Click for next page ( 58


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 57
The Health Impact of Early Childhood Programs: Perspectives from the Brookline Early Education Project Melvin D. Levine and Judith S. Palfrey In the evaluation of early childhood programs the health status of the children enrolled is often a prominent issue. Planners and policy makers are likely to ask whether participation in such programs enhances children's health and, if so, whether the gains are substantial enough to justify the costs. In early childhood programs for which improved health is not a primary objective, program planners may want to know if the addition of a health-monitoring component would be cost-effective. As evaluators survey early childhood programs and their impact on health, they may consider the possibility of modifying the content of traditional preventive health care. They may examine the feasibility of collaborative service models that include the consoli- dation of early education and preventive pediatrics, so that communities can shape and upgrade simultaneously the health care and developmental monitoring of children. At first glance it might seem that the health of children is easily amenable to evaluation and measurement. Accurate numbers, however, are difficult to obtain and are often misleading. In this paper we outline some salient clinical and methodological issues that have become appar- ent to us in working at the Brookline Early Education Project analyzing the health impact of a comprehensive early childhood project. The first section of the paper delineates a number of critical issues facing evaluators. The second section discusses the scope of "health" by detailing the various background and process factors that need to be considered during evaluation. The third section outlines specific questions evaluators can ask as they measure the impact of health. Finally, drawing on our experiences with the Brookline Early Education Project, the last section 57

OCR for page 57
58 reviews seven evaluation prototypes and discusses matching alternative evaluation strategies to specific questions. l RELEVANT ISSUES FACING EVALUATORS Defining Health and Its Borders Health is more than the absence of disease. It is the absence of handicap, social and emotional discord, and environmental stress as well as the presence of resil- iency, stamina, and homeostasis. There is growing aware- ness that traditional pediatric health cannot be viewed apart from psychosocial, behavioral, developmental, and educational status (Richmond, 1975; Rutter et al., 1970; Haggerty et al., 1975). Functional health and its promotion have increasingly become the purview of the pediatrician working in conjunction with professionals from other disciplines (Levine, Brooks, and Shonkoff, 1980). Health issues are likely to involve other areas. For example, it is essential for those managing children with musculoskeletal defects to address the functional (i.e., gross and fine motor and psychosocial) impacts of such handicaps. Professionals helping neurologically impaired children must involve themselves in the assessment of higher-order cognitive function, self-esteem, behavioral adjustment, and related family issues. Health maintenance must include anticipatory guidance and counseling, for patterns of behavior are as much within the domain of child health as are infectious diseases and specific organ disorders. Table 1 samples the broad spectrum of child health disorders. So many factors are involved that it is easier to describe what should be included under the rubric of "health" than to isolate issues irrelevant to health maintenance. Describing Health Status Characterizing the health status of groups of children is even more difficult than characterizing individual health. Since universally acceptable scoring and weighting systems do not exist, the health evaluation of a cohort enrolled in an early childhood project can be costly to obtain and difficult to interpret.

OCR for page 57
59 TABLE 1 Some Negative Health Outcomes Whose Effects Early Education Projects Are Intended to Minimize 1. Poor growth and/or nutrition 2. Sensory deficits 3. Chronic illness and symptoms 4. Poor utilization of health services 5. Recurrent trauma 6. Neurological disorders 7. Neurodevelopmental dysfunctions 8. Psychosocial mobility 9. Mental retardation/multiple handicapping conditions lOe Life-threatening diseases A group's health status cannot be presented as a simple inventory of existing symptoms and conditions. Evaluators who wish to characterize the health status of a group of children need to take into account past medical events, family history, and current health. In addition, there must be estimates of vulnerability and resiliency, descriptions of health practices and knowledge (nutrition, exercise, and total environment), and accounts of medical service utilization. Describing Health Change After defining the limits of health as a subject matter and developing the descriptors to characterize group health status, evaluators must find measures of health change. This can be particularly challenging in the preschool child, as the morbidity itself evolves with age and many of the dysfunctions and disorders are self-limited or transient.

