WHO CARES FOR THE CHILD

Meyer Sonis, M.D.

It has been said that the hand which rocks the cradle rules the world.Ordinarily we have assumed that the hand on the cradle is that ofthe mother. For this reason, she has been praised for the successfuloutcome of her rocking and blamed for the failures . This point ofview has been amply supported by our past literature, as for examplein the form of Barrie's What Every Woman Knows}Strecker's "mom­ism" to explain the high rate of rejectees in World War II , or in thesearch for the schizophrenogenic mother.

As a result of medical and social advances in all areas pertinent tocradle rocking, we have enabled the mother to remove her handsfrom the cradle for varying periods of time and intervals. We haveprovided a multitude of professional hands to aid her in the taskof cradle rocking. Our technological progress has now permitted themother to work, seek a career, to return to school, and with someassurance that the outcome of cradle rocking will yet remain success­ful. As a mother, she has now had to share some of the credit forsuccessful cradle rocking with the professional child caretakers. As amother, however, she has had some difficulty in sharing the blameor seeking corrections for the failures of cradle rocking since she hasfound so many hands on the cradle. The question of Who Cares forthe Child is now a moot one, since it would seem that everyone does.The question remaining, however, is: whose hands are doing what?This, then, is the theme of this paper, namely, an examination of

Dr . Sonis is Professor of Child Psychiatry in the Department of Psychiatry, Schoolof Medicine, University Of Pittsburgh .

Reprints may be requested from the author at W.P J .C., 381J O'Hara Street, Pitts­burgh, Pa. 15261.

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those hands on the cradle which collectively belong to the healthprofessions.

The nature of medical practice with children has undergone sig­nificant changes during the past few decades, and all indications forthe future suggest that such changes will continue. During these pastfew decades, the physician has become decreasingly concerned withthe mortality of children. Increasingly, however, he has become con­cerned with the health and developmental problems of children, therecognition and management of the chronic handicapping diseasesand illnesses in children with their concomitant emotional drainageof the family unit. The emotional and social sequelae of chronic ill­ness in children, program planning for the brain-damaged and/ orretarded child, the need for preventive care, the community resourcesnecessary for the rehabilitation of the deviant child and his family,the significance of early case finding, and the relationship of health,education, and welfare-have all now become, or potentially can be­come, the domain of medicine and the health professions, formerlythe domain of the behavioral and social sciences. The nature ofpediatric practice has placed a broader honizon in the purview of thepractitioner.

During this same period of time, as the nature of medical practicewith children was undergoing change, the consumer of medicalservices has increasingly assumed that the physician and the healthprofessions are or should be interested in and concerned with thehealth and welfare of the child as well as the illness of the patient.The American family has come to expect maximal utilization ofmedical skill and knowledge and want the best for their childrensocially, educationally, and medically. The trend of the Americanfamily toward social mobility upward continues to promise ever in­creasing pressures on the American physician and the health pro­fessions for providing these broadened medical services. There canbe no doubt that the pressure of the consumer is reflected in thewhole host of federal legislation-the regional medical centers forcancer, heart, and stroke; the Medicare programs; the amendmentsto the social security laws allowing for legislation for more compre­hensive pedicare services for children; the comprehensive mentalhealth and retardation centers; the Head Start program; the currentdiscussions on comprehensive health services; the allied health pro-

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fessions law; demonstration city programs. The voice of the con­sumer, whether in the person of the poor, the black, the retarded,or the disturbed, has demanded representation in decisions regardingthe health services to be provided. The voice of the consumer hasbrought about major configurational changes in the delivery ofservices in the public sphere.

During this same period of time, the health service industry hasbeen placed under significant pressure to account for the maldis­tribution of its service, the inequitable nature of such services, theduplication and fragmentation of its efforts, and the increasinglyhigh cost of its services. Simultaneously, the health service industryhas undergone major changes as a result of an increasing spectrum ofthird-party payments for services, consumer pressure for policy repre­sentation, union activity of personnel, and a more conscious need fororderly planning, growth, and development of its services. Thehealth service industry is now a big business requiring major reor­ganization of its existing pattern of organization, programs, andmanpower to meet the needs of comprehensive health care.

