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Child Mental Health in the Americas:

A Public Health Approach1

LEON EISENBERG~

444

The systematic, population-wide application of preventive measures based on what is known about the causes and outcomes of psychiatric disorders can markedly reduce morbidity from mental ill health among children in the Americas. The actions proposed here rely partly upon increasing access for all women and their children to thoroughly tested obstetric and pediatric care; in part they depend on improving nutrition and opportunities for cognitive stimulation; and in part they call for enhancing the mental health skills of prima y care practitioners by appropriate in-service training. There are limits to our knowledge and to the effectiveness of some of our interventions; nonetheless, the greatest barrier to better child mental health is failure to muster the political will to apply what is known to the care of mothers and children in all sectors of society.

N

o single consultant has the knowl- edge to formulate an action plan for child mental health in the Americas. Such a plan must take into account the special situations in individual countries as well as the common denominators across con- tinents; it must reflect the insights of all the scholarly fields that study the social context in which children develop (de- mography, epidemiology, economics, so- ciology, political science, etc.) as well as the clinical fields that evaluate the ways individual children develop (genetics, pediatrics, social work, psychology, nursing, psychiatry).

This presentation has a more modest goal: to describe a public health approach to the promotion of mental health and the prevention of psychiatric disorders,

‘Based on a paper prepared for the Consultation Group for Formulating a Regional Action Plan for Child Mental Health, Pan American Health Or- ganization, Montevideo, Uruguay, 4-8 November 1991. A Spanish version of this article will be pub- lished in the Boletin de la Oficina Sanitaria Panamer- icana, Vol. 114, 1992.

Trofessor of Social Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA.

an approach that takes into account the prevalence and the severity of problems and the evidence for the effectiveness of proposed solutions. One overriding con- sideration about child health must be kept in mind throughout. Equal rights for women are crucial for the successful physical and mental development of chil- dren. Only a world in which women have full citizenship will meet the needs of children. This issue will be dealt with in a companion report on social policy and child mental health.

One further word of justification is necessary. This document is drawn pri- marily from experience in the United States. That should not surprise the reader who is aware that the U.S. is the country the author knows best. However, this fo- cus on the U.S. may lead to doubt about this work’s relevance to Latin

America.

It should not, for on the contrary, the failures as well as the successes of U.S. mental health programs provide valuable material for the design of policy in other countries. For one thing, the U.S. is very heterogeneous. It is both a “first” world

and

a

“third” world

nation; that is, pop- ulation groups living in urban slums and

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in pockets of rural poverty survive under conditions not far removed from those of the poor in some developing countries, at the same time that the majority of Americans enjoy high living standards. For another, the “postindustrial” econ- omy of the U.S. presages circumstances that lie ahead for countries still undergo- ing industrialization. Finally, 22 million of the 249 million people counted in the 1990 U.S. census were classified as His- panic and 30 million as black. Seen in this light, the U.S. experience seems worthwhile-not because it provides a set of prescriptions, but rather because it offers a set of data from which readers are urged to draw inferences appropriate to their own national conditions.

IS THE PREVENTION OF

MENTAL DISORDERS POSSIBLE?

Despite widespread skepticism, effec- tive prevention of some psychiatric dis- orders is not only possible but is, for cer- tain disorders in some countries, virtually complete. What is not possible now, or in the foreseeable future, is the preven- tion of all mental disorders.

Pellagra provides a telling example. Pa- tients suffering from pellagra crowded the orphanages and wards of mental hospi- tals in the U.S. in the early decades of this century. Then, well before it was shown to result from niacin deficiency but after it was recognized as a nutri- tional disease (Z), pellagra was elimi- nated from the U.S. by dietary improve- ments (notably a reduction of the dependence on milled corn as a food sta- ple). This preventive measure was not “psychiatric” in the narrow sense of the term. However, what matters is not the mode of action of the agent, the venue in which it is applied, or the discipline of the practitioner, but the effectiveness of the measure in preventing diseases

manifested by disturbances in mental function (2).

What has been accomplished for pel- lagra is now possible for other organic brain disorders; and there are also prom- ising interventions for the prevention of some of the functional mental disorders. However, means are not available for pri- mary prevention of such major diseases as autism, childhood schizophrenias, or depression.

DEFINITIONS

The public health approach to preven- tion distinguishes between three levels of disease prevention.