OCR for page 57
60 Sometimes changes in health are more apparent than real because different measures are used at different ages. Certain reflexes, for example, can be elicited in children who are three to six months old but not thereafter. Hearing and vision are easier to measure after three years of age than before. Some orthopedic difficulties may not be evident until a child attempts to walk. Children may have immunity to certain diseases at specific ages but not beyond. The descriptors of the health of children thus depend to some extent on which window one looks through at what time. Just as problematic for evaluators is the high prevalence of self-limited acute or subacute illnesses and the spontaneous health resiliency of young children (single, 1964; Miller et al., 1960). This makes it difficult to study both the occurrence of and recovery from acute disease. It may be particularly hard to attribute symptom abatement to treatment effects. Behavioral and developmental disorders of early child- hood reveal considerable instability over time as well. Although some researchers (Thomas and Chess, 1975; Taft, 1978) have suggested that behavioral characteristics may be maintained from infancy through childhood, others (Bell et al., 1971; Carey et al., 1977) have demonstrated that children who have "behavior problems" at age two or three may not be the same children who have difficulty in school. It may be impossible to identify precise endpoints of health change. For example, one may not be able to determine whether a child has had one prolonged episode of otitis media that never really healed or multiple ear infections (Giebink and Quie, 1978). This difficulty . . . - impedes any precise accounting of numbers of acute illness episodes during a given period. The measurement of health change is complicated for three reasons: (1) the actual content of health and morbidity evolves with age, (2) many conditions undergo spontaneous remission, and (3) some disorders are closely associated with others and are therefore indistinguishable from one another. Therefore, before looking at the impact of a program on health, evaluators should develop appro- priate methods of characterizing change: The health (of a group or individual) may vary depending on the period of time under scrutiny. The measures of health should therefore be dynamic, depending on the age and development of the children in a program. The measurement of health "progression" must somehow be differentiated from normal

OCR for page 57
61 chronological change. To document enhancement, evaluators must show that a particular child or group of children at the end of two years improved in overall health character- istics. As difficult as this may be, such documentation stands as a critical requisite for the evaluation of health as a progressive phenomenon. Dealing With Low Prevalence Rates in Pediatric Morbidity Pediatric illness differs fundamentally from its adult counterpart. In the latter, a relatively small number of major illnesses (e.g., hypertension, obesity, coronary heart disease, cancer, and diabetes) are likely to be highly prevalent within a population. Evaluators of adult health programs may be able to measure the impact of a program on these distinct entities and thereby generalize about health status and program-induced change. In contrast, there is no single chronic organic condition of childhood common enough to scrutinize in such a fashion without a very large sample. Therefore, in studying chronic medical conditions in a service program for chil- dren, it is often necessary to employ aggregate ratings that "lump" children with such disparate conditions as congenital heart disease, juvenile rheumatoid arthritis, nephrotic syndrome, recurrent urinary tract infection, and asthma for purposes of analysis. The alternative is to use samples that are too large for most early childhood projects. Resiliency in childhood also differentiates child health from adult health. Most child health setbacks are likely to be acute and self-limited, leaving no scars or aftereffects. Cataloging of such events shows that in a single year most children have been "sick" as many as four or five times (single, 1966). For children such morbidity is par for the course, developmentally appro- priate, perhaps immunologically necessary, and ultimately inconsequential (Mortimer, 1968). Evaluators thus need to weight acute self-limited disease very differently in children. Absence of Data on Normalcy In assaying pediatric health status, we are hampered by a paucity of data on normalcy and normal variation.

OCR for page 57
62 While information does exist regarding the prevalence of specific chronic diseases or congenital anomalies and the incidence of some acute illnesses, this information tends to reflect major social class differences (Morris, 1979), serious problems with reporting (Brewer and Kakalik, 1979; Bureau of Education for the Handicapped, 1979), and inadequacies in many of the measuring techniques (Balinsky and Berger, 1975). This distortion makes it especially difficult to determine if the health status of a partic- ular group of children is below or beyond what ordinarily might be expected. Normative data are even more deficient in assessing developmental status, behavior, family functioning, and health care utilization patterns. Much of traditional medical research has had the benefit of normative data. For example, it is possible to study the effects of a medication on a patient's glucose level, since norms for blood sugar are available. For many of the aggregate measures of community child health, however, no such norms exist (Starfield, 1974). What is "normal" or "to be expected" for a particular population must almost always be reestablished in undertaking evaluation research. In many instances this requires the use of comparison groups or control populations. Selecting Outcome Measures In documenting program effects on health, one critical issue is the precise outcomes to be measured at designated outcome points. One might be tempted to consider only the prevalence of morbidity as an outcome measure. This, of course, leaves out such issues as parental health knowledge, patterns of use, and children's health stamina. Furthermore, it is unlikely that the straightforward rendering of morbidity statistics constitutes an adequate reflection of project effectiveness. An early support project may be beneficial without diminishing the prevalence of a disorder. For example, one would not expect a program to lessen the occurrence of myopia, yet an effective effort might result in a reduction of previously undetected or untreated nearsightedness. In fact, an early childhood project may exert its greatest effects not on prevalence figures but on awareness, management, coping, and the prevention of complications. Another issue in selecting outcome measures is the need for a method of weighting. Health outcomes can be measured in terms of their severity, their impact (on

