Journal of Pediatric Psychology, Vol. 27, No. 7, 2002, pp. 637-646
© 2002 Society of Pediatric Psychology
Society of Pediatric Psychology Presidential Address: Opportunities for Health Promotion in Primary Care
University of Maryland School of Medicine
All correspondence should be sent to Maureen Black, Department of Pediatrics, University of Maryland School of Medicine, 655 W. Lombard Street, Suite 311, Baltimore, Maryland 21201. E-mail: mblack{at}umaryland.edu.
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Objective: To set an agenda for health promotion in primary care settings.
Methods: This is a review of the scientific bases of child development as applied to pediatric psychology and health promotion.
Results: Primary care is an ideal setting for health promotion because there is a "hidden morbidity" of children with unrecognized and untreated behavioral and developmental problems that, if unresolved, may lead to psychiatric and physical disorders and increased use of the health care system. Although pediatric psychologists endorse the importance of health promotion, there are few examples in the literature involving pediatric psychologists. Recommendations are provided for a proactive agenda for health promotion programs involving pediatric psychologists in primary care.
Conclusions: With conceptual homes in clinical and developmental psychology, expertise in theories of clinical and child development, scientific methods, and collaborative relationships with pediatricians, pediatric psychologists are in a unique position to develop and evaluate health promotion programs for use in primary care.
Key words: child development; health promotion; primary care; ecological theory.
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In the 1960s both pediatricians and psychologists recognized the merits of collaboration between the two disciplines and the beneficial impact on children's health and development (Kagan, 1965
; Wilson,
1964). With origins in both clinical and developmental psychology,
pediatric psychology emerged as a discipline dedicated to the
scientist-practitioner model and the examination of how conditions of health,
illness, and disability are related to children's behavior and development
(Routh, 1982;
Wright, 1967). Collaboration
with pediatricians has been a central component of pediatric psychology and a
hallmark of the profession's contributions in research, training, program
development, and clinical practice.
Health promotion refers to a wide range of activities designed to enhance
individual and family functioning. Building on recent advances in public
health, epidemiology, behavioral sciences, and statistics, health promotion
and disease prevention programs use behavioral and environmental factors to
advance physical and mental functioning
(Coie et al., 1993).
In the past, prevention programs were classified as primary, secondary, and
tertiary (Commission on Chronic Illness,
1957), depending on where they occurred in the disease process.
Primary prevention occurred prior to the manifestation of the disease,
secondary prevention occurred among those at risk for developing the disease,
and tertiary prevention occurred after the disease had been diagnosed. In
1994, the Institute of Medicine (IOM) recommended the adoption of a typology
that was more representative of the public health/health promotion nature of
prevention programs (Mrazek &
Haggerty, 1994). Under a framework developed by Gordon
(1983), programs were
classified according to the target population as universal, selective, and
indicated.
Universal programs are directed toward the entire population and are designed to promote healthy functioning or to decrease the likelihood of specific disorders. Public service announcements or campaigns to reduce smoking, use condoms, or increase physical exercise are examples of universal prevention programs, as are laws (e.g., gun control, bans on drug use). Universal programs are available to all and are often sanctioned by the community, but they are not individualized and are unlikely to be successful in the remediation of specific problems.
Selective programs are targeted at specific groups that are at risk for developing a disorder or have very early signs of an emerging disorder. Programs such as WIC (Supplemental Nutritional Services for Women, Infant, and Children), the Food Stamp Program, or the School Breakfast/Lunch Program, all of which have income eligibility, are designed to promote healthy functioning among children of low-income families who are at risk for nutritional problems that may interfere with their development or academic performance. By decreasing risk (e.g., hunger or lack of healthy food in this example) and bolstering protective factors, selective interventions attempt to reduce the likelihood of disorders and promote healthy development.
Indicated programs are designed to prevent the progression of pathological
processes and the emergence of secondary symptoms among those who have
symptoms of the disorder (Hyman,
1999). In addition, indicated programs often include health
promotion, as therapists help children and families build strategies not only
to avoid problems but also to advance healthy development. Indicated programs
are often individualized and characterize many of the activities implemented
by pediatric psychologists.