Concomitantly, as the nature of medical practice with childrenwas changing, and as consumer pressures increased for availability ofcomprehensive services, the academic market place of the health andallied health professions was also being pressed for critical evalua­tions of its objectives. Though research had become big business, theknowledge availability gap continued; for example, the frequentstatement that 10 to 15 years elapse before educational research is inthe hands of the practitioner. Curricular changes were explored andrecommendations made for changes in education in medicine, psy­chology, social work, nursing, and in education itself. Universitieswere asked to examine the nature of their responsibility to a com­munity at large. The issue of service versus training and research wasput squarely before the academic market place, and the status andprestige problems of the various professions placed as squarely uponthe table. The critical problem of access to service and availability ofmanpower for such service was explored, with the resultant emer­gence of new professions.

Psychiatry during the past two decades, under external and inter­nal pressure, has undergone significant changes. It is in this periodof time that Action for Mental Health and Crises in Child Mental

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Health provided foci for changes which have taken place and willtake place in the future; the NIMH grew to its sizable importance;the hospital for the mentally ill gave way to the year of the Com­munity Mental Health Center, the year of the addict, the alcoholic,the aged, and now the year of the child. Within the context of thesechanges, the profession of psychiatry grew in its importance withinthe academic market place, and as an academic discipline began acritical examination of its theories, concepts, opinions and beliefs,practices and procedures. I t is also during this period that childpsychiatry emerged as a subspecialty of psychiatry, and as such hastaken its place within the academic grouping providing medical edu­cation, research, and service. In taking this place, with whateveradvantages and disadvantages such a position brings, child psychiatryhas emerged with an identity of its own. Though, as yet, many issuesexist regarding the ultimate place of child psychiatry within academicmedicine, child psychiatry has brought to the academic medical pro­fession: its community roots and orientation; its focus on childrenas requiring services geared to them as developing organisms; anemphasis on the framework of child development as the basis forclinical services; its body of educational experience and research, andan array of experience with an extended nonmedical team. Withinchild psychiatry, as in psychiatry, a serious appraisal of its clinicalempiricism, academic programs, and organizational identity is under­way.

The sum total of these major advances during these past twodecades has led to a greater acceptance by the health profession of thesequential relationship between the childbearing period, the child­rearing process, the health and development of children, and theservices of health, education, and welfare children require. Further,there has emerged a greater balance in putting together the pieces ofnature and nurture, health and illness, child and family, theory andfact, known and yet to be known, as these pieces are pertinent to thecradle and cradle rocking. Additionally, the health professions andhealth service industry have been brought to the brink of tacklingthese issues focused on a rational system of delivering comprehensivehealth services through a decentralized vehicle to target populationswhere they reside, and with manpower required at a cost com­mensurate with quality control of effectiveness.

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And yet) despite the evident progress made by the health profes­sions in accepting the importance of the childbearing period as asequential precursor for successful cradle rocking, the significance ofconception for the health profession remains the event itself and theissue of whether pregnancy was planned or unplanned. Conception,from all available indications, is an event for which the male andfemale have, prior to the event, been preparing and prepared forbiologically, but not necessarily psychologically; an event which mustbe viewed as a "happening" in time, purpose, and setting; one whichinitiates the biologically time-determined childbearing process; whichinitiates a period of time during which process the female mustaccomplish the biological tasks of pregnancy and the male and femalemust accomplish the psychological tasks of pregnancy. Conceptioncan start the process of childbearing which will continue under bio­logical control to its termination in delivery, but throughout thisperiod of time the pregnancy is a process which can be resisted psy­chologically. Conception can start the process of childbearing whichpsychologically can be very much wished for, but biologically not soordained. The ability to conceive may be enhanced through hor­monal medications and yet not enable the woman to conceive, butupon acceptance of this state of sterility, as evidenced by the decisionto adopt a child, a woman can then conceive. Conception can beavoided with the use nowadays of our contraceptive pills, but therestill are many accidents which speak to the complexities of the repro­ductive functions. Conception can occur at a time of marital discord,in the hope that it can resolve such discord; as a rebellious act againstthe discipline of the parent or parents, and as a means of expressingone's independence, on the one hand, and anger on the other; it cantake place too close to prior pregnancies, thus affecting adverselythe child's and the mother's health and perhaps the welfare of thewhole family; conception can occur when the parents are preoccupiedwith the financial instability of the family, or when the husband andfather is overinvolved in earning more of an income; when thepotential mother is beset with many harsh realities of rearing otherchildren, or when the parents are undergoing crises of love andintimacy. They may be deeply concerned about illness in the familyor the conception may have been preceded by previous miscarriagesor stillbirths or births of children with congenital defects. Conception

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is far from a discrete event: It IS an event providing innumerablepossibilities for the constructive utilization of the professional handson the cradle, but also many opportunities for failure on the part ofthose same hands.