OCR for page 57
63 function, on families, on society), and their relevance, so that composite morbidity may be subdivided into significance for treatment (prescriptive implications) and potential for impairment of future health or function (predictive weight). Even a low prevalence of disorders that are likely to thwart academic function or behavioral adjustment may be more important than a high occurrence of such disorders as flat feet. Evaluators might also want to select outcome measures that have significant implications for treatment. A project should be judged more harshly if it missed problems that were treatable than if it overlooked those for which no therapy was available. Outcome measures should not be too global, particularly with regard to developmental and behavioral assessments. A project that uses IQ as an outcome measure will not be pinpointing the prevalence of problems with attention, language, or other isolated information-processing deficits that can seriously impair function (Levine, Brooks, and Shonkoff, 1980). Similarly, the results of a developmental screening test by themselves are unlikely to be sufficient to describe a pro3ect's impact on children's development (Meter, 1973; Meissels, 1978). ~ more comprehensive picture would include parental reports of function, direct observations of behavior, or specific teacher accounts of skills, abilities, and interest. One challenge for those evaluating early childhood projects is the identification of measures that can be used to provide an in-depth assessment of function to determine whether the program has diminished or minimized the effects of so-called low-severity, high-prevalence dysfunctions of childhood, which include specific learning disabilities, primary attention deficits, and various forms of psychosocial maladaptation during the school years. In delineating outcome measures, evaluators should consider the objectives of the project under scrutiny. For instance, if health is a high priority of a given project and if assurance of primary care is an explicit goal, then it is appropriate to determine if the project has met that goal by assessing patterns of health care utilization of the enrolled children. This approach may be less relevant in projects that have had only an incidental commitment to health. Finally, within a given population uniformity of outcome measurement may be unrealistic and inappropriate, especially in programs emphasizing the individualization

OCR for page 57
64 of services. To measure gains, evaluators may need to specify "target subgroups." For a subgroup with hearing deficits, incremental growth in vocabulary may be a better measure of program effectiveness than mean developmental scores at ace five. Evaluators can identify areas in which they would expect or hope to see progress for particular children. They might also weigh expectations For example, a project may not against accomplishments. be able to diminish the prevalence of problems with short-term memory in children, but it might be able to achieve a generalized improvement in the reading proficiency of children with short-term memory problems, a gain that would surpass what would be expected for nonparticipating children with this developmental dysfunction. Thus, although a project may not diminish the severity or prevalence of short-term memory problems, it may manage to have "better capers," more competent readers, and perhaps happier children within this target subgroup. In some cases a project may want to evaluate only specific target groups to demonstrate program effects. When an evaluation becomes this focused, however, either large numbers or elegant small sample designs are needed to demonstrate that intervention has been successful. Assessing the Cost-Effectiveness of a Health Program Evaluation A major challenge exists in the calculation of a cost-benefit ratio for health program evaluations. There is constant pressure to balance the expense and difficulty of acquiring a particular set of data against its ultimate value for children and its relevance to the objectives of a project. It may be simple to determine immunization rates for a particular population, but if the project is located in a town where most children are well immunize`] anyway, despite its economy this will not be a useful way of measuring program impact. On the other hand, if a service model is likely to improve a family's ability to cope with behavior problems, a series of expensive measures of behavior and parenting may be most relevant (Haggerty et al., 1975; Roghmann et al., 1973; Haggerty, 1965). There can be no one set of criteria for evaluating all projects. Those aspects of health chosen for evaluation will depend largely on the nature of the community, the objectives of the program, the

OCR for page 57
65 availability of evaluation funds, and current public policy questions. Identifying The Evaluation Consumer In designing an evaluation of health outcome, it is essential to understand the needs and priorities of those for whom the evaluation is intended. The content of an analysis depends largely on its intended audience. It can be argued, however, that all evaluations should be able to undergo some degree of rigorous scrutiny, even if intended primarily for nonacademics. Purely anecdotal reports and testimonials are inadequate measures of health care provision under any circumstances; highly esoteric statistical analyses, on the other hand, may have little impact on school committee decision making or on the deliberations of legislators. Often evaluations must apply several formats, each designed for a unique constitutuency. Timing and Staging A critical issue for evaluation is timing. The health effectiveness of a program can be documented while it is . . ~ one could consider assessment in progress. Alternatively, of its impact at the end of a project or at a short or long interval following termination. Decisions about timing must consider what is being measured and demon- strated. If a major goal is to minimize morbidity and suffering and to cushion the traumatic impact of daily events and environments, then it is crucial to offer evaluations while the project is in progress. If the goal is to look at the long-range effects of intervention or general service, postintervention analyses are needed. Findings inevitably reflect the timing of an evaluation, and the implications can be -treat, especially for issues of cost-effectiveness Because of the instability of health conditions in childhood and the high degree of resiliency, the timing of evaluations significantly influences the attribution of program effects, which can be misleading from a public policy viewpoint. For example, if children in a particular program have less difficulty adjusting to the first weeks of kindergarten than nonparticipants, evaluators may feel that they have documented a measurable effect. It may turn out, however,

