The most common single reason for a child to see a health professional is for a "well child visit" or "child health supervision," as it is now termed. Epidemiological research, beginning in the 1950s, has scrutinized these visits in terms of case finding and revealed that they are of little or no public health value in terms of new medical pathology found. The lower prevalence of physical problems and the availability of pre-programmed health education raises questions as to whether these visits provide any professional challenge and whether a clinician is needed at all. Yet, when the visits are reconsidered from a behavioral and developmental perspective, the work can become the most stimulating and rewarding part of primary care. Parents are seeking advice for dealing with their children's development. As many as 90% of mothers of preschool children have some concern about their child's behavior and development, and 28% feel their concerns are serious ones.1 Other parents may have children at risk without asking for help. The prevalence of infantile psychiatric disturbance is hard to document. However, failure to thrive of psychological cause and child abuse/negiect together are clearly some of the most common chronic conditions seen during infancy, beyond the neonatal period.
This article will provide a framework for gathering important clinical information and organizing an individualized plan of action for helping to promote healthier parenting. The components of this framework could be recalled using the acronym PERILS (P is for perception, E is for expectations, R is reactivity, I is for interaction, L is for level of development, and S is for surroundings). Perils should be easy to remember given the risk to the child of suboptimal development. Each component of the acronym will help to recall a clinical dimension that should be considered at the time of each visit.
THE TIME FRAME
Some pediatricians and family medicine doctors schedule health supervision of infants for half an hour, and others may allow only 10 minutes. If at least 15 minutes were available using the approach described here, the first 10 minutes would be spent obtaining relevant diagnostic information including completing the physical exam, and the last 5 would be reserved for a focused discussion regarding the single issue felt to be most important for the child at a given time in his or her development as well as the development of the family unit. The goal for the clinician is to use his or her knowledge of child development and the particular family to develop a clinical hypothesis about the potential direction of the child-family trajectory of development. Occasionally, families will require special follow-up visits to continue a discussion of the "trajectory issue"; others will require little or no additional clinician input beyond the standard visits. We invite all parents to join a weekly discussion group about parenting, which multiplies the opportunities for the kind of preventive intervention being discussed here. However, many parents are unable to attend, and the approach discussed here is aimed at what can be accomplished during routine individualized child health supervision visits.
The sections that follow will summarize literature supporting the importance of each of the risk factors represented by the PERILS acronym and also will present a general approach to expanding the database to identify a specific pattern of risk that could be constructively addressed in the context of a child health supervision visit.
The P in PERILS is a reminder to be on the alert for the parent's perceptions of the child. Parents sometimes speak about infants, even at a few months of age, as if they were capable of adult motivations and intentions. The attributions and misinterpretations of the child's behavior give the impression that they are prejudiced or biased against their own child. This relatively common situation could be referred to as the "prejudiced parent syndrome." Often, something about the child reminds the parent of someone, usually an adult, who stirs up a strong emotional reaction in them, such as anger or guilt.
In a study by Broussard, mothers of 1-month-olds were asked to simply state whether they felt their infants were more difficult or less difficult than the average.2 These infants were followed and had independent psychiatric diagnoses at Wi and 11 years of age as part of the follow-up study. As it turned out, the infants who were felt to be more difficult early on were more likely to have psychiatric diagnoses later. It should be noted that this study was based only on what the parent reported. No attempts were made to look at the infant's behavior, which will be discussed later. A similar type of study was done using parent perception at 1 year, which predicted teacher judgment about behavior at 10 years of age.3 Research indicates that parents who mistreat their infants are more likely to misperceive infant emotional expressions and interpret them negatively. For example, abusive mothers express more anger and annoyance and less sympathy in response to videotapes of crying infants than mothers who had refrained from abuse. Another study found such mothers more likely to misidentify infants' facial expressions in various emotional states. Many parents of infants with nonorganic failure to thrive describe their children as oppositional or "bad." Some cases of child abuse and neglect turn out, in retrospect, to start out with something like the "prejudiced parent syndrome." There is evidence that parent misperception of ongoing infant behavior has immediately measurable negative impact. When parents were asked to purposely misjudge their infants in level of pleasurable affect and respond accordingly, infants stopped what they were doing.
