As the pace of social change quickens, children are faced with new social and environmental risks to their growth and development. Of these changes, childhood poverty poses the greatest threat to children’s well-being. One in four American children under the age of 3 years lives in poverty; (Haggerty 1999) a higher percentage of children live in poverty than any other age group. As pediatricians, we know that children in poverty experience a double jeopardy. First, they are more frequently exposed to risks to their health and development (such as lead poisoning, malnutrition, and family dysfunction). Second, children suffer more negative consequences (such as developmental delay and school dysfunction) from such exposure than do children with more advantaged socioeconomic circumstances. (Barry 2000)
Although recognition of and sensitivity to these risks have increased, primary preventive efforts, the cornerstones of pediatric practice, have failed to keep pace with changing circumstances. On the contrary, the pediatric primary-care clinician is asked to shoulder an ever greater burden in reducing the effects of social disadvantage on children–a trend that continues to increase as the social safety net for children has become increasingly porous. The primary-care clinician is enjoined to provide anticipatory guidance, to perform developmental surveillance, to prevent unintentional injuries, to recognize and address parental substance use and depression, to solve issues of child abuse and family violence, to advocate with the school system and other social agencies, to manage behavioral and family issues, etc–all in the context of a 20-minute health supervision visit. Clearly there is a limit to a clinician’s ability to address such a daunting agenda, and that limit has long since been exceeded, even for families without social disadvantages.
Perhaps the problem lies neither in the primary-care pediatrician’s abilities or motivation nor in the multitude of clinical expectations, but rather in a model of pediatric practice that has been essentially unchanged for the past 50 years: clinicians working one-on-one with a family in an office (with occasional support from a nurse or social worker). We need new models of pediatric primary-care service delivery–ones that link needed services within the pediatric practice (colocate) that traditionally have not been there or link services to other community-based programs. Such services should be those needed by parents to promote their children’s health and well-being and should be tailored to address common problems of children and families in that community. Although many families need and benefit from a coordination of services, families living in poverty may need additional help to ensure that they have the basics and access to other needed services in a fragmented system.
We will present some of the common problems facing pediatricians, family physicians, and nurse practitioners who work with children, especially those growing up in poverty, and suggest solutions based on our experience at Boston City Hospital (BCH), where we are developing a model of enriched pediatric primary care. This work is based on earlier work of Haggerty et al, (Haggerty 1999). We hope to stimulate creative thinking about how important services and professionals can be linked in the pediatric setting or in other child programs (eg, Head Start programs, day care, and family support programs) to enhance preventive efforts and combat social risk.
Providing the Basics
Lack of money restricts a family’s ability to afford medical care, medication, housing, and healthful food, and to live in a safe neighborhood. At BCH, for example, we have found that children are more likely to be underweight in the winter months (Frank 1991) (presumably because limited funds are being diverted from food to fuel), and that iron deficiency is less common among children whose parents received housing subsidies compared with those on a waiting list for such subsidies. All pediatricians working with children at high risk have experienced the frustration of repeatedly prescribing an asthma medication for a child living in a poorly heated, moldy, overcrowded apartment or watching a child’s weight dip on the growth curve because of inadequate food in the home at the end of the monthly Aid for Dependent Children cycle.
It is one thing to recognize the social problems that plague children, quite another to be able to do something about them. Every primary-care clinician who tries to do so runs into significant barriers to helping children and parents receive the benefits to which they are entitled–barriers of inordinate paperwork, telephone delays, arcane rules and regulations, and an unsympathetic bureaucracy. Although well intentioned, most primary-care clinicians have not been trained in what families are legally entitled to, how to help parents gain access to resources and services, and how best to effect change in agencies and bureaucracies.
The most fundamental level of preventive pediatrics is ensuring that children have their needs for food, shelter, safety, and health care met. In collaboration with a community legal-aid agency, we have hired a public-interest lawyer to provide legal aid and advocacy to families at our Pediatric Primary Care Clinic. Serving as a legal family advocate, the lawyer helps families receive Medicaid, ensures that medically necessary nonprescription drugs (such as oral rehydration solution) are received by patients receiving Medicaid, redresses illegal housing evictions and reverses fuel shutoffs, arranges Social Security benefits for children with special needs, and fosters compliance with presumptive eligibility for Medicaid for pregnant women.
This work has evolved into a program that also identifies the system-wide issues affecting many patients and works with local legal-aid agencies and government programs to change those problems. Finally, the lawyer educates physicians, faculty, residents, nurses, social workers, and other staff members about how to advocate for patients effectively (eg, know the law, never take “no” for an answer, and keep talking to the next level of supervisor until the family’s legally entitlements are provided). In some pediatric settings, a paralegal or community outreach worker or case manager with backup from a legal-aid agency could provide similar services.
