, 51% attended post discharge neonatal intensive care unit (NICU) and the remainder attended exclusive primary health care. Risk factors included, 50% perinatal, 19% social and 34% psychosocial and at 12-months 23% were categorised as disabled. Low social risk and NICU follow-up attendance were significantly associated with EI use but only perinatal risk (OR 3.1, 95% CI 1.7, 5.6, p = <0.01) and disability (OR 2.2, 95% CI 1.1, 4.7, p = 0.04) independently predicted EI use. CONCLUSIONS: It is reassuring that children with perinatal risk receive EI, opportunity remains to improve EI uptake in families with social and parental psychosocial risk during the first year of life.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]. / Die psychische Gesundheit von Kindern, Jugendlichen und jungen Erwachsenen--Teil 2: Krankheitslast, Defizite des deutschen Versorgungssystems, Effektivität und Effizienz von "Early Intervention Services"

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.