What are we to do with this information about the parent's perception of the child? A preventive treatment might be characterized as child advocacy. That is, in addition to screening for defects in children, one might also look for strengths and help to influence parents' perceptions in a positive direction. A very active, intense child can either be seen as "bad" or as having a high amount of industry and curiosity. When a negative perception seems to be taking hold, the clinician might help to redefine the child using the positive features and perspective, which can be identified. The "prejudiced parent syndrome" is a more difficult matter to treat. The goal is to help the parent appreciate that their approach to the infant is irrational. Sometimes, this must occur over several visits. Often, once this is recognized, mental health referral is necessary for the parent. Our experience is that, if this tactic is not taken, clinician time would be diverted to responding to the many physical symptoms that often result from the mother's feelings about her child, taking time away from the most important issue of how the child's development is affected by inappropriate parental perceptions.
The E in PERILS is a reminder to think about the parent's expectations. A classic book by Rosenthal, titled Pygmalion in the Classroom, describes a study in which researchers purposely feigned a testing battery.11 They came up with a group of students who they said were "soon to bloom." The children had, in fact, been randomly selected. The selected children subsequently did achieve beyond what was expected. In the same way, it has been shown that a variety of negative labels can also become self-fulfilling prophecies. Research has also shown that parents who overestimate their child's developmental capability end up with children who actually perform less well than those who accurately estimate their child's development. It is not known why this occurs, but the thinking is that children who have had the experience of repeated frustration due to overexpectations may give up easily.
The best treatment for problems in the area of parent expectations is a preventive measure known as anticipatory guidance. An example of a treatment approach in this area is that of a hypervigilant overresponsive mother. During the first 6 months of life, one of the most important things for a child, from a developmental point of view, is the parents' contingent or timely responding to the infant's behavioral cues. It is unnecessary to discuss that challenge of parenting to the already hypervigilant mother during infancy. However, overly vigilant parents are likely to have extra difficulties during the second year of life when infants need to learn from very small doses of frustration. With such a parent, it can be helpful, even as early as the sixth month visit, to anticipate the beginning of separation anxiety, which often begins at 9 months of age. At this time, the long process of the infant's moving away from the parent begins, and overvigilant parents, and consequently their infants, may have a more difficult time.
The R in PERILS is for reactivity, or temperament. The rationale for thinking about this area comes from seminal work by Thomas, Chess, and Birch.5 They first assessed a large cohort of infants for specific behavioral characteristics at 4 months of age and followed those infants until they were 18 years old. The behavioral characteristics were activity level, mood, biological rhythm (eg, the regularity of sleep and bowel function), distractibility, adaptability to changes in routine, approach to new situations and new foods, persistence at tasks, threshold for sensation, and intensity. They identified a subgroup of children who were at increased risk for later independently measured psychiatric difficulties. These "difficult infants" had a high activity level, were highly intense, had irregular sleep and bowel habits, and had a negative mood. Not all of the difficult infants had a negative outcome. Children with the best outcome in this group of difficult infants seemed to have come from families where the parents could be very objective about their infant's behavior. These families recognized that there was something about the child that contributed to the problem behavior rather than perceiving that the child was angry at the parents.
Werner and others have focused on the other side of the coin: infants who could be considered resilient because of positive outcomes despite multiple biological (eg, perinatal problems) and family (eg, alcoholism) risk factors.3 Summarizing her own work (a prospective study in a large sample of infants born on a Hawaiian island who were followed into adulthood) and the work of others, Werner concluded that resiliency was related to the infants' capacity to successfully elicit positive responses due to characteristics such as being active, but cuddly, alert, affectionate, and goodnatured, with few having problems sleeping or feeding.
Carey standardized a series of parent questionnaires for office use for characterizing children into groups of temperament or reactivity.6 This information is useful particularly as it supplements the clinicians' own observations. However, as suggested in the earlier section on perception, these parents' reports may be confounded by their idiosyncratic perceptions. For example, some parent characteristics found to be present prior to the infant's birth were predictive of a portion of the parent's questionnaire responses. Assessing temperament is valuable because there are some approaches to child rearing that work better than others with children with particular temperamental patterns. For example, some babies in the newborn nursery seem to startle themselves. These babies seem to do better when they are swaddled closely in blankets. There are a variety of strategies one might suggest for babies with different temperaments, but the important point to remember about reactivity is simply to be sure that the parent's response to the child remains rational and objective,
A number of studies show that the factors related to reactivity discussed here do not predict negative outcomes without the presence of other risk factors, such as negative parental attitudes, childhood experience of rejection, and lack of social support.7 Nevertheless, it also appears evident that the infant's intrinsic reactivity results in a differential vulnerability or resilience to adverse circumstances that is worthy of the clinicians' attention and should lead to redoubled efforts along the other dimensions discussed here. If the clinician overlooks the child's contribution to a problem, the parents sense that the interpretation is off base, and they are distanced from whatever guidance is offered. Furthermore, infants are never offended if you raise the possibility that at least a portion of a problem may be due to something intrinsic in them. When this approach is taken, many parents who have been overly self-incriminating are extremely relieved to be "taken off the hook" and become open to reconsidering the problem, wherever it may lead.