Parenting And Child Development
Collaboration with Early Childhood Educators
The importance of promoting competent parenting, optimizing children’s development, and identifying children with developmental problems are key elements of pediatric practice. However, many primary-care clinicians lack the time and/or expertise to do so. One way of addressing this problem is to team early childhood educators and child development specialists with practicing pediatricians. Early childhood educators, for example, can meet with parents before or after the pediatric checkup. At that time, they can answer parents’ questions about children’s development and behavior, provide general support and information about ongoing parenting issues, validate parental concerns, suggest solutions, and monitor children’s social and emotional development. (Greenspan 1995) They can identify children’s temperamental characteristics and parents’ expectations for behaviors to improve the fit or adaptation between parent and child. They can conduct parent groups that address behavioral and developmental issues.
We have found this collaboration between early childhood professionals and pediatricians to be especially enriching to pediatric practice. Educators provide a broader view of health that allows pediatric health supervision truly to address issues of behavior and development in a more comprehensive and systematic way. Our collaboration between educators and pediatricians has led to a special pro-gram to promote literacy in young children. (Senior 1998) The program trains pediatricians to promote early literacy and models book sharing in the waiting room by volunteers reading to children.
Most importantly, a developmentally appropriate book is given to each child at each pediatric primary-care visit (starting at 6 months of age). We have given away more than 30 000 books during the past 4 years. An evaluation of the program shows that mothers who received books were four times more likely to read to their children than mothers who had not received books, and, among mothers at high risk, there was an eightfold increase in book sharing with their children. (Needlman 1991) With support from the Casey Foundation, BCH is developing a training center to replicate this program in primary-care settings serving children at high risk nationally.
In some ways, an early childhood educator in a pediatric practice or clinic is comparable to school-based health programs. Physicians and health personnel work in the school because that is where the children are. Younger children, however, are found in the pediatrician’s office, and it is there that we need to have the services of an educator.
The Link Between Parental Health And Child Health: A Two-Generation Approach To Child Health
Parental Health Issues
The best way of helping children is to help their parents, and the best way of reaching parents is through their children. The relationship between parental health and child health has received inadequate attention in the past. New research findings show a clear link between a mother’s use of health services for herself and her use of services for the child, (Barry 2000) as well as between selective aspects of parental and children’s health. Importantly, new and effective treatment of some of these adult health problems recently has become available. These findings suggest the need for a two-generation approach to child health, one that uses the pediatric visit to enhance parents’ health, especially their health behaviors and mental health. After pregnancy, the pediatric primary-care system may represent the only health system with which parents are consistently involved and affords a window of opportunity to address their health.
At BCH, we have developed a successful model of two-generation health care: a clinic for both adolescent mothers and their children. In this program, both compliance and support for young families are enhanced by reducing fragmentation of care for mother and infant. We also will colocate women’s health clinicians and pediatric clinicians to be in the same clinic at the same time to provide similar benefits to older mothers and their children. Neighborhood health centers may be best suited to provide such integrated services, because internal medicine, obstetrics and gynecology, and other disciplines are usually housed in close quarters, with a single administrative body.
Family planning is an example of an important health behavior affecting children that should be addressed in a pediatric primary-care setting. Between 1985 and 1988, 12% of births in the United States to 15- to 30-year-old women were unwanted. Unwanted children are more likely to suffer abuse and neglect and to have behavior problems than their wanted peers. (Atpert 1996) Contraceptive failure or improper use of a contraceptive method results in 47% of unintended pregnancies in the United States (about 1.7 million annually).
Many of the remaining unwanted pregnancies occur because no contraception was used at all. (Barry 2000) Pediatricians must continue to address the prevalence of unintended pregnancy among teenagers, but they also must be aware that older women (including those who already have children) give birth to three times as many unplanned children as do teenagers? New and better contraceptives, such as Norplant and Depoprovera, provide greater effectiveness in preventing unplanned and unwanted pregnancies? and the pediatric setting often offers an underused forum to address child spacing and to provide family-planning information and, in some cases, family-planning services.
Women’s Health Issues
Women’s health before conception recently has received increasing attention? Recent studies have confirmed that vitamin supplementation (especially with folic acid) before conception prevents birth defects, such as spina bifida. (Meyers 1993) Additionally, because a growing number of women having children are unmarried, counseling regarding safe sex is needed to reduce the likelihood of a woman contracting the human immunodeficiency virus or other sexually transmitted diseases and transmitting them to her fetus.
Maternal use of excessive alcohol, psychoactive drugs, and cigarettes during pregnancy is another important determinant of children’s health. Smoking-cessation programs during pregnancy, for example, have proved effective in reducing smoking and improving birth weight. (Haggerty 1999) Although most studies have focused on use during pregnancy, the use of drugs and cigarettes can affect children’s health throughout childhood. Passive smoking during the first 2 years of life, for example, increases the risk of colds, ear infections, respiratory problems (especially asthma), sudden infant death syndrome, and behavior problems. (Senior 1998)
Nicotine gum and nicotine patches are inappropriate during pregnancy, but they can be aids to parents who try to stop smoking after the birth of their children. Smoking-cessation efforts should become an integral part of pediatric primary care by pediatricians identifying parents who smoke and referring them to programs. In a one-stop-shopping model, smoking-cessation programs also could be conducted in the pediatric office (eg, in the evening or Saturday morning by trained individuals).