The significance of conception lies in the fact that it is one morestep in the development of each of the partners, and a step which isbuilt upon the successes or failures they have had in accomplishingthe tasks of previous roles as children, young adults, students, sonsand daughters, man and woman, husband and wife . Conception,therefore, has a meaning specific for each of the partners, specificfor the product of that conception, and specific for the events relatedto this human activity. It is not simply an event.

And yet) despite the significant progress made by the health pro­fessions in obstetrical knowledge and care) the childbearing periodhas remained largely a problem in logistics. Pregnancy, as conception,is not viewed as a significant developmental milestone for the maleand female which offers further opportunity for constructive utiliza­tion of the professional hands made available for cradle rocking. Thechildbearing period, for the health professions, has remained pri­marily a challenge to insure the successful accomplishment of thebiological task for the mother, with minimal attention to the com­panion piece of the psychological tasks for the mother and father.

From all indications, the childbearing period is both a biologicaland psychological process, with a beginning and an end, but an endwhich prepares for the next process of child rearing. Emotionally,the mother enters this process of childbearing with a whole host ofquestions and conflicts which have arisen, been resolved, or per­petuated during her previous developmental phases and which onceagain are mobilized and again require answers. Her questions areabout herself, the baby, the outcome, other children, her husband orlack of one; conflicts about her capacity to be an adequate mother,the additional demand of one more child, her need for support andindependence at the same time, her continued work. Emotionally,the mother continues in this process of childbearing while seekingsatisfying answers to her questions and conflicts, and in turn reflect­ing her increasing capacity to accomplish the psychological tasks ofpregnancy. For example, we may observe no major medical com­plications, the baby is progressing, she maintains the requirements of

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obstetrical care, other ch ildren are progressing, her husband andfamily care, the fetus comes alive, a name for the new baby is con­sidered, she identifies with the unknown baby, prepares for thebaby's future, and so on.

During the course of her pregnancy, the mother will be availableto many hands, whose collective intent, though not necessarily act,is that of helping her do a better job of rocking the cradle. She willreceive advice from her husband, relatives, and neighbors. She mayreceive support from them. She will read the books written by theexpert, or she will abide by the tales of other women. She may attendprenatal classes. For some mothers, the medical o r e available willbe of excellent quality, insuring the possibilities of successful out­come. For others, the care available will be sporadic, without dignity,comfort, and concern. Some mothers will come to a prenatal clinic,wait their turn from 9:00 in the morning until 3:00 in the afternoon,and forego their lunch, while noting the staff going out to theirlunch; and then succeed in having a lO-minute examination at theend of that 6-hour wait. For other mothers, the obstetrician will pro­vide the best skill of an engineer, but little or no attention to herquestions, fears, doubts, or psychological needs. Emotionally, somemothers end the process of childbearing with the psychological taskof pregnancy successfully accomplished. Emotionally, yet othermothers end this process with confirmation of their worst fears aboutthemselves and their capacity adequately to master the process ofchild rearing.

And yet , despite the phenomenal advances made in child health,care, and development, the child-rearing period can provide us withnumerous examples of professional hands on the cradle which haveinterfered and obstructed. For many parents and children, this periodof time called the child-rearing process has been such as to allow forconstructive development of the child's emergence from the cradle.For many other parents and ch ildren, this cannot yet be said.

There still is a group of mothers whose newness to child rearingis evident in their confusions about the various developmental mile­stones of their children. We have provided all of them with avenuesfor securing help, but in so doing, have paid attention mainly to thesterile elements of developmental growth and anticipatory guidance.

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There still is a group of women who, during pregnancy, have givenevery indication of their potential vulnerability to failure in provid­ing an environment adequate for rocking of the cradle, and whoseindications were not heeded or appreciated by the hands of othersavailable to them. It is this group of mothers who now face an out­come of pregnancy whi ch is not completely successful-the stillbirth,the child with congenital defect or defects, the neonate requiringlifesaving measures. For this group of mothers, we have providedhands of excellence for surgical correction of anomalies, earlier iden­tification and treatment of Rh incompatibilities, and methods ofpotential alleviation of the sequelae of phenylketonuria. In brief, wehave provided a host of medical techniques of inestimable value, butwe have not really provided the kind of help required by the parentsand child to deal with the child-rearing consequences of such anoutcome.