Primary prevention is designed to pre- clude development of disease among susceptible populations. It employs health promotion (e.g., the teaching of hygienic practices, universal education to promote cognitive development, the provision of optimal nutrition to enhance disease resistance, social support for family life, peer programs in public schools to di- minish rates of onset of habits injurious to health, etc.) and specific protection

(e.g., immunizations, salt iodization to

prevent goiter, tetanus toxoid injections during pregnancy to prevent neonatal tetanus, etc.).

Secondary prevention seeks to shorten the duration of illness once it occurs, re- duce the likelihood of contagion, and limit sequelae by means of early diagnosis and prompt treatment (e.g., the use of psy- chotropic drugs and psychosocial mea- sures to abort acute psychotic states). Treatment (secondary prevention) of the first disease in a causal series constitutes primary prevention for those conditions that would otherwise follow in its wake

(e.g., anticonvulsants and psychosocial

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Tertiary prevention is directed at indi- viduals with irreversible disease. Its goals are to limit disability (e.g., by placing abandoned children in foster or adoptive homes to avert the developmental attri- tion caused by orphanages), to minimize exacerbations of the underlying disease (e.g., through psychosocial education for the families of schizophrenic patients), and to promote rehabilitation (e.g., by providing social skills training, voca- tional guidance, and sheltered work- shops for retarded adolescents).

In the first instance, the goal is to pre- vent the development of disease; in the second, to shorten its duration after it has occurred; and in the third, to preserve function so far as possible when no ef- fective treatment for the disease itself is available.

PREVENTIVE

INTERVENTIONS

This section cites and describes well- validated ways of preventing mental dis- orders. These measures are listed in a life-cycle perspective that begins before conception and continues into old age.

Family Planning and Prenatal Care

The more numerous and the more closely spaced the pregnancies in the re- productive lives of women, the greater the risks for maternal and infant mortal- ity and the worse the developmental out- comes for the children. Studies in devel- oped countries have demonstrated that the larger the number of children in a family (other variables having been con- trolled for), the lower their educational attainment (3). Unplanned and un- wanted teenage pregnancies are associ- ated with high risks for mother and child (4, 5).

Taken together, these findings indicate the importance of using family planning services to reduce the number of off-

spring and to lengthen interbirth inter- vals in order to optimize the ability of parents to care for their children. The health risks associated with modern con- traception are far less than those associ- ated with pregnancy and childbirth (6). Comprehensive family planning services should include education about contra- ceptive methods and access to them.

Safe abortion must be available as a backup for contraceptive failure. Adoles- cents use contraception irregularly; and even when used faithfully, every contra- ceptive method has a failure rate (which is generally lowest for the birth control pill). Major morbidity and mortality from illegal abortions is inevitable if access to legal and safe abortion is denied.

Inadequate nutrition, cigarette smok- ing, alcohol consumption, drug abuse, and inadequate prenatal care during pregnancy are all associated with in- creased hazards to the fetus, including higher rates of low birth weight infants. Low birth weight, in turn, is associated with higher neonatal mortality and devel- opmental impairment among survivors.

The high technology of the neonatal intensive care unit (NICU) results in greater salvage for very low birth weight infants, but at much greater monetary cost and with far less satisfactory devel- opmental outcomes than those achieved by improving the physical and social con- ditions of the mothers during pregnancy. Thus, although NICUs in the U.S. have lower birth-weight-specific neonatal mor- tality than those in Sweden, overall Swedish neonatal mortality is lower than that in the U.S. because the proportion of low birth weight infants born in the U.S. is half again higher than that in Sweden (7).

Provision of comprehensive prenatal services, trained birth attendants, and backup hospital services for high-risk pregnancies will reduce psychiatric mor- bidity among live-born infants (8). Sosa

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et al. (9) and Klaus et al. (20) have dem- onstrated that the presence of a suppor- tive female companion (named a “doula” from the Greek word for experienced woman) during labor and delivery sig- nificantly reduced the need for cesarian section; this simple remedy diminished maternal morbidity at an obstetric service in Guatemala. Kennel1 et al. (II) repli- cated this striking effect in a randomized trial in Houston, Texas. As the authors state, “labor support is centuries old, but its advantages have now been validated in three controlled studies, . . . Its posi- tive effects should not be overlooked in the trend toward more and increasingly complex technology.”

