Skip to main content

Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes



To develop, implement, and assess implementation outcomes for a developmental monitoring and referral program for children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).


Based on Centers for Disease Control and Prevention’s Learn the Signs. Act Early. campaign, the program was developed and replicated in two phases at 20 demographically diverse WIC clinics in eastern Missouri. Parents were asked to complete developmental milestone checklists for their children, ages 2 months to 4 years, during WIC eligibility recertification visits; WIC staff referred children with potential concerns to their healthcare providers for developmental screening. WIC staff surveys and focus groups were used to assess initial implementation outcomes.


In both phases, all surveyed staff (n = 46) agreed the program was easy to use. Most (≥ 80%) agreed that checklists fit easily into clinic workflow and required ≤ 5 min to complete. Staff (≥ 55%) indicated using checklists with ≥ 75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During the second phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program.


Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support.

This is a preview of subscription content, access via your institution.

Fig. 1

Data Availability

Data and links to materials are available upon request.

Code Availability

Not applicable.


  1. Implementation manual available upon request from the first author. An updated online implementation manual is available at


  • Barger, B., Rice, C., Wolf, R., & Roach, A. (2018). Better together: Developmental screening and monitoring best identify children who need early intervention. Disability and Health Journal, 11(3), 420–426.

    Article  PubMed  PubMed Central  Google Scholar 

  • Bethell, C., Reuland, C., Schor, E., Abrahms, M., & Halfon, N. (2011). Rates of parent-centered developmental screening: Disparities and links to services access. Pediatrics, 128(1), 146–155.

    Article  PubMed  Google Scholar 

  • Black, M. M., Perez-Escamilla, R., & Rao, S. F. (2015). Integrating nutrition and child development interventions: Scientific basis, evidence of impact, and implementation considerations. Advances in Nutrition, 6(6), 852–859.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  • Boh, A., & Johnson, L. (2017). Universal screening to promote early identification of developmental delays: Exploring childcare providers’ beliefs and practices. Early Child Development and Care, 188(12), 1–15.

    Google Scholar 

  • Bright Futures Periodicity Schedule Workgroup, Committee on Practice, and Ambulatory Medicine. (2014). 2014 Recommendations for pediatric preventive health care. Pediatrics, 133(3), 568–570.

    Article  Google Scholar 

  • Bruder, M. B. (2010). Early childhood intervention: A promise to children and families for their future. Exceptional Children, 76(3), 339–355.

    Article  Google Scholar 

  • Centers for Disease Control and Prevention. (2017, August 7, 2017). Learn the Signs. Act Early.

  • Daniel, K. L., Prue, C., Taylor, M. K., Thomas, J., & Scales, M. (2009). ‘Learn the signs. Act early’: A campaign to help every child reach his or her full potential. Public Health, 123(Suppl 1), e11-16.

    Article  PubMed  Google Scholar 

  • Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J., Fitzgerald, R., ..., & Yeargin-Allsopp, M. (2017). Autism spectrum disorder among US children (2002–2010): Socioeconomic, racial, and ethnic disparities. American Journal of Public Health, 107(11), 1818–1826.

  • Guerrero, A. D., Inkelas, M., Whaley, S. E., & Kuo, A. A. (2013). A WIC-based curriculum to enhance parent communication with healthcare providers. Journal of Community Health, 38(5), 958–964.

    Article  PubMed  Google Scholar 

  • Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.

    Article  Google Scholar 

  • Houtrow, A. J., Larson, K., Olson, L. M., Newacheck, P. W., & Halfon, N. (2014). Changing trends of childhood disability, 2001–2011. Pediatrics, 134(3), 530–538.

    Article  PubMed  PubMed Central  Google Scholar 

  • Jimenez, M. E., Fiks, A. G., Shah, L. R., Gerdes, M., Ni, A. Y., Pati, S., & Guevara, J. P. (2014). Factors associated with early intervention referral and evaluation: A mixed methods analysis. Academic Pediatrics, 14(3), 315–323.

    Article  PubMed  Google Scholar 

  • Leech, N. L., & Onwuegbuzie, A. J. (2007). An array of qualitative data analysis tools: A call for data analysis triangulation. School Psychology Quarterly, 22(4), 557–584.

    Article  Google Scholar 

  • Lipkin, P. H., Macias, M. M., Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. (2020). Promoting optimal development: Identifying infants and young children with developmental disorders through developmental surveillance and screening. Pediatrics, 145(1), e20193449.

    Article  PubMed  Google Scholar 

  • Missouri WIC Database. (2010). Fiscal year report of monthly participation. Missouri Department of Health and Senior Services.

  • Missouri WIC Database. (2013). Fiscal year report of monthly participation. Missouri Department of Health and Senior Services.

  • Pinto-Martin, J. A., Dunkle, M., Earls, M., Fliedner, D., & Landes, C. (2005). Developmental stages of developmental screening: Steps to implementation of a successful program. American Journal of Public Health, 95(11), 1928–1932.

    Article  PubMed  PubMed Central  Google Scholar 

  • Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., ..., Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65–76.

  • Rice, C. E., Van Naarden Braun, K., Kogan, M. D., Smith, C., Kavanagh, L., Strickland, B., & Blumberg, S. (2014). Screening for developmental delays among young children—National Survey of Children’s Health, United States, 2007. MMWR: Surveillance Summaries, 63(Suppl 2), 27–35.

    Google Scholar 

  • Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., ..., Dawson, G. (2012). Effects of a brief Early Start Denver model (ESDM)-based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065.

  • U.S. Department of Health and Human Services, and Administration for Children and Families. (2017, January 26, 2017). Birth to 5: Watch Me Thrive!

  • United States Census Bureau. (2010). Quick Facts—Missouri-population estimates [Tables: Population, race, income and poverty].

  • United States Department of Agriculture, and Food and Nutrition Services. (2017, 05/04/17). Frequently asked questions about WIC. Women, Infants and Children (WIC).

  • Zuckerman, K. E., Chavez, A. E., & Reeder, J. A. (2017). Decreasing disparities in child development assessment: Identifying and discussing possible delays in the special supplemental nutrition program for Women, Infants, and Children (WIC). Journal of Developmental and Behavioral Pediatrics, 38(5), 301–309.

    Article  Google Scholar 

Download references


Special thanks to Katie Dunne for contributions to initial program design and implementation, and to Missouri WIC leadership and Eastern District staff for their program contributions and dedication to children’s healthy development.


This study was supported by Health Resources and Services Administration (HRSA) Grant H6MMC1059-03-01 with supplement from the Centers for Disease Control and Prevention (CDC), 2010–2012; Disability Research and Dissemination Center (DRDC) through Cooperative Agreement Number 5U01DD001007 from CDC, 2014–2016. Contents of the publication are solely the responsibility of the authors and do not necessarily represent the official views of HRSA, DRDC or CDC.

Author information

Authors and Affiliations



JF provided conceptualization and oversight for program development/evaluation, and wrote the manuscript with input from all authors. LF, MC, and KG contributed to program design. LF coordinated on-site program implementation and evaluation. MC and WM contributed to data collection and data analysis.

Corresponding author

Correspondence to Janet E. Farmer.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest.

Ethical Approval

All aspects of program evaluation in this project were reviewed and approved by the University of Missouri Health Sciences Institutional Review Board.

Informed Consent

Informed consent was waived since all assessments were voluntary and anonymous.

Consent for Publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Farmer, J.E., Falk, L.W., Clark, M.J. et al. Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes. Matern Child Health J 26, 230–241 (2022).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Developmental monitoring
  • Early identification
  • Developmental delay or disability
  • WIC
  • Health disparities