Child Health Supervision Research Articles

The evolution of problem and social competence behaviors during toddlerhood: A prospective population-based cohort survey.

Research in developmental psychopathology has long been preoccupied with rather broad categories of behavior, but we know little about the specific behaviors that comprise these categories. The objective of this study was to: (a) estimate the prevalence of problem and social competence behaviors in the general population of children at 17 months of age, and (b) describe the continuity and discontinuity in the degree to which children exhibit these behaviors between 17 and 29 months of age. The results show that frequent problem behaviors are not typical of children under two years of age. Further, the results suggest that it is possible to distinguish between different types of problem behaviors before two years of age. In addition, the results show that gender differences in some problem behaviors are already present before two years of age, and increase in magnitude during toddlerhood. Finally, the results show that interindividual differences in problem behaviors observed before two years of age are stable. The predictive accuracy of frequent problem behaviors in children at 17 months of age was limited, however, with often a majority of toddlers not behaving this way a year later. Overall, our results suggest that toddlerhood represents a critical period when behavioral and emotional problems of potentially clinical significance emerge. Pediatricians should routinely ask parents to report the frequency of their young children's problem behaviors during child health supervision visits so that children whose frequent problem behaviors persist over time can be identified and possibly referred for treatment.

AAP Publications Retired and Reaffirmed

Technical Report: Alternative Dispute Resolution in Medical Malpractice. Pediatrics. 2001;107:602–607Policy Statement: Professional Liability Coverage for Residents and Fellows. Pediatrics. 2000;106:605–609Policy Statement: Immunizations for Native American Children. Pediatrics. 1999;104:564–567Circumcision Policy Statement. Pediatrics. 1999;103:686–693Policy Statement: Retinoid Therapy for Severe Dermatological Disorders. Pediatrics. 1992;90:119–120Policy Statement: Smallpox Vaccine. Pediatrics. 2002;110:841–845Policy Statement: Cholesterol in Childhood. Pediatrics. 1998;101:141–147Policy Statement: Privacy Protection of Health Information: Patient Rights and Pediatrician Responsibilities. Pediatrics. 1999;104:973–977Policy Statement: Guiding Principles, Attributes, and Process to Review Medical Management Guidelines. Pediatrics. 2001;108:1378–1382Policy Statement: Death of a Child in the Emergency Department: Joint Statement by the American Academy of Pediatrics and the American College of Emergency Physicians. Pediatrics. 2002;110:839–840Policy Statement: Reimbursement for Foods for Special Dietary Uses. Pediatrics. 2003;111:1117–1119Policy Statement: Age Limits of Pediatrics. Pediatrics. 1998;81:736Policy Statement: Postnatal Corticosteroids to Treat or Prevent Chronic Lung Disease in Preterm Infants. Pediatrics. 2002;109:330–338Policy Statement: Auditory Integration Training and Facilitated Communication for Autism. Pediatrics. 1998;102:431–433Policy Statement: Counseling the Adolescent About Pregnancy Options. Pediatrics. 1998;101:938–940Clinical Report: Helping Children and Families Deal With Divorce and Separation. Pediatrics. 2002;110:1019–1023Policy Statement: Intensive Training and Sports Specialization. Pediatrics. 2000;106:154–157Policy Statement: Risk of Injury From Baseball and Softball in Children. Pediatrics. 2001;107:782–784Policy Statement: In-line Skating Injuries in Children and Adolescents. Pediatrics. 1998;101:720–722Policy Statement: The Treatment of Neurologically Impaired Children Using Patterning. Pediatrics. 1999;104:1149–1151Policy Statement: The Pediatrician's Role in Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP). Pediatrics. 1999;104:124–127Policy Statement: Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease. Pediatrics. 1995;96:161–164Policy Statement: Health Supervision for Children With Sickle Cell Disease. Pediatrics. 2002;109:526–535The Prevention of Unintentional Injury Among American Indian and Alaska Native Children: A Subject Review. Pediatrics. 1999;104:1397–1399Policy Statement: Safe Transportation of Newborns at Hospital Discharge. Pediatrics. 1999;104:986–987Policy Statement: Surveillance of Pediatric HIV Infection. Pediatrics. 1998;101:315–319Policy Statement: Transporting Children With Special Health Care Needs. Pediatrics. 1999;104:988–992Policy Statement: Trampolines at Home, School, and Recreational Centers. Pediatrics. 1999;103:1053–1056Policy Statement: Scope of Practice Issues in the Delivery of Pediatric Health Care. Pediatrics. 2003;111:426–435.