A recently completed randomized prel vention trial for women at risk of bearing children with neural tube defects (be- cause of a previously affected pregnancy) revealed a strong protective effect (72%) from folic acid supplementation (12). Where feasible (principally in industrial- ized countries), screening for elevated blood levels of alpha-fetoprotein, chro- mosomal anomalies (by cytogenetic methods), and morphologic abnormali- ties (by ultrasonography) can permit the detection and abortion of abnormal fe- tuses carried by mothers at risk.

Newborn

Screening

A number of congenital metabolic ab- normalities can be detected by routine screening of newborns. Notable among the correctable conditions are phenylke- tonuria (PKU), galactosemia, and con- genital disorders of thyroid function-all of which result in severe central nervous system pathology if treatment is not in- stituted in the first weeks of life and maintained thereafter. The clinical man- ifestations of the first two conditions can be prevented by appropriate diet and the third by extrinsic thyroxin.

The fact that they occur at low fre- quency in Caucasian populations (one case per 3,600-5,000 live births for thyroid function disorders, one per lO,OOO-25,000 for PKU, and one per 60,000-80,000 for galactosemia--13) makes newborn screening a practicable public health measure only in countries with highly developed health services. Although the cost of case detection is relatively high because the conditions are rare, so are the lifetime costs to the community of caring for severely affected children. Even so, screening programs are of little or no value in the absence of a comprehensive follow-up program capable of ensuring that the infant at risk receives optimal care (14).

Childhood

Immunizations

According to WHO and UNICEF data for 1990, more than two million deaths in children under age five have been pre- vented by means of immunization against diphtheria, pertussis, tetanus, measles, polio, and tuberculosis; yet there are still some three million deaths each year from vaccine-preventable diseases because of the failure to extend the vaccination pro- gram to all susceptible children (25),

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Preventing

Malnutrition

sult in retarded development, both phys- ical and cognitive. It is now possible to Deficits in the intake of specific mi- treat 19 of the 23 major human helminth cronutrients, as well as in overall protein- infections very effectively with one of three calorie intake, can impair brain devel- drugs taken orally: albendazole, prazi- opment with major consequences for quantel, or ivermectin.

cognitive and emotional function. In principle, it should now be possible Iodine deficiency disorders (IDD) con- to treat for iodine deficiency, vitamin A stitute the most pressing instance of a deficiency, and worm infestations by micronutrient deficiency that leads to brain means of oral medication administered at malfunction. IDD affects more than 400 school. Such programs are now being million people in Asia alone (16). Clinical tested in the field (22).

manifestations include stillbirths, abor- Severe protein-calorie malnutrition, life- tions, and congenital anomalies; endemic threatening in itself, increases the likeli- cretinism characterized by mental defi- hood that exposure to infectious agents ciency, deaf mutism, spastic diplegia, and will result in clinical disease, because other forms of neurologic defect; and im- malnutrition impairs host defenses. Fur- paired mental function associated with thermore, malnourished persons show goiter. IDD in individuals at risk can be more pronounced systemic manifesta- prevented for three to five years with one tions of diseases that are more limited in injection of 2-4 ml of iodized poppy seed those who are well nourished. Gastroin- oil, a treatment that can be given by pri- testinal diseases, made more likely by mary care workers. To prevent fetal IDD, malnutrition, increase nutritional stresses iodized oil must be administered before on the host by increasing caloric require- conception; treatment even as early as ments at the same time that food intake the first trimester of pregnancy is not fully and absorption are impaired. Traditional effective. Oil injections are both feasible folk “treatments” for diarrhea, by reduc- and practical as an immediate means of ing intake of food and fluids, worsen the controlling endemic IDD. For reasons of threat.

cost and convenience, the long-term goal The conjoining of chronic malnutrition must be introduction of an iodized salt with disadvantageous family circumstan- program for the entire population (27). ces results in retarded cognitive and so- Program success is dependent upon pub- cial development (23). Studies of mal- lit education to elicit the full support of nourished children indicate that it is the the population (16). interacting and multipl,icative effects of In another area, three field trials (two the simultaneous biological and social with placebo controls) have shown high- insults that result in damage (24). dose vitamin A supplementation to re- Grantham-McGregor and her colleagues duce morbidity and mortality in children (25, 26) have shown that nutrition plus with subclinical nutritional deficiencies social stimulation for hospitalized mal- (28-20). Iron deficiency anemia has been nourished children, maintained after associated with lowered scores on tests hospital discharge by parents educated of mental and motor development in in- by home visitors, resulted in greater de- fancy. Children who had iron deficiency velopmental gains than did a program of anemia in infancy are at risk of experi- renourishment alone. Effective remedia- encing long-lasting developmental dis- tion must be targeted at the entire com- advantage (21). plex of social and nutritional deprivation.