Common to all of these parental health issues adversely affecting child health is the fact that the pediatric visit may provide a special (or the only) professional opportunity for health-promotion services for parents. For this reason, we recommend that issues in women’s health be addressed as part of an extended visit by a professional trained in such issues. This could include: a gynecologist, nurse midwife, or nurse practitioner seeing the mother immediately before or after the pediatric visit; smoking-cessation efforts individually and/or in groups by trained individuals at specified times; and counseling on health issues by a health educator or family planner. As resources allow, the provision of two-generation health care in the pediatric setting will improve not only parent but also child outcomes.
Parental Mental Health
Depression is a common mental health problem with well-documented adverse effects on children’s health. For example, infants born to depressed mothers are at increased risk for low birth weight and irritability at birth and for sleep problems during infancy. During preschool years, children of depressed mothers may continue to have sleep problems and show an increased incidence of other behavior problems, psychosomatic symptoms, and accidents. During school age and adolescence, depression, attention deficit hyperactivity disorder, and other behavior and learning problems may be seen if mothers are depressed.
Addiction is the compulsive use of a psychoactive substance (or substances), loss of control over that use, and continued use despite adverse consequences. Alcoholism is the most common parental addiction. Approximately one in eight children has an alcoholic parent. Although the prenatal effects of alcohol use (such as fetal alcohol syndrome) are important, the health and developmental implications of being parented by an active alcoholic are equally worrisome. Children of alcoholics are at an increased risk for injuries, for example, including the increased risk of motor vehicle fatalities. Overall, they have more hospital admissions and longer lengths of stay than children whose parents are not alcoholic? Adolescent children of problem drinkers have higher rates of depression and low self-esteem, and they drink more heavily than their peers. They are more likely to be placed in foster care and are at increased risk of becoming delinquent or attempting suicide. (Nettleton 2001)
These problems can and should be identified by the primary-care clinician. Linkages with mental health professionals provide a critical adjunct to child health care. Whether these services are provided within the practice or at an accessible referral site will depend on the interest and availability of providers, the prevalence of the problem in the practice, and available resources.
At BCH, we are addressing parental mental health and substance use issues in the pediatric primary-care setting by using a psychiatric nurse specialist with special training in problems of addiction. This clinician is easily available to the primary-care provider for on-site consultations and long-term treatment. Aside from the therapeutic benefits of such an arrangement, the primary-care clinicians are better able to identify such problems when they know that help is close at hand.
The risks to children’s well-being are accelerating because, in part, of an increasingly porous social safety net. Pediatricians are being asked to bear an ever-increasing burden for helping children and families address a myriad of issues, and they have become the providers of last resort. As the distance between what we should do and what we can do as clinicians widens, so too does our frustration and willingness to consider addressing yet one more issue. We often retreat to the comfortable world of otitis media and immunizations and shut out the loud cacophony of the outside world and its effects on our families. We need a new model of care, based on an ecological approach to child health consistent with Bright Futures, (Nettleton 2001) which provides child health supervision guidelines.
To meet these needs, some settings may develop models in which skilled professionals can provide advocacy services, parental health, parental mental health, and child development services in the context of pediatric practice. Although most practices or clinic programs will not have the space or resources to include all of these services, the development and implementation of any one of them will enrich the care of children and families. Other services such as legal aid, family literacy, and mental health may be available in the community and could be colocated in the pediatric setting as outreach efforts on the part of these programs or linked in a manner that ensures accessibility. Similar enhancements to primary-care programs for special groups of children at risk, including those who are homeless, drug exposed, in foster care, and born to teen-age mothers, are being developed in many communities.
The cost of such services presents difficult obstacles. However, given the progressive growth of prepaid practices and competition among plans for patients, services such as those provided by a child development specialist might increase the attractiveness of the plan and allow recruitment of more families. Reducing cigarette smoking, preventing unwanted pregnancy, and reducing drug and alcohol use have potential cost-saving implications that will interest managed-care programs. On the other hand, health care plans may limit services if potential financial benefits are unpertain or acrue to another sector such as schools. For populations at risk, especially health-education collaboration of this type (whether funded and/or cofunded with funds from federal or state department of education budgets, Medicaid, managed-care contracts, tobacco tax revenues, and/or federal family planning funds) should be pursued.
Most of the services we have described are, in fact, already available in most communities and/or health plans. Without new net costs, it may be possible to reallocate some or all of these services to the pediatric primary-care setting in a single-site, one-stop-shopping model. Redeploying services to the pediatric primary-care setting may increase accessibility to these important preventive services and improve the health and well-being of children and their parents.
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