Childhood obesity: Prevention practices of nurse practitioners

The purposes or this study were to (a) describe the prevention practices of nurse practitioners (NPs) regarding childhood obesity, (b) compare the practices of NPs by specialty, practice setting, and awareness of childhood obesity prevention guidelines, (c) identify relationships between prevention practices and demographic variables of NPs, and (d) examine the resources for and barriers to implementing prevention practices. A convenience sample of 99 family NPs (FNPs) and pediatric NPs (PNPs) from the Intermountain area was used. Participants completed a questionnaire based on documented risk factors for childhood obesity as well as prevention guidelines developed by the American Academy of Pediatrics (AAP). NPs working in family practice or general pediatric practice settings were not consistently using the BMI-for-age index to screen for childhood obesity, as recommended by the AAP. However, they were teaching parents to promote healthy food choices and physical activity in their families. PNPs and FNPs working in a pediatric practice setting and NPs who were aware of prevention guidelines were more likely to perform several prevention strategies than FNPs working in a family practice setting and those who were unaware of guidelines. Major barriers to implementing childhood obesity prevention strategies included parental attitudes, the American lifestyle, and lack of resources for both the NP and the family. The main resources NPs used in preventing childhood obesity were a dietician, journal articles, and Web sites. Although the majority of the NPs in this study reported being aware of childhood obesity prevention guidelines (73.7%), most were not consistently using BMI for age or monitoring children at increased risk for obesity. Because childhood obesity is escalating at such a rapid rate, it is critical that NPs working in family practice and pediatric practice settings take the necessary steps to help curtail obesity in childhood, including calculating BMI for age, targeting children at risk, and helping families develop healthy nutrition and physical activity habits. In addition to proper health supervision of children, NPs also need to be advocates in their communities to overcome barriers to childhood obesity prevention.

Health Supervision for Children With Achondroplasia

Achondroplasia is the most common condition associated with disproportionate short stature. Substantial information is available concerning the natural history and anticipatory health supervision needs in children with this dwarfing disorder. Most children with achondroplasia have delayed motor milestones, problems with persistent or recurrent middle-ear dysfunction, and bowing of the lower legs. Less often, infants and children may have serious health consequences related to hydrocephalus, craniocervical junction compression, upper-airway obstruction, or thoracolumbar kyphosis. Anticipatory care should be directed at identifying children who are at high risk and intervening to prevent serious sequelae. This report is designed to help the pediatrician care for children with achondroplasia and their families.

Commentary: Pre–Primary Care Pediatrics

The article “Evidence-Based Community Pediatrics: Building a Bridge From Bedside to Neighborhood”1 explains the importance of using scientific evidence as the foundation of community pediatrics interventions. This commitment to evidence-based community-level health activities by pediatricians is a natural next step in the evolution of pediatrics as we return full circle to the origins of the specialty. In the United States, child heath supervision had its beginnings in the milk stations and child health centers of large cities, to which infants were brought to be fed, weighed, examined, and immunized against contagious diseases. In 1967, the American Academy of Pediatrics (AAP) established guidelines for child health supervision. However, there are indications that practitioners are not meeting the objectives of well-child care for many … Address correspondence to Robert Hoekelman, MD, Department of Pediatrics, University of Rochester, 601 Elmwood Ave, School of Medicine and Dentistry, Rochester, NY 14642. E-mail: rhoekel1{at}rochester.rr.com

Pediatric Interventions to Support Reading Aloud

Pediatricians and family practitioners increasingly provide free picture books and anticipatory guidance about reading aloud as part of routine health supervision for infants and young children, and arrange for volunteers to read aloud to children in the waiting rooms. These interventions comprise the Reach Out and Read (ROR) model, which has been adopted by more than 2000 clinical sites nationally. To date, 12 published studies have evaluated ROR and its variations, including three prospective, controlled trials. All but one have shown associations between ROR and increased reading aloud; additionally, four studies have linked program exposure to clinically meaningful increases in child language. Nonetheless, conclusive evidence of efficacy is lacking. This article provides a systematic, critical review of the literature, focusing on theoretical assumptions, issues of study design and measurement, and directions for future research.

2003 C. Anderson Aldrich award lecture: enhancing developmental services in child health supervision--an idea whose time has truly arrived.

