The health of children.

OBJECTIVE: To summarize the concept of child health and the measurement of child health status in order to help guide the evaluation of the effectiveness of medical, social, and policy programs. CONCLUSIONS: Opportunities for research on children's health status and quality of care abound. Comprehensive and functional definitions create problems of measurement, but investigators are making progress in measuring children's health status both generically and for specific chronic health conditions. RECOMMENDATIONS: Measures of child health need to be developed, improved, tested, and made user-friendly for clinical and policy research. The relationship between health status and a variety of social programs for children and families needs study. The impact of changes in healthcare organization and financing must be investigated, especially for children from vulnerable subgroups. Determining the value and effectiveness of preventive services is a pressing issue. It is crucial to understand better the link among quality of care; other factors biological, family, and social; and children's health status.

Adolescent alcohol use: social determinants and the case for early family-centered prevention. Family-focused prevention of adolescent drinking.

The family plays a central role in the use of alcohol by children and adolescents, yet preventive interventions rarely focus on the family. Early drinking and much subsequent use of alcohol by children and adolescents is sanctioned and sometimes encouraged by their families. Unlike experimentation with alcohol, problem drinking is associated with low levels of family social support and with dysfunctional coping strategies of families that may lead children to use drinking as an adaptive behavior. While risk-factor research has advanced understanding of alcohol use by children and youth, the poor predictive power of individual risks has limited its contribution to successful interventions. On the other hand, protective factors, provided by relationships within and outside the family, can be preventive and health promoting. Parents influence their children's drinking through family interactions, modeling and reinforcing standards, and attitudes that children learn and use to guide their behavior in new situations. Thus, parental influences endure. This article argues that interventions to prevent alcohol abuse should be designed to help parents to carry out their parental functions. This can be accomplished by providing social support, resources, and education for parents, as well as developing extra-familial sources of social support and socialization for children and adolescents.

Behavioral correlates of differences between a child's assessment and the parents' assessment of the child's self-esteem.

When, as commonly occurs, a parent's and child's reports about the child differ, the lack of agreement usually leads to consideration of which information is objective and valid. Little attention has been given to understanding what meaning these differences might have in the context of parent-child relationships or to whether the existence or absence of these differences might be causally related to the child's psychosocial status and functioning. Third- through fifth-grade children (N = 178) in behavior disorder and regular classrooms were asked to complete a self-concept measure; parents were asked to independently complete the same instrument as they thought their child would. Parents of children without behavior disorders were significantly more accurate in their descriptions of their children's perceptions than were parents of children with behavior problems. They also tended to expect their children to have more positive self-concepts than the children actually reported. Parents who are able to accurately report their children's feelings and who err toward more positive assessments may be preventing behavior problems.

Socioeconomic status and preventive health-care use by children in Spain.

National health systems are intended to provide equal access to health-care services to whole populations. However, they do not seem to address successfully the problem of social class differentials in access to health care, in particular access to preventive care. This study examines the relationship between the socioeconomic status (SES) of families and the use of preventive health care by children under a national health system in Spain. The study is based on weighted multivariate ordinal logistic regression analyses of data from the 1987 Spanish National Health Survey for a sample of 5,622 children, one to 10 years of age. A positive relationship was found between preventive health-care use by children and the SES of their families. Adult respondents' level of education and total family income were the most influential variables in this relationship. As these increased, children were more likely to receive visual, hearing, and dental exams. In addition, there was a gradient effect between family income and rate at which children received these preventive health-care services. Universal access to care, like that available in Spain, does not guarantee that social inequalities in children's receipt of preventive health care will not persist. In order to succeed, health-care reform must deal with social issues beyond financial access to care.

The influence of families on child health. Family behaviors and child outcomes.

The family is the most central and enduring influence on children. Families, regardless of their composition, are themselves subject to a variety of social forces that influence how well they are able to meet children's needs. Pediatricians who understand the functions families serve and the factors that constrain them will be better able to assist parents in promoting their children's health and well-being.

Physicians' assessment of functional health status and well-being. The patient's perspective.

BACKGROUND: Ascribing quality to medical care rests in part on the expectation of physician behavior and the content of care. The adoption of functional outcomes of care as legitimate measures of quality will require greater attention to patient-provided assessments of health and add new dimensions to medical practice and quality assessment. METHODS: We conducted a cross-sectional, national population survey of adults to obtain estimates of the frequency with which physicians reportedly inquire about patients' functional health status and emotional well-being, patients' attitudes about such assessments, and the perceived use of data thus obtained in the therapeutic process. RESULTS: The majority of physicians rarely or never ask about the extent to which patients' health limits their ability to perform everyday activities (64.7% to 78.7%); neither do they inquire about limitations imposed by emotional problems (71.4% to 84.4%). Physicians are more likely to make such inquiries in the presence of chronic illness or diminished health status, or with older patients, although such assessments remain the exception to usual practice and a large portion of functional impairment is undiscovered. More than 60% of respondents want their physicians to assess their functional health status and well-being. CONCLUSIONS: While individuals want their physicians to assess their functional performance and emotional well-being as a part of medical care, by their reports this occurs infrequently. The content of care may be less comprehensive than physicians believe to be the case.

