results from formal medical evaluations, almost all influences require the subjective reports of people (often parents reporting for children) who must describe their perception of the presence or absence, severity, and duration of a particular health influence. Such perceptions tend to differ from person to person, raising important concerns about the validity of any single source of information, particularly when policy decisions (such as the distribution of resources) are to be based on such information.

Despite the fact that parents from different cultural backgrounds must complete these surveys, there are often insufficient data demonstrating that survey items are accurately understood by parents across different cultural contexts, and surveys are not consistently offered in multiple languages. While this challenge poses daunting obstacles to the interpretability of survey findings across cultures, new translation methods have been developed and described that may facilitate more valid responses across cultural groups (Erkut, Alacron et al., 1999b).

Another concept implicit in the committee’s conceptual approach is the important role of both positive and negative influences on health. If health trajectories are to be modified, then health measurement at a population level needs to clearly account for the presence and effect of influences, their direct and indirect relationship to each other, and to the health outcome of interest. For example, if substance abuse during adolescence is the outcome of interest, a conceptually driven and integrated health measurement strategy would measure and account for the effect of adverse influences on drug use (e.g., peer influences, school performance, lack of adequate parental supervision) as well as protective factors (e.g., mentoring relationships and educational and economic support).

Despite knowledge that adverse health influences often disproportionately fall on some population subgroups more than others, systematic collection of health care data on subpopulations at a local, state, or national level is episodic. Surveys rarely provide enough information to develop a comprehensive picture of the health of young children, or to understand the role of various influences during early childhood, or to assess their receipt of appropriate personal or public health services or the effect of health care on their health. While there has been recent increasing emphasis on the importance of early childhood, as well as considerable focus on adolescence, there has not been the same kind of focus on health influences in the intervening years.

MEASURING BIOLOGICAL INFLUENCES

The range of biological influences on children’s health are assessed using “biomarkers,” which are indicators signaling events in biological systems or samples (for review, see National Research Council, 1989). There are three categories of biomarkers: biomarkers of exposure, biomarkers of effect, and biomarkers of susceptibility (see Figure 5-1). The markers fall along the time course from exposure (e.g., prenatal exposure to alcohol) to health outcome (e.g.,



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