Although pediatric psychologists have endorsed the importance of prevention
and health promotion (Kaufman, Holden,
& Walker, 1989), there are few examples of either prevention
or health promotion in the pediatric psychology literature, particularly in
primary care (Roberts, 1994).
Yet primary care is an excellent venue for health promotion, particularly with
pediatricians' commitment to anticipatory guidance and early intervention
(Slaby & Stringham, 1994;
Zuckerman & Parker, 1995).
Not only is pediatric psychology in a unique position to collaborate with
pediatricians, but prevention and health promotion should be well received by
managed care companies with their emphases on cost containment and
accountability (Roberts & Hurley,
1997).
This article has three objectives: (1) to highlight the scientific base that underlies children's development, (2) to examine how principles from developmental science can be applied to health promotion, and (3) to provide recommendations for the incorporation of pediatric psychology into health promotion programs in primary care.
Ecological Conceptualization of Children's Development
Child development refers to the adaptational processes that occur as
children acquire increasingly complex skills and are socialized into the
roles, rights, and responsibilities of their society. Development is a
reciprocal process, guided by a complex multidimensional care system that
includes the child and extends to the caregiver, family, community, and
society (see Figure 1)
(Bronfenbrenner, 1993).
Children contribute to their own development through the integration of three
processes: (1) a neuromaturational unfolding of increasing differentiation,
(2) temperament, and (3) interactions they elicit from others. For example, as
children increase in size and demonstrate more skills, their caregivers
respond with expectations for increasingly complex behavior. In addition,
children who are perceived by their caregivers as having easy or pleasant
temperaments are seen as more rewarding and are more likely to elicit positive
caregiving interactions. In contrast, caregivers tend to become less involved
with children whom they perceive to be difficult
(Maccoby, Snow, & Jacklin,
1984). The introduction of an illness or disability can disrupt
this process, particularly if it interferes with a child's ability to learn,
upsets his or her temperament, or imposes restrictions on his or her
activities or interactions with others.
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Caregivers play central roles in children's development. For example,
children tend to have better developmental skills when their primary
caregivers are well educated and emotionally healthy, probably because when
caregivers' needs are met, they can direct more care and positive attention to
their children. In contrast, children of caregivers who lack education, have
mental health problems (e.g., depression), or are burdened by stress and
multiple demands are more likely to experience behavioral or developmental
problems, presumably because their caregivers have limited time and energy
with which to listen or to respond to them
(Rutter, 1989). Caregivers of
children with an illness or disability may experience additional challenges
associated with the financial, emotional, and time demands of caring for a
child who may not feel well or who requires extra attention. Children's
illness or disability can lead caregivers to alter their expectations for
their children. In some cases, caregivers try to protect children with an
illness or disability from the seemingly unnecessary challenges of daily life,
and, in other cases, caregivers try to ensure that children with an illness or
disability are able to handle the challenges of daily life as independently as
possible.
At the family level, children's development is influenced by the resources
and child-centered quality of the household. Children benefit from households
that are nurturant, include regular caregiving routines (e.g., predictable
times for meals), and provide opportunities for interactive play
(Yoos, Kitzman, & Cole,
1999). Again, these interactions may be altered by the demands
that an illness or disability places on family routines or resources.
Communities also influence children's development through the resources they provide. Some resources benefit children directly, such as health care services, day care centers, schools, and playgrounds. Other resources benefit children indirectly by providing services to their families, such as jobs, transportation, neighborhood security, and opportunities for family support. In recent years, federal legislation, such as the Individuals with Disabilities Education Act, has mandated that schools adopt inclusionary policies, whereby children with illnesses or disabilities are included in educational activities as much as possible. These policies not only facilitate the development of children with illnesses or disabilities but also increase the sensitivity of children without illnesses or disabilities.
At the society level, laws and policies protect children and provide opportunities for them, thereby promoting their development. For example, policies such as the Family and Medical Leave Act of 1993 ensure that families can care for their children in times of illness without fear of losing their employment positions.