In 1938, in his famous Babies Are Human Beings , C. Anderson Aldrich was cautious in describing the feasibility of enhancing children's developmental potential: “Every human being, as he grows into childhood, must inevitably be hampered and opposed by the restrictions of his environment, and the best we can hope for is to modify somewhat the urgency of this conflict. The degree to which we are considerate of our baby's early needs, however, may be the measure of his later ability to feel secure in a world of change and to adapt himself to the necessities of circumstance.”1(p xi) Aldrich's contributions occurred at a crucial transitional period for child health. In the early 20th century, child health services were almost exclusively focused on the treatment of the sick child, with the modest exception of cursory examinations to detect signs of contagion, milk stations for feeding and weighing, and urban child health conferences for examining and later immunizing children. Subsequent control of infection through improved sanitation, public health measures, the introduction of antibiotic agents, and effective immunization profoundly influenced the scope of child health care, with the founding of the American Academy of Pediatrics in 1930 heralding a shift of emphasis to include health promotion and disease prevention.2 In 1944, Aldrich helped to pioneer this shift through the founding of the Rochester (Minnesota) Child Health Institute, devoted to research on the development of normal infants and children and to a program of delivering child health care to an entire community. Contemporary efforts to enhance the effectiveness of developmental services similarly occur within the context of a profound transition in children's health services. In the mid-1970s, the recognition of developmental, behavioral, and psychosocial problems as the “new morbidity” of pediatric practice by Haggerty et al3 reinforced an emphasis … Reprint requests to (P.H.D.) Connecticut Children's Medical Center, 282 Washington St, Hartford, CT 06106. E-mail: pdworki{at}ccmckids.org

Rethinking well-child care.

Well-child care is a core service of pediatrics, but it receives little emphasis in pediatric training, reluctant consideration by insurers, and rare attention from researchers. Although it encompasses a variety of health-promoting and disease-preventing services, the desired outcomes of well-child care and quality standards for its provision have not been specified. It is not surprising, then, that preventive care services, as they are being provided currently, are not meeting the needs of many families, especially families with the most vulnerable children. The quality of child health supervision varies greatly among physician practices, and parents are signaling their dissatisfaction by failing to obtain approximately one-half of recommended preventive care services. In addition, evidence of effectiveness is lacking for much of the content of well-child care, which may jeopardize both its place as a covered insurance benefit and its reimbursement. It is time for major revision of well-child care, taking into account the varying needs of individual children and families, the operation of child health care practices, and the broad issues of access to primary care and payment for services within the US health care system. Because preventive health care for children, at least as it occurs within well-child visits, is authoritatively guided by the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care ,1 otherwise known as the periodicity schedule, review and revision of well-child care must begin with that document. Historically, the field of pediatrics has been as concerned with promoting children’s health and development as with treating children’s diseases.2 The current need to return to this holistic approach is evident in the trends in children’s health status. Children’s physical health is better than it ever has been.3 Scientific progress has led to substantial reductions in many of the acute morbidities of the early 20th …

The National Survey of Early Childhood Health

The National Survey of Early Childhood Health (NSECH) is a new survey that was designed to provide nationally representative data on the health and development of children and to fill an information gap in the pediatric literature on parents' views of the delivery of health care to their young children. The selection of topics was guided by previous studies conducted to examine parents' expectations and needs in child health supervision visits. The NSECH is a random-digit-dial telephone survey of a nationally representative sample of 2068 children aged 4 to 35 months. This sample includes an oversample of black and/or Hispanic children so that results for these minority groups could be estimated with greater precision. The sampling frame for NSECH is from the State and Local Area Integrated Telephone Survey (SLAITS), which is a program of surveys conducted by the National Center for Health Statistics that makes economical use of the large sampling frame of the National Immunization Survey (NIS). SLAITS takes advantage of the NIS screening effort by fielding interviews on other health topics with households screened for the NIS. The respondent was the parent or guardian identified as the person most responsible for the sampled child's medical care. Spanish-language interviews composed 19% of all completed interviews. The Council of American Survey Research Organizations response rate was 65.6%. The NSECH provides a unique data set that allows a well-rounded picture of the health, health care utilization, health care content, and interpersonal quality of health services received by young children in the United States. It also contains important information about family characteristics, patterns of health-promoting behaviors, and family routines that are associated with promoting the developmental health of young children. NSECH results can also help national policy makers understand the health needs of families with young children and how well the health system is meeting those needs.