Worm infestations in children can re- Monitoring the growth of young chil-

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dren, a simple method well within local resources, permits the early detection of developmental failure. It is one of the four components of the UNICEF “GOBI” initiative: growth monitoring, oral rehy- dration, breast-feeding, and immuniza- tion (27).

Injury Prevention

Accident-related injuries (more appro- priately termed unintentional injuries) are the leading cause of “years of potential life lost” in the United States, YPLL being defined as the number of deaths from a given cause multiplied by the difference in years between the subject’s age at death and age 65 for each case (28).

Vehicular accidents are a major source of head and spinal cord injuries among survivors. Such injuries are preventable by vigorous enforcement of lower speed limits (29), better highway design, traffic regulations, vigorous prosecution of dnmk driving, automatic seat belts, child safety seats, and air bags.

Among children, cycling is a major cause of hospital admissions for head in- juries. In a recent study (3U), cyclists wearing helmets, as compared to those without helmets, had an odds ratio for brain injury after accidents of 0.12 (95% confidence interval 0.04-0.40).

Poisonings in children can be mini- mized by mandating “childproof” safety caps on bottles of medication and toxic chemicals for domestic use (32). Blood lead levels in children can be reduced by effective controls on the lead content of gasoline for automobiles (32).

Home Visiting

and Enriched

Day Care

David Olds and his colleagues (33, 34) at the University of Rochester have shown that a program providing prenatal and postnatal home visitation, transportation

for health care, and sensory and devel- opmental screening is effective in pre- venting abuse and neglect among chil- dren born to socially disadvantaged primiparas. The nurse-visited women made better use of community services, experienced greater social support, im- proved their diets, and reduced their smoking. Length of gestation and new- born birth weights were improved, and there were fewer verified cases of abuse among poor unmarried teenage mothers.

Studies in both developed and devel- oping countries have shown that chil- dren growing up in deprived circum- stances exhibit deficits in cognitive development, lower levels of academic achievement, and increased rates of be- havioral and antisocial disorders (35). These disastrous outcomes can be made less likely through enriched day care pro- grams that involve parents as active par- ticipants. Several long-term outcome studies have demonstrated better occu- pational history, fewer out-of-wedlock pregnancies, and lower rates of academic and behavioral pathology (36-38).

Day care programs can facilitate attain- ment of a second goal: the teaching of parenting skills to adolescents by having them participate in the care of toddlers under supervision. The effectiveness of this strategy has not been formally dem- onstrated, but its desirability is indicated by the fact that experience in child care within the family, the traditional way these skills have been transmitted, is becoming ever less available. With smaller family size, both parents working, and more single-parent families, one can no longer take for granted that such “naturalistic” education is available to all children.

Community-based

and

School-based Programs

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gram for children in an experimental group provided with periodic develop- mental exams from six months of age, weekly play groups from two years, and daily prekindergarten from three years. Classroom observation demonstrated that children in the experimental group had less learning difficulty and fewer reading problems in second grade.

Ramey and Campbell (40) evaluated a child-centered prevention program empha- sizing language, cognitive, perceptual- motor, and social development for chil- dren 18-54 months old. The enrolled children scored significantly higher than controls on a series of tests of mental ability.

Botvin et al. (42) assessed a school-based 12-unit curriculum delivered by peer leaders or classroom teachers, with pe- riodic booster sessions in subsequent years. The goal was to give junior high school students in an experimental group the skills to resist pressures to smoke and use drugs, to help them develop self- esteem, and to cope with social anxiety. The outcome was a reduction in the onset of smoking among students in the ex- perimental group, as indicated by both self-reporting and saliva tests.

These and other model programs have been reviewed by an American Psycho- logical Association Task Force on Preven- tion (42). The task force noted that the common features of successful programs included “careful targeting of the popu- lation, the capacity to alter life trajectory, the provision of social support and the teaching of social skills, the strengthen- ing of existing family and community supports, and rigorous evaluations of ef- fectiveness” (p. 57).