The I in PERILS is for interaction, which refers to the experience that results for the child from social engagement given his or her individual characteristics and the characteristics of the parent. Several components of interaction have been linked to child outcomes. The sensitivity, promptness, and emotional synchrony of parental responses to infant cues help regulate or organize the infant's states of alertness and fatigue, foster the development of the infant's sense of his or her own competence and sense of security or "basic trust," make the outside environment more interesting, and enhance the drive to explore or "mastery motivation," which may be critical to learning, to faster rates of information processing to repeated stimulation, to later measures of parent-infant attachment, and to problem solving and coping strategies in the preschool years.8 In addition to general responsivity, specific themes also need to be considered when assessing parent-infant interaction. For example, a parent who may ordinarily be responsive may begin to react negatively at times when the infant tries to be an initiator, for example by blocking self-feeding. Particularly intense infants may be more susceptible to this kind of confrontation and even react with failure to gain weight.
Although health clinicians have many opportunities to observe parent-infant interaction, because they are also aware that observed behavior is influenced by many factors, they are often reluctant to draw conclusions from what they see, as to whether the parent's "domestic policy" at home is reflected in the "foreign policy" seen in the exam room. Fortunately, it is hard to produce smooth interactions involving relatively automatic responses if these have not been practiced before. Therefore, observations of good interaction are generally reliable and can at the least lead to clinical hunches or hypotheses that can be tested. The doctor's own reaction to the baby and the parent-infant interaction is an important clinical instrument which should not be dismissed lightly.
Some parent-child interactional problems can be prevented. For example, avoiding unnecessary early separation and providing support during the perinatal period may be thought of as preventive treatments. Opportunities for "bonding" may not significantly improve outcome in random populations,9 but the amount and quality of parent-infant contact with the newborn and the nature of available support can make a difference for those families who are stressed. For example, a random treatment trial of rooming-in resulted in significantly less child abuse and neglect in a large study of a poor urban population.10 Demonstration of the neonate's capacity to respond has repeatedly been shown to promote later positive interaction between parents and their infants.11 While use of the Brazelton Neonatal Behavioral Assessment Scale, the main intervention studied, is not practical as a routine, simply teaching a parent how to lock eyes with their baby is exciting for them and is something that doesn't necessarily happen spontaneously. This can be done by holding the baby at about 30° in a dimly lighted room and moving one's head slowly an inch or so at a time in the horizontal plane. Gently rocking the baby's head back and forth also helps to stimulate him or her to open the eyes by eliciting the vestibulocular reflex.
A study by Casey and Whitt12 showed that developmentally oriented health supervision visits done during the first 6 months of life can also promote interaction. During the examination, in this study, a pediatrician served as a model for the parents by talking and responding to the infant. Cases in which a developmental approach was used were compared with those of the same pediatrician using a more traditional physical examination. These approaches were also compared to cases seen by other pediatricians. Significant differences were found between groups in measures of parent-infant interaction at 6 months. In addition, the positive outcomes were related to responsiveness to infant cry and noncry signals (including an early ability to be patient), which may help to deflect ideas that infants can become spoiled during the first 4 months of life by responding to crying.13
Dealing with clinical interactional problem cases is more complex than preventing problems in more normal families. However, programs have demonstrated positive outcomes for the infants and parents using counseling, support, and "developmental prescriptions." A developmental prescription refers to recommendations for developmentally appropriate infant games that can be taught to parents and are enjoyable for both the parent and the infant and enhance the interactions that facilitate development.
