Preventing low birth weight, child abuse, and school failure: the need for comprehensive, community-wide approaches.

Based on numerous examples from this country and abroad, we now have a reasonable idea of how we can reduce substantially the incidence of low-weight births, child abuse, adolescent pregnancy, school failure, and school dropout. The most effective long-term strategy appears to be the development of a comprehensive, coordinated, community-wide approach focused on preventing low- and medium-risk families from becoming high-risk as well as providing intensive services to those who already have reached a high-risk status. The best results can be obtained when all levels of government and the private sector work together. In this partnership, the best outcomes appear to result when the state and federal governments, private corporations, or both provide technical assistance, additional funding as needed, and help in setting program standards, and when the community maintains local control over establishing priorities and implementation strategies. However, to reach these goals and to maintain program support over the long time periods needed to show positive results (4 to 8 years), it is necessary to become skilled in social marketing techniques to turn program need into demand and to develop a strong local and statewide advocacy group to facilitate passage of needed legislation and prevent funding cutbacks. Pediatricians can modify their practices to make them more supportive to families and can work with other community leaders to bring about the changes in attitudes and about the changes in attitudes and funding priorities at the state and community levels that will be necessary to develop more effective preventive programs.

Strategies for disease prevention and health promotion in maternal and child health: the "ecologic" versus the "high risk" approach.

PIP: This article advocates an ecological approach to prevention of maternal and child health problems such as adolescent pregnancy, low birthweight, developmental disabilities, and child abuse. Over the past decade, the most widely used strategy for addressing these problems has been based on the concept of high risk. This approach assumes that retrospective data can identify a relatively small number of families that will produce the majority of child health and developmental problems in a community and concentrates resources on this group. However, this approach tends to produce either a large at risk group, most of whom will not develop the outcome under question, or a small group with a higher incidence of problems but representative of only a tiny fraction of the total number of children in the community who develop problems. The difficulties inherent in attempting to predict who is at risk of developing what conditions has led to the search for more effective preventive strategies. The ecological approach assumes that child health and development outcomes are related to parent functioning, which is influenced by both formal (health and human service providers) and informal (family and friends) community support systems, in turn influenced by cultural values and government policies. Interventions based on this model aim to improve community resources that can strengthen family functioning. In addition to primary health care services, such a program should include 5 components at the local community level: 1) a representative community council; 2) a community-wide health education program; 3) basic parent support services (parent-child centers, birthing centers, home visitors, homemaker services, transportation); 4) a consumer advocacy organization; and 5) a reliable assessment system. Forming a coordinating council and advocacy group involves little or no extra governmental expense, and existing data sources can be used for needs assessment and program monitoring. Different agencies (agricultural extension, health, and social services) could donate a portion of their budgets to health education and parent support, and these services could be organized into a community-wide delivery system.^ieng

Enhancing infant development and parent-practitioner interaction with the Brazelton Neonatal Assessment Scale.

Studies performed in low socioeconomic populations have shown that the demonstration of a newborn's developmental capacity to his mother during the first few days post partum enhances subsequent mother-infant interactions. This study was undertaken to determine whether demonstrating the Brazelton Neonatal Assessment Scale to white middle-class mothers would result in similar outcomes. Mothers of 75 neonates were randomly assigned to either an experimental group or to one of two control groups. Direct observation, subjective assessment of mother-infant interactions, and maternal questionnaires were used 1 and 3 months later to assess outcomes on several dimensions. Mothers in the experimental group spent more time playing with, talking to, and looking at their infants than did those in either control group, and were less likely to use feeding as a method of interacting with their infants. Experimental group mothers also were more likely to ask developmentally related questions. However, no differences were found in most indices of maternal-infant interaction used. The results of this study and a review of the literature indicate that the recommendation that such a demonstration be performed with all neonates must be weighed against the other methods available for enhancing infant development and healthy parent-child interaction.

Prevention of behavioral problems in young children.

Behavioral problems in young children are quite common and arise from a complex interaction between child and environmental characteristics. Many are transient disorders related to situational family stresses and will respond to a number of brief intervention approaches or simply the passage of time. As yet we have no accurate way of predicting which children are likely to develop more serious problems in the future. Because of this, systematic screening and treatment of individual children and families does not seem as effective an approach to prevention as a community-wide program designed to improve the support systems available to all families. Examples are quality day care centers, family planning facilities and guidance, parenting resource centers, and home visitor programs. The pediatrician can be an influential person supporting the development of these kinds of programs in his or her community. For families in the pediatrician's own practice he or she can help parents cope with troublesome behaviors through education and brief intervention techniques such as behavior modification and link them with community services for more complex problems. In addition the physician can help to promote "competence" by teaching parents how to interact with their children in more affectionate and cognitively stimulating ways.

A follow-up study of parent education in pediatric office practices: impact at age two and a half.

The relationship between physician efforts to educate mothers of first born children about child behavior and development, and various outcome measures of mother and child functioning has been extended from 18 months to a time period of two and a half years. As was found earlier, there was a modest relationship between physician effort and mother gain in knowledge about child development, her feeling of being supported by the practice in her child-rearing role, and the frequency of her participation in affectional and cognitively stimulating activities with her child. These relationships, however, did not significantly increase in strength over time. At the end of 30 months there were still no significant positive relationships between teaching input and the child's developmental status, and mothers receiving care form physicians who taught more continued to report more behavior problems with their child than mothers receiving care from physicians who taught less. A content analysis of a small sample of the visits of high and low scoring physicians indicated that neither focused their teaching efforts on ways that mothers could interact with their children in more affectionate and cognitively stimulating ways. It is suggested that more focused teaching in this area might lead to better child development outcomes.