OCR for page 57
66 that the two groups are virtually indistinguishable if they are evaluated in mid-February of the kindergarten year. Allocators of resources would wonder if great expenditures to promote "educational readiness" were really worthwhile if their effects were demonstrable only during the earliest months of kindergarten and thereafter washed out. Traditional health issues follow a similar pattern. If a child's flat feet are detected in an early childhood project, but the child has no pain or functional limita- tion and it is documented that the finding would otherwise not have emerged until the first or second grade, what has been gained? In any event, by the time the child is eight or nine, the parents are likely to be aware of the condition. In that case, what is the value of early detection? Assuming that the condition is discovered early and the child given corrective shoes, does it really make a difference (Bleck, 1971; Cowell, 1977)? In some cases it may be better not to diagnose a problem that is going to resolve itself or that may not cause symptoms or require treatment for several years. It may be that years after a program ends there is little difference in the prevalence of previously undiagnosed findings. One might argue that ultimately the important problems will be detected. There is a danger that early detection may obligate programmers to unnecessary expenditures for interventions, especially for conditions that are likely to remit spontaneously. Once again, it is important to review the objectives of a project. The timing of an evaluation of program effects should relate to the objectives. In stating objectives there should be some consideration of the anticipated or desired duration of effects. Outcome measures can then be timed to assess these accordingly. Having delineated these issues for the evaluation of program effects on health, we now turn to a more detailed examination of the measurement of health status. The next section describes this as a necessary step in demon- strating the influence of a specific program on health. THE SCOPE OF CHILD HEALTH As early childhood programming expands, the literature from education (e.g., U.S. General Accounting Office, 1979; Lazar, 1977; Bronfenbrenner, 1975; White, 1975; Zigler and Valentine, 1979) and pediatrics (e.g.,

OCR for page 57
67 Richmond, 1975; Thomas and Chess, 1975; Taft, 1978; Carey et al., 1977; Roghmann et al., 1973; Klaus and Kennell, 1976; Morris et al., 1976; Badger et al., 1976) makes it clear that the scope of child health that can be addressed is very wide. Clearly, evaluators should focus on those aspects of a health program that are most likely to reveal efficacy. In our work at the Brookline Early Education Project (Pierson, 1974) and the school clinics at Children's Hospital Medical Center in Boston (Levine, 1979), we have found it most helpful to define (1) the background health characteristics of the children, (2) the ongoing health and developmental processes at home and in the program, and (3) the outcomes that the program intends to achieve. Only with these areas clearly defined does it become possible to address specific questions regarding program impact. Background Variables From the intrauterine period onward, the experiences of children vary significantly. Some endure prenatal and postnatal trauma, some are born into impoverished and disorganized families, some inherit genetic disorders, and some fail to receive adequate nurturance. Others, because of their constitutional makeup, never adjust optimally to their milieu and continually hunger for greater satisfaction from it. Still others arrive with ease, cope readily, and manifest little or no disability in dealing with the external world. Programs dealing with young children generally take these variations into account for staffing and pro- grammatic reasons. To do so for outcome measurement is equally critical. Children who are more "at risk" will require greater levels of service; their outcomes may turn out to be excellent, but they differ from children not at risk. For instance, the most pertinent outcome measures for a middle-class deaf child might be ease with a hearing aid, skill in using a total communication system, and ability to attend a normal school for at least some of the day. On the other hand, outcome measures for a normally hearing child from a socio- economically depressed and disorganized home might be assurance of primary health care, money for food, and an adequate after-school, supervised program. Because the health needs of children are so varied, programmers, monitors, and policy makers should keep

OCR for page 57
98 the needs of public Policy makers and investigators, cross-fertilization between disciplines is likely to accelerate the process. We will have achieved a great deal if this paper can help foster such collaboration. REFERENCES Alberman, E. D., and Goldstein, H. (1970) The "at risk" register, a statistical evaluation. British Journal of Preventive and Social Medicine 24:129-135. Allen, H. F. (1957) Testing visual acuity in preschool children: norms, variables and a new picture test. Pediatrics 19:1093-1100. American Academy of Pediatrics, Committee on Children with Handicaps (1972) Vision screening in preschool children. Pediatrics 50:966-967. - Baddeley, A. (1976) The Psychology of Memory. New York: Basic Books. Badger, E., Burns, D., and Rhoads, B. (1976) Education for adolescent mothers in a hospital setting. American Journal of Public Health 66:469-472. Balinsky, W., and Berger, R. (1975) A review of the research on general health status indices. Medical Care 13:283-295. Bell, R. Q., Weller, G. M., and Walding, M. F. (1971) Newborn and preschoolers: organization of behavior and relations between periods. Monograph of the Society for Research in Chi Development 36(1-2). Bleck, E. E. (1971) The shoeing of children--sham or science? Developmental Medicine and Child Neurology 13:188-195. Brewer, G. D., and Kakalik, J. S. (1979) Handicapped Children. Bricker, D. D., and Iacino, R. (1977) Early intervention with severely/profoundly handicapped children. In E. Sontag, ea., Educational Programming for the Severely and Profoundly Handicapped. Reston, Va.: Council for Exceptional Children. New York: McGraw Hill.