Pediatric psychology fits into this process at every level. Although most
pediatric psychologists are involved in individually oriented programs with
children and caregivers, there are excellent examples of community-oriented
programs involving pediatric psychologists
(Black & Krishnakumar,
1998).
Transactional Care System
The ecological model is often applied to children's development through a
transactional care system (see Figure
1) (Sameroff & Chandler,
1975). This model illustrates the dynamic nature of children's
development and emphasizes the reciprocal interactions between children and
their caregivers. The transactional care system operates over time; as in any
systems model, changes in one component are reflected throughout the system.
In addition, the effects are cumulative, such that interactions that occur
early in the system continue their influence over time. The process becomes
clear when applied to problems associated with children's growth.
As Figure 2 illustrates, a
woman who is undernourished during her pregnancy and does not receive prenatal
care is more likely to give birth to a child with low birthweight (LBW) (<
2500 g). In comparison with full-term infants, infants born with LBW are
smaller and often have weaker cries and sucking skills
(Hack & Taylor, 2000).
These characteristics make infants with LBW more difficult to feed,
particularly for mothers who are undernourished themselves. A cycle emerges
whereby the small and weak infant is difficult to feed, does not grow well,
may be vulnerable to illnesses or disabilities, and lags behind in
developmental skills. Mothers often feel frustrated or frightened by infants
who are small and sickly and may limit their caregiving to holding
(Graves, 1976). This process
results in a negative cycle whereby infants do not elicit or receive the care
and attention they need to promote optimal development.
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Intervention can occur at multiple points. For example, intervention could be directed to the infant with LBW, perhaps through nutritional and developmental intervention that might be available through community nutrition programs, such as WIC, or through early intervention programs sponsored through the Individuals with Disabilities Education Act. If the child's growth and development improve, the child will be more likely to elicit and receive age-appropriate care and interaction from the caregiver.
In another example, intervention could be directed toward the caregiver and
the interaction between the caregiver and the child. Children's cues are
analyzed (e.g., how does a child express happiness or distress?), and
caregivers learn how to read and respond to children's cues. For example,
helping a caregiver recognize that an infant turns toward sound as early as
the first day of life increases the likelihood that the caregiver will talk to
the child, thereby increasing the interactions between the caregiver and
child. Videotaping the child and caregiver during mealtime or playtime is
another strategy that can help caregivers view themselves through the eyes of
their children and learn to be more responsive to their children's cues
(Black, Cureton, & Berenson-Howard,
1999; Webster-Stratton,
1994). Several examples of successful randomized controlled trials
utilize components of the ecological model to promote the development of
undernourished children (Black, Dubowitz,
Hutcheson, Berenson-Howard, & Starr, 1995;
Grantham-McGregor, Powell, Walker, &
Himes, 1991; Infant Health and
Development Project, 1990).
Returning to the example of the child born with LBW, if LBW were prevented, perhaps by a health promotion program directed toward improving the nutritional status of pregnant women and providing access to prenatal care, the cycle could be interrupted at the beginning. The infant would grow and develop at an expected rate, thus eliciting and receiving age-appropriate care and interactions from the caregiver and family, and the developmental problems associated with LBW would be avoided. There would be no need for extensive community interventions and resources could be spent on other issues.
Evaluation of Health Promotion Programs
Evaluation of health promotion programs occurs at three levels
(Feinstein, 1977). The first
level, efficacy, refers to optimal conditions. For example, university-based
health promotion trials are usually highly controlled and supervised, and
therefore serve as efficacy trials. The second level, effectiveness, refers to
trials conducted under field conditions. Most children receive services in
community or school-based programs, not in university centers. Thus,
effectiveness evaluations are necessary to determine whether procedures
efficacious under optimal conditions will work once they are integrated into
existing systems. The third level, efficiency, refers to the costs associated
with the health promotion program. Policy makers and managed care
administrators, who are responsible for the fiscal management of services,
want to be sure not only that programs are effective in promoting health but
also that the costs associated with the program are manageable.
