AMERICAN JOURNAL OF
Public Editorials Health September 1979 Volume 69, Number 9
Established 1911
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1980), Chairperson Ruth B. Galanter, MCP (1980) George E. Hardy, Jr., MD, MPH (1981) David Hayes-Bautista, PhD (1981) C. C. Johnson, Jr., MSCE (1980) Selma J. Mushkin, PhD (1981) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1981) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1981) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Michelle Horton Production Editor Monica Pogue Administrative Assistant Ann Profozich
Classified Advertising
Professional Paradigms in Child and Family Health Programs Future child and family health programs will be influenced both by research findings and by conceptual models and professional paradigms that influence the perception of problems and of potential solutions.' Chamberlin and his colleagues begin their evaluation of parent education in pediatric practices with discussion of questions about the well-child visit and end their report with a proposal to rethink preventive services for mothers and children.2 Questions about the future of well-child visits have been motivated by successes in prevention and treatment of biomedical problems and by increasing recognition of behavioral and developmental problems that contribute to morbidity and mortality of children and youth.3 4 Although Engel states, "The dominant model of disease today is biomedical and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness," he proposes a biopsychosocial model that would support increased attention to behavioral and developmental problems that might involve parent education in their solution.S However, Engel's biopsychosocial model, despite his discussion of a general systems theory perspective, does not explicitly include the ecological perspective that the health of the organism is influenced by interaction with the environment. Increasing evidence that health of the child and of the adult are greatly influenced by social relationships suggests the need to complement the view that focuses upon the isolated individual with a socioecological perspective that focuses upon the individual's family and community relationships.6'7 Engel's focus upon a pathological perspective of coping with disease and illness should also be complemented by a developmental perspective of fostering health, growth, and development. A biopsychosocial, ecological, developmental paradigm in child health would support a focus upon. the role of the parent while a biomedical, individualistic, pathological paradigm has contributed to a focus upon the role of the professional in screening, diagnosis, treatment, or prevention of specific pathology of the isolated child. The public health goal of primary prevention in child health might be most effectively achieved through a focus upon strengthening and supporting the family's role in fostering child development.
CONTRIBUTING EDITORS William J. Curran, JD, SMHyg Public Health and the Law Barbara G. Rosenkrantz, PhD Public Health Then and Now Jean Conelley, MLS Book Corner
AJPH September 1979, Vol. 69, No. 9
Characteristics of parental care as contrasted to direct professional care of the child include priority, duration, and continuity of contact; amount, extensity, intensity, and consistency of parent-child interaction; pervasive parental influence upon the child's environment and experiences; variability among families; and the continuing responsibility of the parent. Evidence that an infant's future health is more predictable from family environment variables than from child biomedical variables suggests the need to complement the current focus on the child with a major focus on family functioning.4 Increasing evidence of the father's influence upon child development suggests the need for a major effort to include the father or other family members in comprehensive child and family health programs.6 Thus both characteristics of parental care and accumulated research findings of correlations of family variables 849
EDITORIALS
with child health and development support an increasing emphasis upon supporting parental care in child health programs. The pioneering evaluation of the effects of current parent education during well-child visits by Chamberlin and his colleagues found only marginally significant effects upon maternal knowledge of child development and self-reports of maternal behavior.2 Since the goals of parent education in pediatric paractices appear to be similar to the goals of parent-centered early intervention programs, analyses of the accumulated research on such programs provide additional evidence of the effectiveness of parent education. Vopava and Royce,8 in an evaluation of variations among successful early intervention programs, found that projects that began at earlier ages, had goals for parents, involved home visits, and had a more favorable staff to child ratio, had significantly greater long-term effects upon the child's academic progress. A US General Accounting Office report entitled "Early Childhood and Family Development Programs Improve the Quality of Life for Low-income Families" concluded that such programs "can result in reduced health, social and educational problems in young