Review
‘Is my child developing normally?’: a critical review of web-based resources for parents Nia Williams* BSc MBBS; Sabena Mughal BSc; Mitch Blair MBBS FRCPCH, Department of Paediatrics, Faculty of Medicine, Imperial College, London, UK. *Correspondence to first author at 46 Tasso Road, Hammersmith, London W6 8LZ, UK. E-mail:
[email protected] DOI: 10.1111/j.1469-8749.2008.03148.x Published online October 21 2008 Early detection of developmental problems improves outcomes for parents and children. Parents want to be involved in assessment and need high-quality, accurate, and reliable data on child development to help monitor progress and inform decisions on referral. The aim of this paper is to review which websites are readily accessible to parents on child development and to assess their quality. An internet search (on Google and Yahoo) was conducted using the search terms ‘child development’, ‘parenting’, and ‘developmental milestones’. Criteria were agreed for evaluating web-based resources, adapted from and based on previously reported methods. Data were collected on site content, diagrams and layout, readability (Flesch Reading Ease Scale), design, navigability, overall design, and interactive features. Forty-four relevant websites were identified for further analysis: six government, three university, 15 health-care professional, four American Academy of Pediatrics, 10 by journalists, and six undisclosed. The best websites are presented, with justification for their choice. Overall, information available for parents about child development is accurate but much of it is incomplete, unclear, or difficult to access. There is a need to develop an easily accessible, clear, and authoritative resource for parents with illustrations. Focus groups are being held to inform this research further.
An estimated 12 to 20% of young children have significant problems in one or more areas of development.1–3 The early detection of developmental problems, combined with early intervention, if appropriate, leads to improved outcomes for children and their families. These include improved school and employment records as well as decreased teenage pregnancies and criminality.1,4–7 The American Academy of Pediatrics (http://www.aap.org), therefore, advocates the identification of developmental delay before a child’s second birthday.8 Despite this advice, in the West, fewer than 30% of children with serious developmental and behavioural difficulties are identified before beginning school.9–12 Developmental surveillance is a vital process in the promotion of optimal development in children.12 This concept is defined by Dworkin as ‘a flexible, continuous process whereby knowledgeable professionals performed skilled observations of children during the provision of health care’.13 It includes the physical and cognitive development of infants and young children, and considers the behavioural, emotional, and social aspects of childhood development. Child health-promotion programmes have recently reemphasized the importance of a longitudinal continuous approach, replacing fixed age reviews, and the value of raising awareness of developmental issues at a population level. Including parents in the developmental assessment of their child has been shown to have many advantages.14,15 One of these is related to the parents’ management of the child’s behaviour during testing.10 Eliciting parental concerns is efficient, leading to savings in professional time.16,17 It also provides a family-focused, collaborative approach to paediatric primary care.18 Parental concerns are as accurate as quality screening tests, and differences in factors such as socioeconomic status, parental well-being, or child-rearing experience have not been shown to effect parents’ abilities to raise important concerns about their child’s development.18–20
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For parents to identify areas of concern within their child’s development, they need an accurate and accessible source of information about normal child development.21 There is a dearth of studies looking into the sources of information available to parents on child development worldwide, and we are unaware of any recent research looking into the sources used by parents. The internet is quickly becoming one of the fastest and cheapest ways of researching health topics. Many parents in the West turn to the internet for answers to concerns about their children and parenting issues. However, it is difficult for parents to assess which sites contain credible, accurate, and up-to-date information. The aim of this paper is to review which websites are