Effectiveness of anticipatory guidance: recent developments.

Anticipatory guidance is a key component of child health supervision. This review discusses the latest evidence on the effectiveness of anticipatory guidance and its impact on child and family functioning. Anticipatory guidance on parent-infant interaction, sleep patterns, and injury prevention improve functional outcomes of children and their families. Recent findings also demonstrate that encouraging parents to share books with their children and free book distribution during well child care visits are associated with improved child language development and increased home literacy activities. Guidance promoting injury prevention and reading at home is supported by the best evidence. Future models of child health supervision should address missed opportunities for anticipatory guidance and parents' desire for more information about what they can do to enhance their children's growth, development, and functioning.

Health supervision for children with Turner syndrome.

This report is designed to assist the pediatrician in caring for the child in whom the diagnosis of Turner syndrome has been confirmed by karyotyping. The report is meant to serve as a supplement to the American Academy of Pediatrics' "Recommendations for Preventive Pediatric Care" and emphasizes the importance of continuity of care and the need to avoid its fragmentation by ensuring a medical home for every girl with Turner syndrome. The pediatrician's first contact with a child with Turner syndrome may occur during infancy or childhood. This report also discusses interactions with expectant parents who have been given the prenatal diagnosis of Turner syndrome and have been referred for advice.

Natural history of rhizomelic chondrodysplasia punctata

Rhizomelic chondrodysplasia punctata (RCP) is a rare autosomal recessive disorder with many associated medical complications. Prior to this study, natural history information about RCP was limited and based on experiences with small populations of affected individuals. We delineate the natural history of RCP through systematic analysis of 35 previously unreported individuals (as well as review of 62 literature cases with respect to survival and cause of death). Survival, growth, and developmental expectations and medical needs are summarized based upon experience with this population. Survival is greater among this population than previously reported, with 90% surviving up to 1 year and 50% surviving up to 6 years. Cause of death is most often respiratory problem. All infants with RCP have joint contractures, bilateral cataracts, and severe growth and psychomotor delays. Recommendations for health supervision of children with RCP and for parental counseling are presented.

Down syndrome and breastfeeding.

The aim of the study was to investigate the frequency of breastfeeding among children with Down syndrome. The mothers of 560 children with Down syndrome attending four university hospitals in Italy were interviewed and the neonatal clinical records retrieved. Information was collected on the type of infant feeding and on why some mothers had not breastfed their children. Two groups of healthy children whose feeding habits had been previously investigated were recruited as control subjects (1601 and 714, respectively). A paediatrician in each hospital was interviewed about the neonatal admission policy of children with Down syndrome. Among the 560 Down children, 246 (44%) were admitted to the neonatal unit. Compared with the two control groups, children with Down syndrome were significantly more frequently bottle-fed (57% vs 15% and 24%, respectively, odds ratio 7.5, 95% CI 6.0-9.4 and 4.2, 95% CI 3.3-5.4. respectively). Only 30% of infants admitted to the neonatal unit were breastfed. The main reasons reported by the mothers for not having breastfed were infants' illness in infants who had been admitted to the neonatal unit and frustration or depression, perceived milk insufficiency and difficulty with suckling for those babies who had not been admitted to the unit. The paediatricians reported that the admission of a baby with Down syndrome to the neonatal unit could sometimes take place not for medical reasons, but for diagnostic work-up or for a more appropriate diagnosis and to maintain communication with the family. Down syndrome babies are less frequently breastfed compared with healthy children. Support in breastfeeding should become a relevant point of health supervision for children with Down syndrome.

Preventing child neglect and physical abuse: a role for pediatricians.