children."9 Recommendations of that report that comprehensive child development programs should be increased gradually, evaluated, revised and improved as effective techniques are discovered and refined would also apply to parent education in child health programs. The marginally significant findings from current parent education within pediatric practices reported in this issue of the Journal suggest the need for improvements in both implementation and evaluation of specific techniques. Although the analysis is of effects of a total educational input score, different parent education techniques have different effects upon mothers and children. The use of handouts, a lending library, or bulletin board cannot be expected to have the impact of planned discussion with the parent during the wellbaby visit. Techniques that increase maternal knowledge may not be equally effective in changing maternal behavior. Increases in maternal reports of negative personality traits and a higher total symptom score for the child at higher levels of parent education raise the question whether a pathological focus upon identifying and responding to pathology was communicated by some parent education efforts. The skills and motivation of the parent educator as well as the amount of parent contact would influence program effectiveness. Successful parent-centered intervention programs have been implemented by professionals from many disciplines and by both high school and college graduate paraprofessionals. Additional research is needed on the effectiveness of different parent education personnel in child health services, as well as specific parent education techniques, including home visits and parent groups. More effective methods for evaluating the effects of parent education are also needed. Future reports of this nature should be extended by observations of mother-child interaction. Maternal reports of infant behavior and development should be supplemented by longitudinal follow-ups with objective measures of child development. Models for such evaluations are provided by evaluations of the parent-cen850
tered early intervention programs to which reference has been made. Research that has contributed to the differentiation of biomedical and biopsychosocial models for health services and to the formulation of individualistic, pathological and socioecological, developmental paradigms is relevant to current discussions of the well-child visit. Perhaps the goals of a biomedical, individualistic, pathological paradigm can be achieved in fewer child health visits but the broader goals supported by a biopsychosocial, socioecological, developmental paradigm would require comprehensive child and family health services that are more clearly focused upon strengthening the parental role in fostering health and development. Evidence of the long-term effectiveness of experimental parent-centered early intervention programs raises the question whether recommendations that those programs should be increased will be implemented by the health, education, child care, or child welfare systems. Since the health care system does have contact with parents and children during the prenatal and perinatal period and during the infancy and preschool years, the opportunity exists for the health system to make a major contribution to family functioning and to child health and development. Effective child and family health programs can be achieved through research, development and the evaluation of methods for strengthening and supporting family care and through training of professionals to apply parent education and involvement methods in child health programs.
EARL S. SCHAEFER, PhD
Address reprint requests to Professor Earl S. Schaefer, PhD, Department of Maternal and Child Health, School of Public Health 201-H, University of North Carolina, Chapel Hill, NC 27514.
REFERENCES 1. Kuhn TS: The Structure of Scientific Revolutions. Second Edi-
tion. Chicago: University of Chicago Press, 1970. 2. Chamberlin RW, Szumowski EK, Zastowny TR: An evaluation of efforts to educate mothers about child development in pediatric office practices. Am J Public Health, 69:875-886, 1979. 3. Haggerty RJ, Roghmann KJ, Pless IB: Child Health and the Community. New York: John Wiley, 1975. 4. Werner EE, Bierman JM, French FE: The Children of Kauai. Honolulu: University of Hawaii Press, 1971. 5. Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129-136, 1977. 6. Schaefer ES: Scope and focus of research relevant to intervention: A socioecological perspective. In TD Tjossem (ed.) Intervention Strategies for High Risk Infants and Young Children. Baltimore: University Park Press, 1976. 7. Berkman LF, Syme SL: Social networks, host resistance and mortality: A nine-year follow-up study of Alameda County residents. Am J Epid 109:186-204, 1979. 8. Vopava I, Royce J: Comparison of the long-term effects of infant and preschool programs on academic performance. Presented at the annual meeting of the American Educational Research Association, Toronto, 1978. 9. Report to the Congress by the Comptroller General of the United States: Early Childhood and Family Development Programs Improve the Quality of Life for Low-income Families. Washington, DC: US General Accounting Office, 1979, p. i, HRD-79-40.