readily accessible to parents on child development and to assess their quality. Method We searched the internet by typing common search terms such as ‘child development’ and ‘parenting’ into the Google and Yahoo search engines between February and May 2007. We assessed any websites that fell within the first 10 pages of search-engine results, i.e. the first 100 results. Jadad and Gagliardi22 evaluated 47 internet rating tools that focused on health-information websites. Many of the tools were criticized for not describing the criteria used for evaluation (70%), and only 11% gave instructions for their use. Because of Jadad and many other authors’ agreement that the many health-related internet rating tools available are incomplete,23,24 we developed a framework that combined several methods together with an evaluation of readability using the Flesch Reading Ease Scale.25 The following domains were included in the final model. ACCURACY OF DEVELOPMENTAL CONTENT
The content of information was assessed based on its accuracy compared with the book From Birth to Five Years,26 which was used as a criterion standard. Marks for the presence and accuracy of five categories of development were given to each website: gross motor development; vision and fine motor development; hearing and speech; emotion, behaviour, and play; and ‘red flag’ information. Therefore, a website with accurate information on gross motor develop-
ment only would score 2 out of 10, whereas a website with accurate information on all categories would score 10. Websites with inaccurate or misleading information were scored 0 and not marked further. READABILITY
For parents to understand and retain information about their child’s development, it is vital that written resources are aimed at a suitable level of literacy. Over 50 readability formulae have been published that aim to assess structural elements and reading difficulty of text. One of the most commonly used measures is Flesch’s Reading Ease Scale25 (results from 0 to 100 with lower scores meaning more difficult to read). This scale uses polysyllabic words and sentence length to determine the difficulty of the text precisely and objectively (Table I).25,27,28 DESIGN AND NAVIGABILITY
Layout and the presence of diagrams or visual aids were seen to be important in making the information easy to understand. Within the websites with accurate information, high marks were given to sites with animation or diagrams that helped convey their message clearly and memorably, medium marks were given to sites with clear points or tables, and low marks were given to sites with long paragraphs of text without illustration or clear points. Navigability was then scored based on how many mouse clicks were required to reach the desired page from the resource’s home page. Points were deducted for obstacles such as requiring a subscription to view the content. ADDITIONAL FEATURES
Other factors that we considered when evaluating the internet resources were any interactive features such as forums or message boards, links to other relevant websites, and the presence of an internal search engine. Results Information from 44 different websites was assessed using the criteria set out in the methods. Table I includes overall category marks for all websites. See Appendix SI (supplementary information published online) for the origin of each website and its authors. CONTENT ACCURACY
Table I: Flesch Reading Ease Scale (FRE)25 FRE
Reading difficulty
IQ % UK Example required population who understand
91–100 81–90 71–80 61–70
Very easy Easy Fairly easy Standard
81+ 84+ 87+ 90+
90 86 80 70
51–60
Fairly difficult Difficult
104+
40
111+
24
126+
4.5
31–50 0–30
Very difficult
Comic books The Sun The Daily Mail Reader’s Digest, National Geographic USA today, Newsweek Wall Street Journal, Harvard Law Review Chemistry text, British Dental Journal
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The average score for accuracy was 6.6 out of 10 (range 2–10), with seven websites receiving full marks for the accuracy of their information. All websites contained accurate information, although some only contained information on certain elements of development (Tables II and III). Fourteen of the websites (32%) displayed some information about ‘red flag’ signs for their child’s development. READING EASE
The mean score on the Flesch Reading Ease Scale was 81.72 (range 42.87–100). All of the websites except one (DB Peds [http://www.dbpeds.org]) were written to a standard level of plain English (60–70). DESIGN AND NAVIGABILITY
The layout and use of diagrams or visual aids was marked. The mean score was 2.6 (range 1–4.5) out of 5.