Some Aspects of the Infant's Surroundings that Predict Socioemotional and Cognitive Outcomes in 4-Year-Old Children
Clinicians must recognize that the interactional patterns discussed are only partially under conscious control and therefore not always responsive to simple advice. There is evidence that these parental respons' es have been strongly influenced by the quality of parenting the parent received. Clinicians who are alert to interactional problems are also likely to see maternal depression because it is so common. Some depressed mothers show blunted, interactive responses, while others show fits of anger or intrusive responses to their infants. The large range of clinical phenomena means that clinical intervention plans for interactional problems often need to be multimodal. Treatment often involves helping parents reflect on how they were raised and how they feel about that now. Family therapy approaches may be an important adjunct in some cases, sometimes leading to other family members assisting with care when one parent is overwhelmed. Medication and other treatment for parental depression will be necessary in other cases. Advocacy for financial, home visiting, and other support services for stressed families can also be an important adjunct, as will be discussed in the section on surroundings.
LEVEL OF DEVELOPMENT
The L in perils is a reminder to look at the area of level of development and how it is perceived by the parents. Even experienced pediatricians have been known to do poorly at identifying cases of delayed development.11 It should be noted that parents do not reliably recap developmental milestones, and twothirds of children with mild retardation, the most prevalent cause of delay, had normal milestones.15 The parents' overall impression of their child's developmental function and report of the child's current level of functioning are more useful than a review of past milestones. However, some children have problems that their parents do not appreciate or verbalize. Therefore, identification of developmental delay may require the clinician's judgment, which can be aided by screening instruments (beyond the scope of this review), and the challenge for the clinician then becomes one of understanding the child's assets as well as limitations so any needed educational assistance can be communicated to and viewed by the parents in a constructive and acceptable light.
In addition to detecting developmental deviations in order to provide services, another reason for detecting children with developmental delay is to avoid inappropriate parental expectations. Such expectations can hamper social and emotional development as well as family relations. When such discomfort occurs for infants, they may fuss or withdraw. Treatment involves "developmental prescriptions" of tasks that are not too hard but are sufficiently challenging to be interesting and educational. There is evidence that the infant's developmental progress can be optimized by a curriculum of challenging but not overwhelming learning experiences.16
Another reason for addressing developmental delays is to provide support to the family. If the infant is not as healthy and as cognitively normal as the parents had expected, the parents often have difficulty accepting the reality of the situation. Counseling is sometimes required to help the family in the mourning process in the loss of the child they dreamed of or believed they deserved. Having an intervention on which to focus also provides an avenue for active coping.
The S in PERILS is for surroundings, used here as a mnemonic for two domains. One is the baby's ecological niche or environment, including the family and their support system. (One can also recall the s's as social support and socioeconoraic status.) The word surroundings also evokes another important clinical dimension - the infant's interest in, and curiosity about, what is around him or her.
The health-promoting and stress-reducing nature of social support has been well documented. General measures of socioeconomic status, such as the income and education of the parents, are related to later cognitive development and rates of child maltreatment. In a study of 215 4-year-old children,17 Sameroff and colleagues found that negative socioemotional and cognitive outcomes are best predicted by the number of risk characteristics that occur, not some global index of socioeconomic status. The environmental characteristics studied varied greatly eg, from maternal anxiety to family size, see Table for the complete list), and various combinations of these factors had similar predictive power. These findings suggest that interventions based on the unique clinical characteristics of families are more likely to be helpful than a generic intervention program for all.
Aspects of social support and available resources have been shown to influence parental perceptions and attitudes toward the child, as well as child behavior and developmental outcomes. Dunst and Trivette have constructed a theoretical model for the action of social support. According to theii model, social support influences parent well-being and health, which, in turn, influences family functioning. Support, well-being, and family functioning influence styles of parent-child interactions; and support, well-being, family functioning, and interactive styles influence child behavior and development.18 Other researchers, particularly Bradley and Caldwell, have attempted to isolate specific observable characteristics of the environment or process variables to explain the way the global family situational factors may mediate developmental progress.19 "Verbal labeling" is one such process variable. For example, while one mother changes a diaper, she uses this as an occasion for a rich verbal exchange, labeling body parts, while another may be silent.