OCR for page 57
99 Broman, S. H., Nichols, P. L., and Kennedy, W. A. (1975) Preschool IO: Prenatal and Developmental Correlates. New York: John Wiley & Sons, Inc. . Bronfenbrenner, U. (1975) Is early education effective? In H. J. Leichter, ea., The Family as Educator. New York: Teachers College Press, Columbia University. Bureau of Education for the Handicapped (1979) Progress Toward a Free, Appropriate Public Education. A Report to Congress on the Implementation of Public Law 94-142: The Education for All Handicapped Children Act. HEW Publication No. (OK) 79-05003. Washington, D.C.: U.S. Department of Health, Education, and Welfare. Carey, W. B., Fox, M., and McDevitt, S. C. (1977) Temperament as a factor in early school adjustment. Pediatrics 60:621-624. Cassady, G. (1975) Perinatal outcome and referral age. Pediatrics 56:160. Center for Disease Control (1975) Increased Lead Absorption and Lead Poisoning . in Young Children. Atlanta, Gal: U.S. Department of Health, Education, and Welfare. Center for Disease Control (1977) SummarY of Immunization Status: Preliminary Report: U.S. Immunization Survey, 1976. - Atlanta, Gal: U.S. Department of Health, Education, and Welfare. Chance, G. W., O'Brien, M. J., and Swyer, P. R. (1973) Transportation of sick neonates, 1972: an unsatisfactory aspect of medical care. Canadian Medical Association Journal 109:847. Chisholm, J. J. (1971) Lead poisoning. Connolly, C. (1971) Social and emotional factors in learning disabilities. In H. R. Myklebust, ea., Progress in Learning Disabilities. Vol. II. New York: Grune & Stratton, Inc. Cowell, H. R. (1977) Shoes and shoe corrections. Of North America 24:791-797. Scientific American 224:15-23. Pediatric Clinic

OCR for page 57
100 Davie, R., Butler, N., and Goldstein, H. (1972) From Birth to Seven: The Second Report of the National Child Development Study. London: Longman. Denckla, M. (1978) Naming of object-drawings by dyslexic and other learning disabled children. Brain and Language 3:231. Dingle, J. H. (1964) Illness in the Home. Cleveland, Ohio: The Press of Case Western Reserve University. Dingle, J. H. (1966) The common cold and common cold like illnesses. Medical Times 94:186-190. Elardo, R., Bradley, R., and Caldwell, B. M. (1975) The relation of infant's home environments to mental test performance from six to thirty-six months: a longitudinal analysis. Child Development 46:71-76. Fitzhardinge, P. M. (1975) Early growth and development in low birthweight infants following treatment in an intensive care nursery. Pediatrics S6:162-172. Fitzhardinge, P. M., and Steven, E. M. (1972) The small for date infant. II. Neurological and intellectual sequelae. Pediatrics 50:50-57. Folman, S. J. (1977) Nutritional Disorders of Children: Prevention, Screening and Follow-up. HEW Publication No. (HSA) 77-5104 Washington, D.C.: U.S. Department of Health, Education, and Welfare. Frankenburg, W. K. (1974) Selection of diseases and tests in pediatric screening. Pediatrics 54:612-616. Frankenburg, W. K., and North, A. F. (1974) A Guide to Screening for the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) Under Medicaid. HEW Publication No. (SRS) 74-24516. Washington, D.C.: U.S. Department of Health, Education, and Welfare. Giebink, G. S., and Quie, P. G. (1978) Otitis media: the spectrum of middle ear inflammation. Annual Review of Medicine 29:285-306.

OCR for page 57
101 Goldstein, K. M., Caputo, D. V., and Taub, H. B. (1976) The effects of prenatal and perinatal complications on development at one year of age. Child Development 47:613-621. S. L. Access to and Utilization of Ambulatory Medical and Dental Services Among Children in Genesee County, Michigan. Community Child Health Studies, Harvard School of Public Health, Cambridge. Gottlieb, N. H., and Wechsler, H. (1976) Immunization levels in Boston schools--a second look. New England Journal of Medicine 294:1459. Haggerty, R. J. (1965) Family diagnosis: Gortmaker, (1979) research methods and their reliability for studies of the medical-social unit, the family. American Journal of Public Health 55:1521-1533. Haggerty, R. J. (1976) Who will monitor access? Pediatrics . 57:169-170. Haggerty, R. J., Roghmann, K. J. 9 and Pless, I. B. e (1975) Child Health and the Community. New York: John Wiley & Sons, Inc. Hanson, M. A., and Levine, M. D. (1980) Early school health: an analysis of its impact on primary care. Journal of School Health 50:577-580. Harvard Child Health Project Task Force (1977) Toward a Primary Medical Care System Responsive to Children's Needs. Cambridge, Mass.: Ballinger Publishing Co. Hayden, A. H., and McGuiness, G. D. (1977) Bases for early intervention. In E. Sontag, ea., Educational Programming for the Severely and Profoundly Handicapped. Reston, Va.: Council for Exceptional Children. Horton, K. B. (1976) Early intervention for hearing-impaired infants and young children. In T. Tjossem, ea., Intervention Strategies for High Risk Infants and Young Children. Baltimore, Md.: University Park Press. Institute of Medicine (1973) Infant Death: An Analysis by Maternal Risk and Health Care. Washington, D.C.: National Academy of Sciences.