AJPH September 1979, Vol. 69, No. 9
Public Editorials Health September 1979 Volume 69, Number 9
Established 1911
EDITOR Alfred Yankauer, MD, MPH EDITORIAL BOARD Michel A. Ibrahim, MD, PhD (1980), Chairperson Ruth B. Galanter, MCP (1980) George E. Hardy, Jr., MD, MPH (1981) David Hayes-Bautista, PhD (1981) C. C. Johnson, Jr., MSCE (1980) Selma J. Mushkin, PhD (1981) George M. Owen, MD (1979) Doris Roberts, PhD, MPH (1980) Pauline 0. Roberts, MD, MPH (1979) Ruth Roemer, JD (1981) Sam Shapiro (1979) Robert Sigmond (1979) Jeannette J. Simmons, MPH, DSc (1981) David H. Wegman, MD, MSOH (1979) Robert J. Weiss, MD (1980) STAFF William H. McBeath, MD, MPH Executive DirectorlManaging Editor Allen J. Seeber Director of Publications Doyne Bailey Assistant Managing Editor Michelle Horton Production Editor Monica Pogue Administrative Assistant Ann Profozich
Classified Advertising
Professional Paradigms in Child and Family Health Programs Future child and family health programs will be influenced both by research findings and by conceptual models and professional paradigms that influence the perception of problems and of potential solutions.' Chamberlin and his colleagues begin their evaluation of parent education in pediatric practices with discussion of questions about the well-child visit and end their report with a proposal to rethink preventive services for mothers and children.2 Questions about the future of well-child visits have been motivated by successes in prevention and treatment of biomedical problems and by increasing recognition of behavioral and developmental problems that contribute to morbidity and mortality of children and youth.3 4 Although Engel states, "The dominant model of disease today is biomedical and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness," he proposes a biopsychosocial model that would support increased attention to behavioral and developmental problems that might involve parent education in their solution.S However, Engel's biopsychosocial model, despite his discussion of a general systems theory perspective, does not explicitly include the ecological perspective that the health of the organism is influenced by interaction with the environment. Increasing evidence that health of the child and of the adult are greatly influenced by social relationships suggests the need to complement the view that focuses upon the isolated individual with a socioecological perspective that focuses upon the individual's family and community relationships.6'7 Engel's focus upon a pathological perspective of coping with disease and illness should also be complemented by a developmental perspective of fostering health, growth, and development. A biopsychosocial, ecological, developmental paradigm in child health would support a focus upon. the role of the parent while a biomedical, individualistic, pathological paradigm has contributed to a focus upon the role of the professional in screening, diagnosis, treatment, or prevention of specific pathology of the isolated child. The public health goal of primary prevention in child health might be most effectively achieved through a focus upon strengthening and supporting the family's role in fostering child development.
CONTRIBUTING EDITORS William J. Curran, JD, SMHyg Public Health and the Law Barbara G. Rosenkrantz, PhD Public Health Then and Now Jean Conelley, MLS Book Corner
AJPH September 1979, Vol. 69, No. 9
Characteristics of parental care as contrasted to direct professional care of the child include priority, duration, and continuity of contact; amount, extensity, intensity, and consistency of parent-child interaction; pervasive parental influence upon the child's environment and experiences; variability among families; and the continuing responsibility of the parent. Evidence that an infant's future health is more predictable from family environment variables than from child biomedical variables suggests the need to complement the current focus on the child with a major focus on family functioning.4 Increasing evidence of the father's influence upon child development suggests the need for a major effort to include the father or other family members in comprehensive child and family health programs.6 Thus both characteristics of parental care and accumulated research findings of correlations of family variables 849
EDITORIALS
with child health and development support an increasing emphasis upon supporting parental care in child health programs. The pioneering evaluation of the effects of current parent education during well-child visits by Chamberlin and his colleagues found only marginally significant effects upon maternal knowledge of child development and self-reports of maternal behavior.2 Since the goals of parent education in pediatric paractices appear to be similar to the goals of parent-centered early intervention programs, analyses of the accumulated research on such programs provide additional evidence of the effectiveness of parent education. Vopava and Royce,8 in an evaluation of variations among successful early intervention programs, found that projects that began at earlier ages, had goals for parents, involved home visits, and had a more favorable staff to child ratio, had significantly greater long-term effects upon the child's academic progress. A US General Accounting Office report entitled "Early Childhood and Family Development Programs Improve the Quality of Life for Low-income Families" concluded