Although pediatricians may know a great deal about the social networks of the families in their care just through their experience in the community and by caring for siblings, it is still useful to collect this information in a systematic form to avoid gaps in knowledge and to focus on specific factors that have been found important. One is to have the parents diagram their social network by simply drawing in the "people important to them" on a blank piece of paper with a large circle representing the household.20 Social support scales useful for clinical purposes have been reviewed.18 The Maternal Social Support Index is an eight-item scale focusing on identifying ways in which existing network members are perceived as viable options for help. The Social Support Questionnaire includes 27 questions eliciting information related to the respondent's satisfaction with each type of support available to him or her. The Family Resource Scale contains 30 items
covering the adequacy of both physical and human resources available, including food, shelter, transportation, time to be with family, child care, etc. The Home Screening Questionnaire (HSQ)21 is not a social support scale but one that contains parent report items derived from the Home Observation for Measurement of the Environment (HOME), a direct observation and interview assessment.19 The HOME and HSQ have items that have been sensitive to child developmental outcomes, such as the availability of play materials and books, and other home characteristics indicative of parental concern with achievement. The HSQ may be particularly suitable for low-income, high-risk populations.
The other aspect of surroundings to note is the infant's interest in his or her surroundings. We know that by 5 or 6 months, infant deprivation is first seen as a lack of interest in the environment.22 Furthermore, among otherwise normal families, parents who respond promptly and consistently to infant cries and nondistress signals have infants who show greater interest in exploring their environments.23 Clinically, by 5 or 6 months of age, one can begin noticing whether the infant is curious about interesting objects, such as the shinny ophthalmoscope handle. Observation of visual attention (although in a much more sophisticated manner) has been the best single early predictor of later intelligence.24 Of course, the younger the infant, the more infant state (how sleepy or hungry the child might be) affects his or her reactions, so poor infant curiosity should not be over- interpreted but stimulate further information gathering.
One type of preventive intervention in the realm of surroundings would be in response to a caretaker whose style is suboptimal from a cognitive enrichment point of view. For example, the 3-month visit is a good time to reinforce the need to talk to infants and to demonstrate how talking elicits a social response that has been shown to enhance observed interactions at 6 months.12 The 6-month visit is a good time to begin talking about reading books to babies (eg, beginning with plastic or cloth ones with pictures of facial characteristics and shiny mirrortype reflectors) especially in families where this response might not be natural. Parents should be informed of the range of expected infant responses. Parents can be encouraged to borrow baby books from the library, and some practices are beginning to give away books.
Another approach to preventive intervention in the area of surroundings is the "family systems assessment and intervention model," as articulated by Dunst and Trivette.18 The model requires that one first identify the needs that the family considers important enough to deserve investment of their time and energy. These needs may range from basic need for food and shelter, to enrichment (eg, adult education to change jobs and preschool education for a child), to "generativity" (sharing experiences with others, security, etc). It is emphasized that to be an effective helping person in this realm, one must truly be interested in understanding the family's needs and concerns rather than making any assumptions. It is particularly important to be aware of the family strengths, because one is more likely to be helpful building from things the family already does well. A detailed "mapping" (which may be possible using the above questionnaires) of the family's social network often reveals untapped but potential sources of needed assistance. Dunst emphasizes that "it is not just a matter of whether needs are met but rather the manner in which mobilization of resources and support occurs that is a major determinant of enabling and empowering families."18 In other words, the clinician must act as a quiet catalyst for the family to gain insight into how they can help themselves rather than the clinician being the hero who rescues the family. If clinicians begin to consider these dimensions in the families they follow, they will become sensitive to these factors in a way that will be viewed as humane and caring by the families.
Although data about each component of the PERILS acronym cannot be collected at each visit, the acronym and the concepts presented above should help clinicians prioritize data collection and begin interventions into parenting during health supervision visits in a way that focuses on each child's and family's developmental trajectory. This article does not address how standard information regarding nutrition and safety, etc, is communicated to parents during child health supervision visits. Some practices may find that educational video messages and group classes may be the most effective and cost-effective manner to ensure that all parents are aware of the current recommendations regarding these important areas. This article describes current knowledge regarding child developmental risk factors, which are also associated with child and family discomfort and morbidity. These areas should be increasing in priority in our system of professional triage as technological solutions become available for the traditional priority areas of infection and nutrition. As in all aspects of anticipatory guidance during child health supervision, research is needed regarding the productivity of specific trigger questions used to uncover the various risk factors discussed here as well as the efficacy of outcomes for the pathways of clinical intervention that may follow. However, unlike the goal of providing standard health information, the individualized process outlined in this article will continue to require a high level of complex medical decision making to pinpoint the most the unique set of vulnerabilities and strengths that are to be addressed and will also continue to require human sensitivity and trust to achieve the goals of early preventive intervention.
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Some Aspects of the Infant's Surroundings that Predict Socioemotional and Cognitive Outcomes in 4-Year-Old Children