Navigability of the websites was marked, with a deduction of one point for every two clicks away from the homepage. The mean number of clicks needed to reach the relevant part of the website was two (range 0–6), indicating that most of the pages were easily accessible from their site’s main homepage. ADDITIONAL FEATURES
Twenty of the websites (45%) had a forum or interactive message board on the site, where parents could discuss their concerns and receive feedback from other users. In addition, 17 websites (39%) had an ‘Ask Doctor’ feature, where parents could send queries about their child’s development to a medical professional. Thirty-six of the websites (82%) had an internal search engine, and 37 of them (84%) displayed useful and relevant links to other resources. Discussion The readability of almost all websites was at a standard level of English or easier, which is a suitable level for most of the population. The information tended to be accurate, but
many websites did not contain information on all categories of development or had no information on ‘red flag’ signs and therefore lost marks. One of the main problems with most of the sites was the method of displaying the information. Long paragraphs of text were used in many cases, which were not as eye-catching or well laid out as sites with tables or bullet points. The sites with the best layout included Ask-nanny.com (http:// www.ask-nanny.com) and Pampers US (http://www.us. pampers.com). No website contained accurate diagrams or illustrations to complement the text, which could enhance learning for parents. The overall design and navigability of the websites was impressive, though many were difficult to access, for example requiring a paid subscription to join. Most of the sites had effective internal search engines and useful links that enhanced their function as an educational tool for parents. Less impressive was the absence of additional features such as forums or message boards to aid discussion among parents on many of the sites. Having said this, the quality of information shared among parents is uncensored and its content will vary in accuracy and usefulness. These features are therefore of limited use and should be
Table II: Marks for content, design, and other features for all websites Website
Possible marks About Paediatrics American Academy of Paediatrics Ask-Nanny Baby and Kids Baby builders Babycentre BBC parenting Blankees Canadian Parents Caring for kids Centres for disease control Child development info Dr Spock Family education India parenting I village UK I village US Kidshealth LD online March of Dimes Mothercare Mumsnet Pampers US Parenting Parents Practical parenting PBS Raising Children Raising Kids Schwab Learning University of Minnesota Wikipedia
Content and accuracy
Design Accessibility
Navigability
Design ⁄ layout
10 4 10 8 8 3 10 2 5 6 2 10 8 10 8 6 8 6 10 8 8 2 8 8 5 10 4 8 9 6 4 4 8
5 4 5 3 4 4 3 5 4 3 4 5 5 1 3 1 4 5 2 5 5 4 5 3 5 5 5 3 2 2 5 1 5
a (Deductions) –2 –1.5 –0.5 –0.5 –0.5 –1 –2 –1 0 –1 –2.5 –0.5 –1 –2 –1.5 –1 –2 –1 –2 –1.5 –1 –0.5 –2 –0.5 –1 –0.5 –1.5 –0.5 –1 –0.5 –1 –1.5
5 4 3 4 3 4 1 1 2 2.5 2 4 2 1 1 1 1.5 3 1 3.5 3.5 1 1 4.5 1 1 1 3.5 3.5 1 3 1 3
Additional features Forum Ask Dr
2 2 0 0 2 0 2 0 0 2 0 0 0 2 2 2 2 2 0 2 0 0 2 2 0 2 2 2 2 2 2 0 0
2 1 0 2 0 0 1 0 0 2 0 0 0 2 0 1 0 0 1 2 0 2 0 2 0 0 0 1 0 2 1 0 0
Internal Search
Links
2 2 2 0 1 0 2 2 0 2 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
2 1 1 2 2 0 2 2 2 1 0 2 2 2 2 1 2 1 0 2 2 0 1 0 0 1 0 2 2 2 2 2 2
Numbers in bold are maximum scores possible (highest score best). aNavigability is marked by deducting points if the website fails to perform in this category.
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Table III: Breakdown of marks for accuracy of information in different categories of development Website
Possible marks About Paediatrics American Academy of Paediatrics Ask-Nanny Baby and Kids Baby builders Babycentre BBC parenting Birth to three Blankees Canadian Parents Caring for kids Centres for adoption medicine Centres for disease control Child development info DB peds Dr Spock Early childhood intervention Family Education First Signs How kids develop Illinois Dept. of human services India parenting I village UK I village US Kidshealth LD online Maryland Public schools Mothercare Mumsnet New Parents Guide Pampers US Parenting Parenting Newsletter Parents Practical Parenting PBS Wholechild Raising Children Raising Kids Reach out and read Schwab Learning Speech and language University of Minnesota Wikipedia Your baby today
Accuracy of information Gross Vision ⁄ fine motor motor
Hearing and speech
Emotion ⁄ behaviour ⁄ play
‘Red flag’ information
2 1 2 2 2 1 2 0.5 1.5 0 1.5 0.5 1.5 2 2 2 2 2 2 0 2 2 2 2 1.5 2 2 2 0 2 2 2 1 0.5 2 1 2 2 2 1 1 0 1 2 1
2 1 2 2 2 1 2 0.5 1.5 2 1.5 0.5 1.5 2 2 2 2 2 2 2 2 2 0 2 1.5 2 2 2 0 2 2 2 1 0.5 2 1 2 2 1 1 1 2 1 2 1
2 1 2 2 2 0 2 0.5 1.5 1 1.5 0.5 1.5 2 2 2 2 2 2 2 2 2 2 2 1.5 2 2 2 2 2 2 2 1 0.5 2 1 2 2 2 0 1 0 1 2 1
2 0 2 0 0 0 2 0 0 1 0 0 2 2 0 1 2 0 0 2 2 0 0 0 0 2 0 0 0 0 0 0 1 0 2 0 0 1 0 0 0 1 0 0 0
2 1 2 2 2 1 2 0.5 1.5 1 1.5 0.5 1.5 2 2 2 2 2 2 1.5 2 2 2 2 1.5 2 2 2 0 2 2 2 1 0.5 2 1 2 2 1 1 1 0 1 2 1
Total
10 4 10 8 8 3 10 2 6 5 6 2 8 10 8 9 10 8 8 7.5 10 8 6 8 6 10 8 8 2 8 8 8 5 2 10 4 8 9 6 3 4 3 4 8 4
Numbers in bold are maximum scores possible (highest score best).