1. Howard Dubowitz, MD, MS* 1. *Professor of Pediatrics, University of Maryland School of Medicine, Baltimore, Md After completing this article, readers should be able to: 1. Describe the importance of preventing child abuse and neglect. 2. Identify key risk and protective factors for child abuse and neglect. 3. Delineate useful principles and practical guidance for pediatricians on screening, brief assessment, and initial management of problems related to child abuse and neglect. Preventing child abuse and neglect spares a child pain and suffering, both physical and psychological. This is intuitively and morally preferable to intervening “after the fact.” Further, early intervention or prevention may be more effective than later intervention. For example, the time when a family has a new baby often is described as “a window of opportunity,” and early efforts to support the family and strengthen their parenting abilities may be particularly effective and cost-effective. Child maltreatment is not a rare phenomenon. Data from the 3rd National Incidence Study of Child Abuse and Neglect revealed that approximately 1% of children were identified as abused and 1.5% as neglected in 1993, and these rates are likely the “tip of the iceberg.” A number of studies have found that as many as one in four girls and one in ten boys has been sexually abused during childhood. Another reason for preventing child abuse and neglect is its immense morbidity and significant mortality rates. Research has documented the multiple physical, cognitive, behavioral, social, and emotional sequelae of child maltreatment. Brain damage, learning problems, aggression, juvenile delinquency and adult criminal behavior, depression, and parenting difficulties are a few of the potential long-term problems. The goal of preventing child maltreatment fits well with the goals and scope of pediatrics. “As physicians who assume a responsibility for children’s physical, mental, and emotional progress from conception to maturity, pediatricians must be concerned with social and environmental influences, which have a major impact on the health …

Health Supervision for Children With Down Syndrome

Health Supervision for Children With Down Syndrome

Assessing health system provision of well-child care: The Promoting Healthy Development Survey.

Preventive care guidelines for children include parent education and counseling, developmental assessment, and screening for psychosocial and safety risks. Health care providers are in a unique position to identify and follow up on potential problems and to influence parenting knowledge, attitudes, and behavior to ensure the healthy development of young children. Few quality measures are available to assess health care system performance in this important area. To develop a feasible, valid, and reliable methodology for evaluating health care system performance in providing family-centered anticipatory guidance and child and family assessment services on behalf of children from birth through 48 months old. Methods. The Promoting Healthy Development Survey (PHDS) was developed and tested with a diverse group of families in 3 managed care organizations (n = 1478). A standard mail administration protocol was used, including an informed consent with a waiver of documentation, 2 mailings, a postcard reminder, and telephone reminders. The 36-item parent survey assesses whether health care providers(1) talk with parents about topics recommended in Bright Futures and the American Academy of Pediatrics Guidelines for Health Supervision,(2) provide follow-up for children who may be at risk for developmental problems,(3) and address psychosocial well-being and safety within the family. The PHDS also assesses the degree to which parent's interactions with providers are family-centered, helpful, and facilitate parental confidence. Psychometric, bivariate, and multivariate analyses were conducted to assess the reliability, validity, and patterns of variation in the seven quality measures derived from the PHDS. Psychometric analyses demonstrated that the PHDS quality measure scales have strong construct validity (mean factor loading: 0.69) and internal consistency (mean Cronbach's alpha: 0.80). Parents reporting positive parenting behaviors had significantly higher scores on the anticipatory guidance quality measure compared with parents not reporting positive behaviors. Parents who reported that their questions on specific anticipatory guidance topics were answered were more likely to report higher confidence in related parenting activities (odds ratio [OR]: 5.9, 95% confidence interval [CI]: 3.4-10.2; OR: 8.3, 95% CI: 5-13.8)and were less likely to report concerns about their child's development in related areas compared with parents who reported they wished they had talked more with their child's doctor about these topics (OR: 0.46, 95% CI: 0.29-0.72; OR: 0.58, 95% CI: 0.37-0.89). The 7 PHDS quality measure scores for health plans ranged from 17 to 67 (on a 0-100 scale; where 100 is the best score possible) and varied significantly across health plans. Performance was highest for provision of anticipatory guidance information from health plans and lowest for family psychosocial assessment. Scores for families with Medicaid coverage were significantly higher on 2 of the PHDS measures and significantly lower for 3 measures compared with scores for families with commercial insurance. Age of child, whether child is first- born, parental marital status, education, income, and race were significant predictors for 1 or more of the PHDS quality measures (average R(2) = 0.05). The PHDS provides a comprehensive, psychometrically valid and reliable assessment of how well health plans and the health care providers working within these plans promote the healthy development of young children. The PHDS seems to differentiate among health care plans and among the different aspects of preventive care provided within a health plan. For the population studied here, there is significant room for improvement in ensuring families and children receive appropriate and family-centered care to promote the healthy development of children between 3 and 48 months old. Because the PHDS is conceptually based on national recommendations for child health supervision, improved performance on the PHDS would indicate greater adherence to these national recommendations and progress toward the achievement of Healthy People 2010 goals. The generalizability of the findings presented in this report are being examined using data collected in 5 statewide Medicaid samples (N = 11 696) and data from the National Survey of Early Childhood Health, which has incorporated most of the PHDS items.