OCR for page 57
102 Institute of Medicine (1977) Primary Care in Medicine. A Definition. Washington, D.C.: National Academy of Sciences. Joint Committee on Infant Hearing Screening (1971) Joint committee statement on infant hearing screening. Journal of the American Speech and Hearing Association 13:79. Joint Committee on Infant Hearing Screening (1972) Joint committee statement on infant hearing screening. Journal of the American Speech and Hearing Association 16:160. Kempe, C. H., and Heifer, R. E., eds. (1972) Helping the Battered Child and His Familye Philadelphia, Pa.: J. B. Lippincott Co. Kephart, N. C. (1971) The Slow Learner in the Classroom. Columbus, - Ohio: Charles E. Merrill. Kessner, D. M., Snow, C. K., and Singer, J. (1974) The Assessment of Medical Care for Children. Volume 3. Washington, D.C.: Institute of Medicine. Klaus, M. H., and Kennell, J. H. (1976) Maternal-Infant Bonding. C. V. Mosby Co. Knobloch, H., and Pasamanick, B. (1966) Prospective studies on the epidemiology of reproductive causally: methods, findings and some implications. Merrill-Palmer Quarterly of Behavior and Development 12:27-43. Koff, E., Boyle, P., and Pueschel, S. M. (1977) Perceptual-motor functioning in children with phenylketonuria. American Journal of Diseases of Children 131:1084-1087. Kopelman, A. E. (1978) The smallest preterm infant. American Journal of Diseases of Children 132 461-462. Kronstadt, D., Oberklaid, F., Ferb, T., and Swartz, J. (1979) Infant behavior and maternal adaptation in the first six months of life. American Journal of Orthopsychiatry 49(3) 454-464 e St. Louis, Mo.: Lazar, I. (1977) The Persistence of Preschool Effects: A Long-Term Follow-up of 14 Infant and Preschool Experiments. Report prepared for the Adminis- tration for Children, Youth, and Families, U.S. Department of Health, Education, and

OCR for page 57
103 Welfare by the Education Commission of the States. Levine, M. D. (1979) The School Function Program: Profile of a General Pediatrics Consultative Service Model. Report prepared for the Robert Wood Johnson Foundation under Grant No. 4293. Levine, M. D., and Oberklaid, F. (1980) Hyperactivity--symptom complex or complex symptom. American Journal of Diseases of Children 134:409-414. Levine, M. D., Brooks, R., and Shonkoff, J. P. (1980) A Pediatric Approach to Learning Disorders. New York: Wiley Medical. Levine, M. D., and Meltzer, (1981) Developmental output failure: impaired productivity in the school aged child. Pediatrics 67:18-25. _ . D., Oberklaid, F., Ferb, T. E., Hanson, M. A., S., and Aufseeser, C. L. The pediatric examination of educational readiness: validation of an extended observation procedure. Pediatrics 66:341-349. Levine, M. D., Palfrey, J. S., Lamb, G. A., et al. (1977) Infants in a public school system: the indicators of early health and educational need. Pediatrics 60:579-587. Levy, J. D., Bonanno, R. A., Schwartz, C. G., and Sanofsky, P. A. (1979) Primary care: patterns of use of pediatric medical facilities. Medical Care 17:881-893. Lippmann, O. (1974) Directions for Use of the H.O.T.V. Test. The Good-Lite Company, Forest Park, Ill. Lippmann, O., Illiterate, E., Frankenburg, W. K., and Camp, B. W., eds. (1975) Pediatric Screening Tests. Springfield, Ill.: Charles C Thomas. Lowe, C. U., and Alexander, D. F. (1974) Health care of poor children. In A. Schorr, ea., Children and Decent People. New York: Basic Books. Levine, M. Palfrey, J. (1980) Meter, J. (1973) Screening and Assessment of Young Children at - Developmental Risk. President's Committee on Mental Retardation. HEW Publication No. OS-73-90. Washington, D.C.: U.S. Department of Health, Education, and Welfare.