Prevention

in Clinical

Settings

Iatrogenic Disease

Iatrogenic disease resulting from in- appropriate prescribing practices can be

reduced by training primary health care workers in the recognition and manage- ment of psychosocial disorders. Geil et al. (43) have documented the high prev- alence of mental disorders in primary child health care in developing countries. Training in the recognition and manage- ment of psychiatric disorders in general practice can not only reduce unnecessary diagnostic studies and inappropriate medication but can also make effective mental health care available. Psychologic morbidity is a common accompaniment of chronic physical disease; Pless and Wadsworth (44) have shown that it may persist into adulthood. A program of combined comprehensive biomedical and psychosocial pediatric home care has been shown in a controlled clinical trial to pro- duce long-term mental health benefits five years later (45).

Child Neglect and Abuse

Child neglect and abuse, major prob- lems the world over, demand prompt and effective intervention. Schoolteachers and health care workers need to know how to recognize neglect and abuse and how to initiate referral to community agencies charged with management. In some in- stances, visiting homemakers and social workers can help to salvage families so that they become safe places for their children; in others, rapid removal from the home will be essential, not merely for the child’s mental health but for its very survival.

Nevertheless, that is only the first step. Foster care may suffice in the short term if the child’s family of origin can be re- constituted and the child returned to it (for example, when neglect has resulted from an acute family crisis, hospitaliza- tion of a parent, eviction from the home, etc.). But over the long run foster care is unsatisfactory. Once it becomes clear that the family is incapable of fulfilling its re-

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sponsibility, the child should be legally freed for adoption and an adoptive home found. Over the past 30 years in the United States, the magnitude of the placement problem has grown, but a sys- tem adequate for its management is not yet in place (46, 47).

Epilepsy

The prevalence of epilepsy in less de- veloped countries has been estimated to be as high as 15 to 50 cases per thousand inhabitants, as compared to rates of 3 to 5 per thousand in industrialized coun- tries. Improvements in obstetric care, more effective accident prevention, and prompt treatment of CNS infections will reduce this prevalence.

Untreated epilepsy is associated with progressive neurologic compromise and increasing psychosocial impairment made worse by the stigma associated with the disorder. Greater skill in recognizing epi- lepsy and making appropriate use of an- ticonvulsant medication can markedly di- minish the psychosocial handicap (48).

Schizophrenia and Affective Disorders

Although the primary prevention of the schizophrenias eludes present capabili- ties, secondary prevention measures em- ploying neuroleptic drugs for patients and psychoeducational training for family members can reduce the duration of ill- ness episodes and the likelihood of re- lapse (49-52). Tertiary prevention, by keeping hospital stays to a minimum, redesigning institutional programs, and providing social skills training and shel- tered workshops, can avert chronic social breakdown syndromes among patients with chronic disorders (53).

Similar considerations pertain in the case of affective disorders. The knowledge base necessary to permit primary prevention is not yet available, but the use of tri- cyclics, lithium, and interpersonal psy-

chotherapy (54) can shorten morbid ep- isodes and reduce the likelihood of recurrence (55-56). In view of the long- term morbidity associated with depres- sive illness (57) and the rising incidence of depression in recent birth cohorts (58), emphasis on the diagnosis and treatment of depression in primary care facilities should have high priority in public health programs.

IS PREVENTION

ALWAYS

PREFERABLE?

Having shown that prevention of some mental disorders is possible, we must still ask: Is it always preferable? From the standpoint of the individual who would otherwise have become ill, avoidance of illness is almost always more desirable than treatment because it avoids the mor- bidity associated with illness and its care. However, when prevention requires changing habitual behavior, and partic- ularly when change causes withdrawal symptoms (as in smoking cessation), the “cost” of prevention may deter its ac- ceptance. Moreover, in the case of smok- ing the time lag between risk-taking and its pathologic consequences is a matter of decades. This reinforces public skep- ticism, especially because smoking ces- sation reduces rather than altogether eliminates the probability of disease.

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From the standpoint of the commu- nity, in contrast to that of the individual, decisions about undertaking preventive measures require a weighing of compet- ing social aims (59). To pursue the ex- ample provided by smoking, its elimi- nation involves the loss of jobs in tobacco farming and cigarette production, of tax revenues, and of export-generated for- eign exchange. These factors do not gain- say the extraordinary benefits from smoking cessation: significant reductions in rates of cancer, ischemic heart disease, chronic obstructive pulmonary disease, prematurity, and other health hazards. But they do highlight the magnitude of the political challenge (60).