Determinants of counseling in primary care pediatric practice: physician attitudes about time, money, and health issues.

To assess pediatrician goals and practice in preventive counseling, and to use social learning theory to examine physician attitudes about preventive health issues, time, and reimbursement to explain physician counseling behavior. Random sample survey of American Academy of Pediatrics fellows. A total of 1620 pediatricians were surveyed with a return rate of 72%. The 556 pediatricians who had finished training and who currently performed child health supervision were included. Pediatricians were asked about their goals in 6 areas of health supervision: biomedical issues, development, behavior, family functioning, safety education, and supportive interpersonal interaction. They were also asked about the prevalence of counseling, importance of specific topics, their self-efficacy, outcome expectation in these areas, and their concerns about time and reimbursement for preventive counseling. Assurance of physical health and normal development were the most important goals of child health supervision among the pediatricians surveyed. Goals involving behavioral, family, and safety issues were less important and less likely to be addressed in practice. Most did not regularly discuss family stress, substance abuse, gun safety, and television. In these areas, physicians had less confidence they could provide guidance and lower expectation that they could prevent problems. Only 17% felt that they receive adequate reimbursement for preventive counseling. Most have adequate time (53%) and receive adequate respect (57%) for their preventive efforts. Physicians who were more concerned about time for preventive counseling reported less overall counseling (r = -0.28, P<.001). Concern about reimbursement was not associated with reported counseling. Multiple regression analysis found that the primary predictors of physician counseling were an issue's importance, a physician's perceived self-efficacy, and perceived effectiveness of counseling, while concerns about time and reimbursement were secondary. Physician goals in child health supervision were primarily biomedical, with psychosocial and safety issues of lesser importance. Concern about time for preventive counseling was associated with less reported counseling. Physician attitudes regarding the importance of a health issue and their confidence and effectiveness in counseling were more predictive of physician practice than their attitudes about time and reimbursement for preventive care.

The child health supervision visit as an opportunity to address parenting issues during infancy.

The child health supervision visit as an opportunity to address parenting issues during infancy.

Preschool development. Part 2: Psychosocial/behavioral development.

1. Raymond A. Sturner, MD* 2. Barbara J. Howard, MD† 1. 2. *Associate Professor of Pediatrics, Director of Behavioral Pediatrics Fellowship Training Program. Drs Sturner and Howard are Codirectors of The Center for Promotion of Child Development Through Primary Care, Millersville, MD, and serve on the pediatric staff of the Patuxent Medical Group in Annapolis, MD. Dr Sturner is the author of the START test and owns the patent on the Communication Screening System. 3. 4. †Assistant Professor of Pediatrics, The Johns Hopkins University School of Medicine, Division of General Pediatrics, Baltimore, MD. Dr Howard is a content consultant for edutainment videotapes for children and parents. 1. Assessment of psychosocial and behavioral milestones during health supervision visits requires consideration of both child temperament and parental style. 2. Problem behaviors often occur when the child’s need for independent functioning, mastery, or self-identity conflicts with parental attitudes and expectations. 3. The clinician should be able to categorize parental concerns about psychosocial issues into “developmental variation,”“ problem,” or “disorder,” using the definitions provided by the DSM-PC . 4. The high continuity of aggressive and oppositional behavior from preschool to later years mandates preventive interventions for preschoolers. 5. Child health supervision that features discussion of one or two key issues based on a clinical hypothesis of each individual child/family’s developmental trajectory may be of greater value to families than recitation of generic advice about multiple topics. During the preschool years, children are rapidly developing patterns of behavior and psychosocial skills that can be long-lasting. Clinicians have important opportunities to monitor and help shape optimal development when seeing preschool children for their health supervision visits. This is the second of a two-part article discussing the development of the preschool child from the point of view of the clinician who is conducting a visit using Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents . Both articles are organized by the“ trigger questions” suggested for visits at ages 2, 3, 4, and 5 years of age. The trigger questions regarding psychosocial and behavioral aspects of the child’s development are reviewed here; the first article ( Pediatrics in Review September 1997) focused on the “more traditional” developmental areas of communication and motor development. Any dichotomy between behavior and development is murky because behavioral issues often are uncovered when reviewing areas traditionally called development, and behavior can be interpreted only in light of the child’s level of developmental functioning. Research indicates that emotions and cognition are interconnected in …

AAP: health supervision for children with Marfan syndrome.

AAP: health supervision for children with Marfan syndrome.