The nation's system of preventive pediatric care requires major revisions if chronic health problems and unmet behavioral and developmental needs among American children are to be addressed, so reports The Commonwealth Fund's Edward L. Schor, M.D., in "Rethinking Well-Child Care" (Pediatrics, July 2004).
Pointing to the prevalence of obesity, attention-deficit disorder/hyperactivity, behavior disorders, depression, adolescent risk behaviors, and the stresses faced by parents, Schor warns, "The term 'well-child care' is applicable to fewer children." As acute pediatric medical care becomes, more and more, the work of hospitals, emergency physicians, and pediatric sub-specialists, well-child care calls for new approaches—to pediatric office practice, to the scheduling of office visits, and to health care partnering.
Well-child care accounts for 22 percent of an average pediatrician's patient contacts and an unknown, but no doubt substantial, part of child health care expenditures. Schor calls these services "the primary opportunity for prevention or early intervention for the vast array of developmental and behavioral problems that are so prevalent in American society and are of great concern to parents." Nevertheless, he cites such problems as:
- 94 percent of American parents report unmet parenting guidance, education, or screening needs by pediatric clinicians.
- Minority or economically disadvantaged parents are two to four times more likely to express dissatisfaction with the growth and development care their children receive than white, non-poor, insured families.
- In a national survey, 36 percent of parents of young children reported not discussing significant specific, recommended child health issues with their pediatricians.
- In one large study, 40 percent of parents of children covered by Medicaid were not asked by pediatricians whether they had concerns about their children's learning, development, or behavior.
- The Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics—also known as the periodicity schedule for well-child visits—is based mainly on immunization requirements, not pediatrics' traditional holistic consideration of a child's health and concern for children's development.
- Children attend fewer than one-half of the recommended well-child visits, even when there are no financial barriers.
Pediatricians themselves report an array of obstacles to providing quality well-child care: time constraints, low levels of reimbursement for preventive pediatric care, lack of reimbursement for specific developmental services, lack of training in child development, lack of trained non-physician staff members, limited access to community services to support families and children, and few external incentives. The author notes that these obstacles are systemic, not personal, praising pediatricians' commitment to high-quality care. With current guidelines and practices, the author writes, "it seems there simply is too much to do."
Moreover, although the AAP's periodicity schedule shapes well-child care in the United States, it is anachronistic and unscientific (indeed, some managed care organizations are refusing to cover all the schedule's suggested first-year office visits). Schor advocates a complete revision, guided by research from the fields of child and family development. Such a revised schedule should include office visits whose timing reflects or coincides with children's key developmental transition points.
As part of this change, Schor recommends a new terminology, dispensing with the "six-month" or "nine-month" pediatrician visits—names that tell parents little about a visit's purposes and more importantly leave them unable to prepare for a constructive discussion about the issues vital to their children at that point in their lives. Naming each visit to highlight its focus, the author writes, makes the value of each visit more clear. He suggests the nine-month visit, for example, might be called the "Understanding Your Child's Personality" visit.
Schor also calls for the elimination of unnecessary procedures. He notes that performing a physical exam at the time of every office visit is most likely without value in identifying physical problems. Other changes advocated by Schor have to do with the mechanics of office visits. He has three suggestions for making better use of the time before and after an office visit: Prompt parents more carefully about the next office visit in order to help them prepare; use pencil and paper or computerized structured-screening tools before meeting with the physician in order to increase efficiency (and further prepare parents for a discussion); and then reinforce advice, guidance, and counseling with the judicious use of printed or other material.
Schor also notes that many parents and children miss scheduled office visits. Advanced access-scheduling systems that trim the wait between when an appointment is made and the appointment itself would be helpful.
Standards of care also come under Schor's scrutiny. He would like the pediatric profession to develop a "single authoritative source"—a manual—"of standards for well-child care needs."
Finally, reemphasizing pediatrics' traditional commitment to promoting children's health and development, Schor calls for reasserting partnering in well-child care. He notes that the American Academy of Pediatrics, through its Bright Futures program, partners with other child health care agencies and organizations. Schor believes that the AAP "needs to reach out even more." Of early childcare and special education, welfare, foster care, and education, he writes, "These systems and others are natural partners for pediatrics and pediatricians and should be enlisted not only in caring for individual children but also in formulating national policies that define the desired outcomes of, and thus support the need for, high-quality well-child care."