that such programs "can result in reduced health, social and educational problems in young children."9 Recommendations of that report that comprehensive child development programs should be increased gradually, evaluated, revised and improved as effective techniques are discovered and refined would also apply to parent education in child health programs. The marginally significant findings from current parent education within pediatric practices reported in this issue of the Journal suggest the need for improvements in both implementation and evaluation of specific techniques. Although the analysis is of effects of a total educational input score, different parent education techniques have different effects upon mothers and children. The use of handouts, a lending library, or bulletin board cannot be expected to have the impact of planned discussion with the parent during the wellbaby visit. Techniques that increase maternal knowledge may not be equally effective in changing maternal behavior. Increases in maternal reports of negative personality traits and a higher total symptom score for the child at higher levels of parent education raise the question whether a pathological focus upon identifying and responding to pathology was communicated by some parent education efforts. The skills and motivation of the parent educator as well as the amount of parent contact would influence program effectiveness. Successful parent-centered intervention programs have been implemented by professionals from many disciplines and by both high school and college graduate paraprofessionals. Additional research is needed on the effectiveness of different parent education personnel in child health services, as well as specific parent education techniques, including home visits and parent groups. More effective methods for evaluating the effects of parent education are also needed. Future reports of this nature should be extended by observations of mother-child interaction. Maternal reports of infant behavior and development should be supplemented by longitudinal follow-ups with objective measures of child development. Models for such evaluations are provided by evaluations of the parent-cen850
tered early intervention programs to which reference has been made. Research that has contributed to the differentiation of biomedical and biopsychosocial models for health services and to the formulation of individualistic, pathological and socioecological, developmental paradigms is relevant to current discussions of the well-child visit. Perhaps the goals of a biomedical, individualistic, pathological paradigm can be achieved in fewer child health visits but the broader goals supported by a biopsychosocial, socioecological, developmental paradigm would require comprehensive child and family health services that are more clearly focused upon strengthening the parental role in fostering health and development. Evidence of the long-term effectiveness of experimental parent-centered early intervention programs raises the question whether recommendations that those programs should be increased will be implemented by the health, education, child care, or child welfare systems. Since the health care system does have contact with parents and children during the prenatal and perinatal period and during the infancy and preschool years, the opportunity exists for the health system to make a major contribution to family functioning and to child health and development. Effective child and family health programs can be achieved through research, development and the evaluation of methods for strengthening and supporting family care and through training of professionals to apply parent education and involvement methods in child health programs.
EARL S. SCHAEFER, PhD
Address reprint requests to Professor Earl S. Schaefer, PhD, Department of Maternal and Child Health, School of Public Health 201-H, University of North Carolina, Chapel Hill, NC 27514.
REFERENCES 1. Kuhn TS: The Structure of Scientific Revolutions. Second Edi-
tion. Chicago: University of Chicago Press, 1970. 2. Chamberlin RW, Szumowski EK, Zastowny TR: An evaluation of efforts to educate mothers about child development in pediatric office practices. Am J Public Health, 69:875-886, 1979. 3. Haggerty RJ, Roghmann KJ, Pless IB: Child Health and the Community. New York: John Wiley, 1975. 4. Werner EE, Bierman JM, French FE: The Children of Kauai. Honolulu: University of Hawaii Press, 1971. 5. Engel GL: The need for a new medical model: A challenge for biomedicine. Science 196:129-136, 1977. 6. Schaefer ES: Scope and focus of research relevant to intervention: A socioecological perspective. In TD Tjossem (ed.) Intervention Strategies for High Risk Infants and Young Children. Baltimore: University Park Press, 1976. 7. Berkman LF, Syme SL: Social networks, host resistance and mortality: A nine-year follow-up study of Alameda County residents. Am J Epid 109:186-204, 1979. 8. Vopava I, Royce J: Comparison of the long-term effects of infant and preschool programs on academic performance. Presented at the annual meeting of the American Educational Research Association, Toronto, 1978. 9. Report to the Congress by the Comptroller General of the United States: Early Childhood and Family Development Programs Improve the Quality of Life for Low-income Families. Washington, DC: US General Accounting Office, 1979, p. i, HRD-79-40.
AJPH September 1979, Vol. 69, No. 9