Health Promotion Applied to Primary Care
The model proposed by Reiss and Price
(1996) for the promotion of
mental health can be applied to health promotion programs relevant to
pediatric psychology in primary care. These principles include (1)
identification of the risk and protective factors and mechanisms that underlie
threats to optimal health, (2) implementation of the strategies for health
promotion through rigorous methods, such as randomized clinical trials, and
(3) development of community partnerships to ensure that health promotion
programs are consistent with the community context and therefore likely to be
sustained.
For example, we conducted a short-term health promotion project among
low-income adolescent African American mothers
(Black, Siegel, Abel, & Bentley,
2001). Despite recommendations from the American Academy of
Pediatrics (AAP) and WIC that infants should receive only breast milk or
formula for the first 4 to 6 months of life, many mothers introduced
complementary foods (e.g., cereal in the bottle) as early as 2 weeks of age
(Bentley, Gavin, Black, & Teti,
1999). Ethnographic research indicated that the mothers' reasoning
(and that of the grandmothers) was that infants' cries and behavior usually
signaled hunger. The home-based intervention, which was guided by the
ethnographic research and ecological theory, extended the information provided
by pediatric providers by helping mothers interpret their infants' cues.
Mothers in the intervention group were more likely to adhere to the AAP
recommendations and to delay the premature introduction of complementary
feeding, compared to mothers in the control group. This example illustrates
that relatively brief, developmentally and culturally sensitive prevention
programs, implemented through primary care settings before problems have been
identified, can be effective in promoting caregiving recommendations. Such
programs enable providers to meet the increasing demands from parents for
advice regarding children's early growth and development
(Young, Davis, Schoen, & Parker,
1998) and to prevent health, behavioral, and developmental
problems.
Behavioral and Developmental Problems Among Children in Primary
Care
In the 1970s, Haggerty introduced the term "new morbidity,"
representing the social challenges to children's well-being, including
problems associated with poverty, disparities, child abuse, parental mental
illness or disability, and other areas
(Haggerty, Roghmann, & Pless,
1975). As pediatricians expanded their services to embrace this
expanded mandate, they discovered that 25% of children in primary care were
experiencing psychosocial problems, often referred to as the "hidden
morbidity" (Costello et al.,
1988; Haggerty,
1995; Kelleher, McInernt, Gardner, Childs, & Wasserman, 2000).
Unfortunately, many children with psychosocial problems are not identified and
therefore do not receive intervention
(Reiger, Goldberg, & Taube,
1978). The "hidden morbidity" has serious national
implications because children with behavioral and developmental problems are
less able to benefit from educational programs and other community services
and are at increased risk for serious psychiatric illness
(Szilagyi & Schor, 1998)
and for becoming high users of the health care system
(Janicke & Finney,
2000).
Behavioral factors are closely linked to physical health outcomes and to
the etiology and management of most acute and chronic illness or disabilities.
For example, obesity—a major public health problem among children and
adolescents in the United States—increases the risk for lifelong
psychosocial and medical problems, including cardiovascular disease and type 2
diabetes (Dietz, 1998;
Trojano & Flegal, 1998).
Dietary patterns and physical activity are two important determinants of
obesity that are largely under behavioral control
(Birch & Fisher, 1998;
Kohl & Hobbs, 1998). Thus,
there is an urgent need for programs to promote healthy patterns of dietary
behavior and physical activity that could be incorporated into primary
care.
Health Promotion Agenda for Primary Care
The recommendations for a health promotion agenda in primary care are built
on the structure provided by the scientist-practitioner model underlying the
profession of pediatric psychology. Health promotion programs should be guided
by a sound theory that incorporates the child's ecological context. Evaluative
criteria should be considered at the time the health promotion program is
implemented so the impact can be measured. Since program sustainability is
always a concern, advocacy for reimbursement should be a priority. Finally,
training and dissemination will ensure that future pediatric psychologists
learn from their mentors and can advance the field toward health promotion in
primary care.
Theory
There is a need for health promotion programs based on sound theoretical
principles and empirically validated strategies to guide the selection of
variables, strategies for implementation, and processes responsible for
behavioral change and maintenance.