Typical behaviors of one-year-old children and their mothers.

Behaviors of 504 middle-class children at 1 year of age and their mothers were assessed with descriptive checklists. Many typical stage-related behaviors led to parental concern or frequent parent-child conflict; 24% of the mothers identified at least one conflict area and 42% expressed concern about at least one aspect of thier children's behaviors. Approximately 13% of the mothers thought their children were very or moderately difficult to rear, and about 6% thought their children had behavioral or emotional problems. The mothers reported considerable variation in the number and type of cognitively stimulating activities that they engaged in with their children. The implications of these findings for well-child care are discussed.

An evaluation of efforts to educate mothers about child development in pediatric office practices.

The efforts expended by pediatricians in a variety of private practice settings to educate mothers of first-born children about child behavior and development were examined in relation to various outcome measures of mother and child functioning over a time period of one-and-a-half years. Mothers learned more about child development in group settings than in solo practice settings, but differences between medical groups with and without nurse practitioners were not significant. Mothers receiving care from pediatricians who made at least a moderate effort to teach, learned more about child development, described more use of positive contact with their children, and felt they were helped more in their childrearing efforts than did mothers receiving care from pediatricians who made little effort to teach. However, there were no significant differences in measures of the child's developmental status related to physician teaching input, and mothers exposed to higher levels of teaching input reported more behavioral problems with their children. The most important predictor of the child's developmental status at 18 months of age was the amount of positive contact between mother and child at one year. It is suggested that the effects of changing the frequency of well-child visits on the mothers' interaction patterns with their children and on their feelings of being supported by the physician be ascertained before making recommendations about the optimal number of such visits.

Relationships between child-rearing styles and child behavior over time.

We investigate the hypothesis that "authoritarian" styles of child rearing will lead to more home and school problems than will "accommodative" styles. One hundred thirty-five children have been followed up from age 2 into first grade. Follow-up observations show no significant differences between groups on any of the scores indicating malfunctioning for boys or girls at home or school. However, the home behavior of boys being raised with accommodative styles was described in more positive terms by their mothers than those raised with authoritarian styles. The accommodatively raisded girls were described in more positive terms by their first grade teachers. We found no evidence in this study that the permissive style is producing large numbers of "spoiled brats" nor that the authoritarian styles are producing large numbers of overly aggressive or inhibited children. The way parents handle authority relationships is not sufficientyl predictive of later problems to warrant any widespread attempts by physicians to change them. The physician should respect individual differences in child-rearing syle and only intervene where there is substantial evidence that a particular approach is having a harmful effect.

Can we identify a group of children at age 2 who are at high risk for the development of behavior or emotional problems in kindergarten and first grade?

A group of 198 children were followed from age 2 through first grade to see how consistent their behavior was across time and across settings. Measures of child behavior in the home were obtained when the children were ages 2, 4, and 5. Classroom behavior was ascertained when the children were in nursery school, kindergarten, and first grade. Correlations between early home and school behavior patterns were all quite low. Only when home and school measures were made close to the same point in time did relationships reach even a moderate level. Behavior within the same setting was more consistent over time than behavior across settings but even here relationships were not strong enough to be clinically useful for making predictions about individual children. It is concluded that early behavior in the home, as measured by these methods and for this population, is not be itself sufficiently predictive of later home or school behavior to warrant identifying the child or his family as being at "high risk" for future problems. Pediatrics 59.971-981, 1977, SOCIAL DEVELOPMENT, SCREENING, BEHAVIOR, CHILD DEVELOPMENT, HIGH RISK.

Delivery of primary health care--union style. A critical review of the Robert F. Kennedy plan for the United Farm Workers of America.

The primary health-care program developed by the United Farm Workers of America, an example of a consumer-controlled system, provides quality health care at locations and time convenient to patients and employs bilingual clinic personnel from the same worker background to bridge the cultural gap between provider and consumer. By combining health-care delivery with union activities, it has been possible to finance the system through grower contribution by contract and to alter unhealthy working and living conditions on the farms. However, the lack of decision-making power by the health workers has resulted in poor working conditions and a high turnover of personnel. Complete consumer control has built into it the same hazards as complete professional control, and some balance of power is clearly necessary if the needs of both are to be adequately met.

The use of teacher checklists to identify children at risk for later behavioral and emotional problems.

Measures of child behavior based on teacher checklists have been shown to be reliable and valid indicators of a child's current school functioning. Such measures, however, are not very accurate predictors of behavior in other settings, or of the development of future behavior problems; they should not be used to label a child as "high risk." The primary care physician could help the teacher decide which children to refer for more thorough evaluation by providing the teacher with information on the child's development and neurologic status, home behavior, and family situation. Follow-up studies suggest that many behavioral disturbances seen in pre-school settings are transient situational disturbances that could be adequately managed through use of behavior modification techniques or simply through the passage of time.

Parental use of "positive contact" in child-rearing: its relationship to child behavior patterns and other variables.

In an investigation of child-rearing styles maternal use of "positive contact" was measured by asking the mother how often she played with the child, praised the child, and the like, and combining the responses into a score. Home observations on a sample of families revealed that mothers scoring above the mean used fewer communications in the form of directives and "unmodified power" and more communication in the form of praise and social conversation than mothers scoring below the mean. The mother's use of positive contact was related to her educational level, the birth order of the child and number of children in the family, the father's use of positive contact, and to a friendly outgoing pattern of child behavior. There was no relation to the mother's use of physical punishment, her protectiveness, her tendency to comply with the child's demands, or her child-rearing ideology and other attitudes. Child care workers are in a strategic position to educate parents about the importance of this kind of contact, especially with later-born children in large families.