Developing communality: family-centered programs to improve children's health and well-being.

Despite decades of enormous investment in research and public programs, the United States continues to face pandemics of preventable health problems such as low birth weight, teenage pregnancy, drug abuse, and interpersonal violence. With some justification, these problems have been blamed on the failings of families. The reasons why families may function poorly in their child-rearing roles have not been coherently or vigorously addressed by our social policies; sometimes these policies have aggravated the problems. This paper provides background to allow a better understanding of families' role in the social determination of children's health, and argues for programs and policies that assist families through the creation of social supports embedded in communities that are characterized by trust and mutual obligation.

Foster care.

The placement of children in foster care is a signal that families are in trouble and that our social system is struggling. Foster care, designed to provide remedial services to the child and family and thus to facilitate family reconstitution, often fails. Health care of children in foster care cannot be separated from the circumstances that led to their placement or from the structure and operation of the foster care system itself. Physicians caring for children in foster care should be aware of the challenges presented by these children's high rate of chronic illness and emotional problems and by the barriers imposed by the foster care system.

Families, family roles, and psychological diagnoses in primary care.

This study examined the effect of belonging to a specific family on rates and occurrence of psychological diagnoses among the family members. Data were obtained from 693 families totaling 2907 parents and children during ambulatory care visits to a prepaid health care center. Families tended to have the majority of their members either with or conversely without a psychological diagnosis. The likelihood of having a psychological diagnosis was increased by 35% if another family member had been so diagnosed. Consequently, a small (3%) proportion of families accounted for a large (25%) proportion of these diagnoses. Children whose fathers were high utilizers of general health care services, or whose parents, particularly mothers, had a psychological diagnosis, were significantly more likely to have a diagnosis in this category as well. Families in which both parents had such a diagnosis were twice as likely to have an affected child. Siblings appeared not to exert any effect on one another in this regard. Family size and birth order had no effect on the incidence of psychological diagnoses.

Unintentional injuries. Patterns within families.

The occurrence of unintentional injuries is known to be influenced by physical and socioeconomic environmental factors as well as human behavior. Questions remain about how personal characteristics interact with the social, psychological, and physical environment to increase the risk of injury. The present study investigated the role of families in the injury experience of individual family members. Health encounter data from 693 families over a six-year period were analyzed. A small number of families accounted for a disproportionately large number of visits for injuries. Individual members of families tended to have similar rates of injury, and these rates were stable over time. Individual accident experience is influenced by the family to which one belongs. Injury prevention programs may find increased success by directing intervention strategies toward families.

Use of health care services by children and diagnoses received during presumably stressful life transitions.

Transition periods in the lives of children are potentially stressful and might therefore be associated with adverse changes in children's physical or emotional health. The computerized medical records of 1,521 children continuously enrolled in a prepaid health plan for 6 years were analyzed to identify if such a trend was present. The overall rates of children's health care use steadily decline with increasing age until early adolescence, at which time girls' rates modestly increase and boys' continue to decline. However, the prevalence of diagnoses for which an emotional basis may be presumed increases markedly during two major transitional periods: (1) early elementary school and (2) early adolescence. During both periods, there are notable differences between boys and girls with regard to rates and temporal patterns. Girls do not demonstrate the same increased rates during elementary school years as do boys. The study provides evidence from population-based data that for some children early school years and adolescence are times of increased stress. Children who are once diagnosed as having an emotional problem, presumably related to stressful life transitions, tend to continue having similar difficulties.

The Chesapeake Health Plan: an HMO model for foster children.

The model of health care delivery described here is a successful, workable approach to meeting the health care needs of foster children. Given sufficient flexibility in the regulatory process, it may be adapted to a variety of definable, high-risk populations. The actual delivery of care depends in part upon the administrative and physical resources available, but it is equally dependent upon the philosophy of care of the program and its staff and upon cooperative efforts between health care and social service agencies.

The foster care system and health status of foster children.

The foster home care system is the most commonly used alternative for the care of dependent children in the United States. However, it often fails to achieve its objective of returning the child to his home or providing a permanent substitute family. Children entering foster care have frequently suffered social, emotional, and medical neglect, and physical abuse. They have a high rate of chronic medical problems, educational handicaps, and severe emotional impairment. In many cases the health care that foster children receive fails to recognize and/or adequately address their disabilities. In order for the pediatric practitioner to work successfully with a foster child, he must not only provide comprehensive health care, but also must be familiar with the social welfare system within which the child lives.