OCR for page 57
104 Meter, J. (1975) Early intervention in the prevention of mental retardation. Pp. 385-409 in A. Milunsky, ea., Prevention of Genetic Disease and Mental Retardation. Philadelphia, Pa.: W. B. Saunders Company. Meissels, S. J. (1978) A Guide to Early Childhood Developmental Screening. Massachusetts State Department of Education. Miller, F. J. W., Court, S. D. M., Walton, W. S., and Knox, E. G. (1960) Growing Up in Newcastle Upon Tyne. London: Oxford University Press. Milunsky, A. (1975) Prevention of Genetic Disease and Mental Retardation. Philadelphia, Pa.: W. B. Saunders Company. Minear, R. E., and Guyer, B. (1979) Assessing immunization services at a neighborhood health center. Pediatrics - 63:416-419. Morris, A. G., London, R., and Glick, J. (1976) Educational intervention for preschool children in a pediatric clinic. Pediatrics 57:765-768. Morris, J. N. (1979) Social inequalities undiminished. Lancet 1(8107):87-90. Mortimer, E. A. (1968) Frequent colds. Pp. 211-215 in M. Green and R. J. Haggerty, eds., Ambulatory Pediatrics. Philadelphia, Pa.: W. B. Saunders Company. National Research Council (1976) Toward a National Policy for Children and Families. Advisory Committee on Child Development. Washington, D.C.: National Academy of Sciences. Needleman, H. L., Gunnoe, C., Levitan, A., et al. (1979) Deficits in psychologic and classroom performance of children with elevated destine lead levels. New England Journal of Medicine 300:659-665. Neligan, G. A., Kolvin, I., Scott, N. M., et al., eds. (1976) Born too soon or born too small. Clin. Dev. Med. 61. Philadelphia, Pa.: Spastics International Medical Publications, J. B. Lippincott Co.

OCR for page 57
105 Nelson, K. B., and Ellenberg, J. H. (1979) Newberger, (1976) Neonatal signs as predictors of cerebral palsy. Pediatrics 64:225-232. C. M., Newberger, E. H., and Harper, G. P. The social ecology of malnutrition in childhood. In J. Lloyd-Still, ea., Malnutrition and Intelligence. Lancaster, Pa.: Medical and Technical Publishing Co. Newberger, E. H., Newberger, C. M., and Richmond, J. B. (1976) Child health in America: toward a rational public policy. Milbank Memorial Fund Quarterly (Summer):249-298. Oberklaid, F., and Levine, M. D. (1980) Precursors of school failure. Review 2:1 (July). Pediatrics in Oberklaid, F., Dworkin, P., and Levine, M. D. (1979) Developmental behavioral dysfunction in preschool children. American Journal of Diseases of Children 133:1126-1131. Office of the Auditor General of California (1979) Special Education Financing Warrants Review Report, No. 843. Sacramento, Calif. Oski, F. A., and Hinig, A. S. (1978) The effects of therapy on the developmental scores of iron-deficient infants. Journal of Pediatrics 92:21-25. Palfrey, J. S., Mervis, R. C., and Butler, J. A. (1978) New directions in the evaluation and education of handicapped children. New England Journal of Medicine 298:819-824. Palfrey, J. S., Hanson, M. A., Norton, S., et al. (1980) Selective hearing screening for very young children. Clinical Pediatrics 19:473-477. Pierson, D. (1974) The Brooklyn Early Education Project: model for a new education priority. Childhood Education 50:132-136. Pierson, D. E., Levine, M. D., Ferb, T. E., and Wolman, R. (1980) Auditing Multidisciplinary Assessment Procedures: A System Developed for the Brooklyn Early Education Project. Paper presented at the Third International Conference on Early Identification of Children Who Are Developmentally "At Risk," Teton Village, Wyo., September 22-26.

OCR for page 57
106 Public Health Service (1976) Forward Plan for Health FY 1978-1982. Washington, D.C.: U.S. Department of Health, Education, and Welfare. Reynolds, R. C., Banks, S. A., and Murphee, A. H. (1976) The Health of a Rural Community. Gainesville, Fla.: University of Florida Press. Richmond, J. B. (1966) Communities in action: a report on Project Head Start. Reading Teacher 19:323-331. Richmond, J. B. (1975) An idea whose time has arrived. Pediatric Clinics of North America 22:517-523. Robinson, M. E., and Schwartz, L. B. (1973) Visuo-motor skills and reading ability: a longitudinal study. Developmental Medicine and Child Neurology 15:281. Roghmann, K. J., Hecht, P. K., and Haggerty, R. J. (1973) Family coping with everyday stress: self reports from a household survey. Journal of Comparative Family Studies 4(1):49-62. Rubin, R. A., Rosenblatt, C., and Balow, B. (1973) Psychological and educational sequelae of prematurity. Pediatrics 52:352-363. and Denckla, M. Relationship of IQ score and reading score to visual, spatial and temporal matching tasks. Journal of Learning Disabilities 9:169. Rudel, R., (1976) Rutter, Me (1974) Emotional disorder and educational underachievement. Archives of Disease in Childhood 49:249. Rutter, M., and Martin, J. A. M., eds. (1972) The child with delayed speech. Clinics in Developmental Medicine, No. 43. London: Spastics International Medical Publications. Rutter, M., Tizard, J., and Whitmore, K. (1970) Education, Health and Behaviour. London: John Wiley & Sons, Inc. Sameroff, A., and Chandler, M. (1975) Reproductive risk and the continuum of caretaking casualty. In F. Horowitz, ea., Review of Child Development Research, Vol. 4. Chicago, Ill.: Sheridan, M. (1970) Stycar Vision Test Manual. 2nd rev. ed. Windsor, Berks, England: NFER Publishing Co. University of Chicago Press.