used with caution. Four of the websites (Canadian Parents [http://www.canadianparents.com], Raising Kids [http:// www.raisingchildren.net.au], LD online [http://www.ldonline.org], and Pampers US [http://www.us.pampers.com]) offered an ‘Ask the expert’ feature, in which parents could send their queries by e-mail to qualified experts, which could be useful in reassuring parents who are worried and those with well-based concerns. SOME OF THE BEST WEBSITES
Ask-Nanny (http://www.ask-nanny.com) is a site that was set up by a qualified nanny. It has a development chart that is easily accessible and free. It contains accurate information on all categories of development but no details on ‘red flag’
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signs. The main weakness of this site is the lack of illustration, but it is generally a very well laid out, simple-to-use guide for parents. Raising Children (http://www.raisingchildren.net.au) is a site funded by the Australian government’s Stronger Families and Communities strategy. It is very well laid out, with information on the development of newborns to 9-year-olds. Again, however, there are no illustrations. Pampers US (http://www.us.pampers.com) has the best interactive animated resource. It does not contain details of every stage and category of development, but it is very eyecatching and user-friendly. The University of Washington has set up a website for health professionals with an interest in the medical and
developmental concerns of adopted children (http:// www.adoptmed.org). It contains well-illustrated information on the development of infants up to 15 months of age. Babycentre (http://www.babycentre.co.uk) contains detailed information on both physical and emotional child development, with details on ‘red flag’ signs. Some of the information presented is somewhat long-winded rather than being in bullet point form, but the information is thorough and accurate. STUDY WEAKNESSES
We concede that the World Wide Web is a vast network of information with almost unlimited options for searching and discovery. However, we believe that we used the two most popular search engines in this study. More websites could have been evaluated, but parents are unlikely to read past the first 100 search results. An important factor to consider is that parents may have used different search terms in their quest for information. However, as we retrieved sites from several diverse sources, including those with and without corporate sponsorship, the search terms used seem reasonable. Conclusion Overall, information available for parents about child development is accurate. However, much of it is incomplete, unclear, or difficult to access. Professionals should be encouraged to work closely with parents to develop an easily accessible, clear, and authoritative resource, with illustrations. Accepted for publication 2nd July 2008. Supporting Information Additional Supporting Information may be found in the online version of this article: Appendix SI: Websites reviewed Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. References 1. Glascoe FP. It’s not what it seems: the relationship between parents’ concerns and children’s cognitive status. Clin Paediatr (Phil) 1994; 33: 292–98. 2. Boyle CA, Decoufle P, Yeargin-Allsop MY. Prevalence and health impact of developmental disabilities. Pediatrics 1994; 93: 863–65. 3. Rydz D, Srour M, Oskoui M, et al. Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires. Pediatrics 2006; 118: 1178–86. 4. Boocock SS. Early childhood programs in other nations. Future Child 1995; 5: 94–115. 5. Barnett SW. Long-term effects of early childhood programs on cognitive and school outcomes. Future Child 1995; 5: 25–50. 6. Bennett FC, Guaralnick MJ. Effectiveness of developmental intervention in the first five years of life. Pediatr Clin North Am 1991; 38: 1513–28.
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