Context
Health promotion programs should target multiple caregiving levels. Child
development results from an interactive, reciprocal caregiving process that
extends from children through family, community, and societal levels
(Bronfenbrenner, 1993). As
illustrated by the Jamaican intervention that included both nutritional
supplementation and developmental intervention
(Grantham-McGregor et al.,
1991), successful health promotion programs are integrated and
address multiple caregiving levels of the system.
Health promotion programs should be developmentally relevant. Although it
can be difficult to assemble a disease-specific group of children at the same
developmental level, it is not realistic to expect that a program designed for
one developmental level is necessarily appropriate for children at other
levels. For example, adherence to medical regimes is particularly salient
among adolescents, who are often struggling with issues of identity and
independence (Johnson, Perwien, &
Silverstein, 2000).
We need health promotion programs developed in collaboration with
interdisciplinary and community partners, including families, so they are
culturally relevant and can be incorporated into existing systems. The health
problems confronting children in this century are vastly different from those
confronting previous generations of children
(Haggerty, 1995). Not only
have social problems replaced many of the infectious diseases as major
contributors to children's morbidity but families have also changed. In some
communities, single-parent and multi-generational families have replaced the
traditional two-parent mother and father families. In addition, diversity in
ethnicity, gender roles, education, and economic resources contribute to the
confusion frequently confronting the role of families in children's health
care (Knitzer, 1993;
Sue, 1992). Families need to
be involved as partners in treating their children's problems
(Epstein et al., 1993), and
evaluations should include satisfaction and quality of life, as well as
specific treatment outcomes. In most managed care organizations, more
attention has been directed to cost and utilization than to satisfaction and
quality of life, particularly for relatively mild forms of behavioral and
developmental problems (Simpson &
Fraser, 1999). The large databases maintained by many managed care
organizations provide opportunities for psychologists to develop and evaluate
quality of life measures.
Evaluation
Health promotion programs should incorporate evaluation into the design of
the program. Rigorous designs, such as randomized controlled trials in which
evaluators are not aware of group assignment and systematic evaluation
procedures are used to examine change, provide relatively unbiased evidence
regarding the efficacy or effectiveness of the prevention
(Black & Holden, 1995).
Evaluation should extend beyond main effect models. It is not unusual for
prevention trials to have differential effects based on individual risk and
protective factors (Rutter,
1987). Individuals with a stronger sense of well-being and
connectedness (higher levels of self-esteem, self-efficacy, and support) are
often more able to take advantage of interventions
(Bronfenbrenner, 1993). For
example, when we evaluated the long-term effects of a home-based intervention
on the developmental skills of children with failure-to-thrive, we found that
benefits of the intervention were limited to children whose mothers were not
burdened by the negative affect associated with depression, anxiety, or
hostility (Hutcheson et al.,
1997). Presumably mothers with a negative affect were wrapped up
in their own issues and unable to benefit from the home intervention.
We need evaluations that focus on skills and behavior, rather than only on
knowledge and attitudes. The link between knowledge and behavior is often
indirect (Sigel, 1992), and
programs that change knowledge or attitudes have not gone far enough in
demonstrating a convincing impact. For example, Fisher and Fisher
(1992) found that early
programs to prevent HIV-risk behaviors were successful in promoting knowledge
but had no impact on risk behaviors. Once HIV prevention programs focused on
skill development, they were more successful in preventing risk behaviors
(Rotheram-Borus, O'Keefe, Kracker, &
Foo, 2000).
Health promotion programs should take a long-term perspective and examine
the impact of programs over time. For example, in a 15-year follow-up of a
randomized trial of home intervention among low-income mothers and children in
Elmira, New York, Olds and colleagues
(1997) found that families in
the intervention group had lower rates of child abuse and neglect, crime,
welfare use, and substance abuse, along with increased workforce
participation.
Reimbursement
Innovative models of reimbursement for health promotion, particularly those
that move beyond the need to rely on DMS-IV diagnostic codes to bill for
services, are needed. If psychologists have no way to bill for health
promotion services, children with chronic illnesses and disabilities will be
denied critical services unless they have a psychiatric diagnosis. This
restrictive reimbursement practice has dismantled many interdisciplinary teams
and replaced the provision of services to children with chronic illnesses or
disabilities with a less effective, though financially viable, single provider
model of care.
The Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and
Adolescent Version (Wolraich, Felice,
& Drotar, 1996), provides an opportunity for pediatric
psychologists to collaborate with pediatricians in the identification and
treatment of children with behavioral and developmental problems that have not
reached the threshold necessary for a psychiatric diagnosis. The DSM-PC was
developed with the philosophy that the quality of children's environments
should be incorporated into an assessment of their symptoms because the
environment could alter a child's vulnerability to behavioral and
developmental problems. In addition to 12 Situation Codes, providers are
encouraged to include risk and protective factors in their assessments of the
impact of environmental conditions on children's behavior and development.
Although the DSM-PC has been presented to pediatricians in national meetings
and in training sessions, it has not been adopted by most pediatric practices
and there are many unanswered questions regarding training and implementation
(Drotar, 1999). In addition,
it is unclear how managed care companies will view the DSM-PC codes because
the increased number of diagnostic classifications for children in the DSM-PC
will make it easier to identify children, thus leading to more requests for
reimbursement.
Training
Training pediatricians to screen for behavioral and developmental problems
is another potential role for pediatric psychologists. Although some
psychologists may fear that pediatricians will use these skills to provide
behavioral services themselves, Drotar
(1999) has argued that given
the existing demands on pediatricians and the large number of children with
unrecognized behavioral and developmental problems, most pediatricians will
refer children with behavioral problems to psychologists. Pediatricians who
have been trained by psychologists are likely to be more familiar with the
contributions of psychologists, thus facilitating collaboration.
Pediatric psychologists should incorporate trainees into health promotion
programs so future generations of pediatric psychologists are prepared to
implement and evaluate health promotion programs. Although training in health
promotion is incorporated into many pediatric psychology doctoral programs,
trainees will be more conversant with principles of health promotion if they
also have training in public health and epidemiology
(Winett, 1995). Training
models should be extended beyond mental health disorders to include general
health issues of relevance to children in primary care, such as nutrition,
injuries, child maltreatment, and risk-taking practices.
Dissemination
Findings should be published, whether they are positive or negative. For
example, the Fort Bragg continuum of care demonstration project is an example
of a trial conducted within the Army that was not effective in reducing mental
health diagnoses (Bickman, Lambert,
Andrade, & Penaloza, 2000). Future research can benefit from
the publication of these findings and should examine subgroup effects and
specific services of care.
Health promotion programs should include information on the costs of the
program, so estimates can be made on the efficiency of the program. For
example, Olds and Kitzman
(1993) estimated that the cost
of the 2
-year program ($3,300 in 1980 dollars) was recovered for
low-SES families before the child reached 4 years of age.
Pediatric psychologists should advocate for the sustainability of
successful programs. Although the advocacy or political process is not
familiar to most pediatric psychologists, the scientific background of the
profession prepares us to examine the efficacy, effectiveness, and efficiency
of programs, together with community, interdisciplinary, and consumer
partnerships. Thus, we can follow the guidelines posed by Wright
(1967) when he wrote about the
importance of taking a militant stand regarding programs that make a
difference in the lives of children.
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Conclusions |
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TopAbstractIntroductionConclusionsReferences |
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Primary care is an ideal setting for health promotion because there is a "hidden morbidity" of children with unrecognized and untreated behavioral and developmental problems likely to lead to psychiatric and physical disorders and increased use of the health care system. Pediatric psychologists, with expertise in theories of clinical and child development, scientific methods, and collaborative relationships with pediatricians, are in a unique position to develop and evaluate health promotion programs for use in primary care.
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Acknowledgments |
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Portions of this manuscript were presented in the presidential address of the Society of Pediatric Psychology, at the annual meeting of the American Psychological Association in San Francisco, August 1998. Preparation of this manuscript was partially supported by grant MCJ-240301 from the Maternal and Child Health Research Program, U.S. Department of Health and Human Services and by the Lanata-Piazzon Partnership.
Received March 28, 2001; revision received September 4, 2001; accepted November 16, 2001
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