OCR for page 57
107 Shipman, V.C. (no Maintaining and Enhancing Early Intervention date) Gains. Abridged version of Project Report 76-21 prepared for the Office of Child Develop- ment, U.S. Department of Health, Education, and Welfare, under Grant No. H-8256. Simmons, J. Q., and Tymchok, A. (1973) The learning deficits in childhood psychosis. Pediatric Clinics of North America 20:665-680. Smith, B., and Phillips, C. J. (1978) Identification of severe mental handicap. Child: Care, Health and Development 4:195-203. Smith, D. W., and Wilson, A. A. (1973) The Child with Down's Syndrome. Pa.: W. B. Saunders Company. Smith, S., and Simpson, K. (1975) The Battered Child Syndrome. London: Butterworth. Philadelphia, Starfield, B. (1974) Measurement of outcome: a proposed scheme. mailbag ~- ~-!-bE~3aBUJ_~: (winter):39-50 Stewart, A., and Reynolds, E. O. R (1974) Improved prognosis for infants of very low birth-weight. Pediatrics 54:724-735. Stewart, A. L., Turcan, D. M., Rawlings, G., et al. (1977) Prognosis for infants weighing 100 grams or less at birth. Archives of Disease in Childhood 52:97-104. _ Strangler, S. R., Huber, C. J., and Routh, D. K. (1980) Screening Growth and Development of Preschool Children. New York: McGraw-Hill Book Company. Sultz, H. A., Schlesinger, E. R., Mosher, W. E., and Feldman, J. G. (1972) Long Term Childhood Illness. Pittsburgh, Pa.: University of Pittsburgh Press. . Taft, L. T. (1978) Child development: prenatal to early childhood. Journal of School Health (May):281-287. Taylor, L., and Newberger, E. H. (1979) Child abuse in the international year of the child. New England Journal of Medicine 301:1205-1212. Thomas, A., and Chess, S. (1975) Temperament and Development. New York: Brunner/Mazel.

OCR for page 57
108 Tilford, J. A. (1976) The relationship between gestational age and adaptive behavior. Merrill-Palmer Quarterly 22:319-326. Tjossem, T. (1976) Early intervention: issues and approaches. In T. Tjossem, ea., Intervention Strategies for High Risk Infants and Young Children. Baltimore, Md.: University Park Press. U.S. General Accounting Office (1979) Early Childhood and Family Development Programs Improve the Quality of Life for Low Income Families. HRD-79-40. February 6. Vukovich, D. M. (1968) Pediatric neurology and learning disabilities. In H. R. Myklebust, ea., Progress in Learning Disabilities. Vol. I. New York: Grune & Stratton, Inc. Webb, T. E., and Oski, F. A. (1973) Iron deficiency anemia and scholastic achievement in young adolescents. Journal of Pediatrics 82:827. Weiss, H. B. (1979) Parent Support and Education: An Analysis of the Brookline Early Education Project. Thesis presented to the faculty of the Graduate School of Education, Harvard University. Werner, E. E., Beirman, J. M., and French, F. E. (1971) The Children of Kauai: A Longitudinal Study from the Perinatal Period to Age Ten. Honolulu: University of Hawaii Press. White, B. L. (1975) Critical influences in the origins of competence. Merrill-Palmer Quarter 21:243-266. Whitfield, T., and Walker, D. (no Personal communications regarding ongoing date) studies of the Community Child Health Studies Group at Harvard School of Public Health. Wiig, E., and Semel, E. (1976) Language Disabilities in Children and Adolescents. Columbus, Ohio: Charles E. Merrill. Wolff, P. H., and Hurwitz, I. (1966) The choreiform syndrome. Developmental Medicine and Child Neurology 8:160-165. Zigler, E., and Valentine, J., eds. (1979) Project Head Start: A Legacy of the War on Poverty. New York: The Free Press.