Another point: If the incidence of a dis- ease targeted for prevention is low, the ratio between benefit to the individual and cost to the community shifts mark- edly. Consider the case of maple syrup urine disease (MSUD or branched chain ketoaciduria). The incidence of MSUD in newborns is between one case in 250,000 newborns and one in 300,000 (13). Un- treated, MSUD is associated with mental retardation, convulsions, repeated infec- tions, and (in the classic form of the dis- ease) early death. Treatment with diets low in branched chain amino acids can improve the prognosis for the patient if the disorder is detected in the newborn period and if treatment is begun promptly. However, the costs of screening, the low yield of confirmed cases, and the com- plexity of the dietary regime all combine to make prevention of MSUD a public health measure feasible only where health care systems are highly developed.

COMPONENTS

OF ACTION

PLANS FOR CHILD MENTAL

HEALTH

The available data base suggests that effective child mental health plans should consist of certain components that are

generally applicable but that will require different emphasis in different countries and will be more feasible in some coun- tries than in others because of cultural, political, religious, or other considera- tions. These components include:

1. Family planning. Because enabling parents to control family size is essential for the health of mothers and children, every nation should introduce sex edu- cation in the schools, including infor- mation about contraceptive methods and their reliability. Sexually active individ- uals should have access to contracep- tives. Safe abortion should be available when contraception fails.

2. Prenatal care. To give all infants a safe start in life, a comprehensive pro- gram of prenatal care should be available to all pregnant women. This must in- clude assurance of adequate nutrition and counseling on the importance of avoiding cigarette smoking, alcohol use, and drug use during pregnancy. Appropriate birth attendants must be available for delivery, together with hospital backup for high- risk pregnancies. The stress of labor and parturition can be reduced by having “doulas” available for hospital deliveries. Where resources permit, newborns should be screened for phenylketonuria and congenital hypothyroidism.

3. Immunization. Toprotectagainstbrain damage and death, the WHO Expanded Program on Immunization should be ex- tended to all infants and children. Re- ducing morbidity and mortality in child- hood will in turn enable parents to plan for fewer births because of greater con- fidence that their children will survive to adulthood.

4. Optimal nutrition. Growth monitor- ing of infants and toddlers is essential if malnutrition is to be intercepted. Where appropriate, iron and vitamin A supple- mentation should be introduced. Iron deficiency anemia should be promptly cor- rected. In settings where worm infesta-

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tions are common, school-based public schools provides a natural “laboratory” health programs for treating such infes- for instructing adolescents in parenting tations with appropriate drugs can im- skills and at the same time increases day prove child nutrition. care resources for the community.

5. CkiId safety. To avoid head injuries and consequent brain damage, every country should invest in injury preven- tion programs. With respect to automo- biles, this should include child safety seats and airbags, highway speed limits and modern highway engineering, and mea- sures to reduce drunk driving. Motor- cyclists and bicyclists should be required to wear helmets. To prevent accidental poisoning, bottles containing medica- tions or toxic chemicals should have “childproof” tops. In addition, the use of lead-free gasoline and lead-free house paint, together with the progressive de- leading of all housing stock, can reduce blood lead levels in children.

6. Home visiting and day care. Infants and toddlers in homes at risk (character- ized by poverty, low education, unwed teenage mothers, histories of difficulties with older siblings) will benefit from home visiting by nurses at periodic intervals to advise mothers on infant care, monitor the progress of the child, and mobilize additional community services where they are required. Such children will also ben- efit from enriched day care programs that not only stimulate cognitive develop- ment but also serve as a vehicle to teach skills to parents.

8. Mental health in primary care. Teach- ing mental health principles to all child health workers will permit earlier rec- ognition and more effective treatment of development and behavior problems in young children. The care of children with chronic physical disorders should in- clude measures to prevent psychologic morbidity. The prevention of epilepsy by better obstetric care, accident prevention, and prompt treatment of CNS infections should be accompanied by training in the diagnosis and treatment of epilepsy when it does occur in order to prevent psycho- social impairment among affected chil- dren. In community health clinics and school clinics, all primary care health workers should be alert to signs of child neglect and abuse and be familiar with the process of referral to competent au- thorities in the community.

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