We have come a long way in our knowledge of phenylketonuria andprovision for correcting such deficiencies. We have asked parents toparticipate in our efforts at detection, prevention, and alleviation,and have raised their hopes and expectations. At the same time, theseparents will need to await the results of their ministrations, continueto live with the uncertainty of outcome of their efforts and, despitethis uncertainty, be expected to provide a balanced approach to childrearing, not looking for more or less than the child can appropriatelyproduce for his age. We have not appreciated the dilemma producedfor the cradle rockers.

There still are many hospitals which have developed excellence ofmedical techniques for insuring the life of the premature infant, butat the same time have not recognized or taken steps to minimize thealienation of infant and mother brought about by the separation. Inmany of these situations, we have not appreciated the increasingsense of inadequacy felt by these mothers as they see others able tohelp their infants, while they remain third parties to the transaction.

Th ere still are many hospitals offering children and their parentsthe best of physical medical knowledge, but within the context ofviewing parents as foreign bodies in the well-oiled operation of thehospital.

There still are man y parent organizations dealing with disease and

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defect entities in children, which continue to be needed because thehealth professions are unavailable adequately to meet their needs asparents while they face uncertainty of outcome in their children.

There still are many children who have become unofficial wards orfoster children of the hospital because, while they undergo long-termcorrection and rehabilitation of defects and trauma, their parentsare alienated from the care and management of the child.

There still are many children who are diagnosed as diabetics andwho require frequent hospitalization for control of their diabetes,but in the process of such excellent medical care we have providedthe soil for the chronic suicide of the child in his psychologicalstruggle with control and parents.

There still is a large group of children whose outpatient and in­patient records have now become as thick as a large-sized dictionary.This is a group of children whose symptomatology has led the hos­pital to utilize costly laboratory procedures and extensive diagnosticand treatment procedures in search of a cure, but they are childrenwhose records, if carefully read and collated, would reveal the priceto be paid in destructive child development for sporadic, fragmented,but technically excellent, medical care.

It would seem that the health professions, wittingly or unwittingly,have placed their collective hands on the "cradle." There is much toindicate the value of these hands to the cradle and the mother in herrocking of the cradle, but there is equally much to indicate whatmore is required of these hands. The health professions have beenplaced in the important position of becoming, if they choose, thecaretaker for the health and development of children, as well as aresource for the alleviation of illness. For some members of themedical profession, the care of ch ildren who are ill cannot be sep­arated from their health and development. For others in the medicalprofession, this assumption does not necessarily follow. A review ofthe progress made during the past two decades will reveal that allof the separate pieces for the development of comprehensive healthservices for children are in the hands of the medical profession.

At the present point in time, it is difficult to know which path orpaths will be followed in putting the pieces together. The decision asto which path to follow will be greatly dependent on solutions tothese various givens, i.e., political climate, self-interest groups, lay

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and professional, legislation already enacted and implemented, gov­ernmental institutions. Perhaps of greatest significance to the cradleand cradle rocker is not the decision as to which path to follow, sinceall roads lead to Rome, but the decision as to whether Rome is theultimate destination.

It is my own belief that the ultimate destination for our nationcan be a mandate that the development of children is a public utilityand trust. If so, it would follow that the planning for delivery ofhealth services to this target population would require considerationby the pediatric professions of the following principles.

1. The characteristic patterns of the chiLd and youth populationwhich may be served during the next decade:

During the past decade the health service industry and the healthprofessions have benefited enormously from the scientific advancesmade in the information availability and retrieval systems. Duringthe next decade continued advances in such systems, and our in­creased sophistication in the utilization of them, will ultimately pro­vide a more rational basis for the planning and delivery of healthservices, the aim of which is matching service required to the natureof population to be served. For children and youth, in any givengeographic area, such advances will provide the means for translatingthe nature of the environment children live in, the nature of familieswith whom they live, and the impact of such data on child develop­ment and disease into more meaningful information than heretoforehas been available. The health services for this target population willbe planned and delivered with consideration given to demographic,epidemiological, and psychosocial characteristic patterns of the popu­lation; earlier identification of populations at risk; and anticipatedchanges and trends of population patterns.

2. The pattern of child disease and illness which may be antic­ipated during the next decade:

As a result of advances made in the pediatric professions duringthe past two decades, there has been a significant change in the pre­dominant patterns of disease and illness in children who confrontthese professions. For this reason, it can be anticipated that thepediatric professions will be faced with the need for attention to theincreasing number of children who will be able to survive, but whodo so with patterns of disease and illness reflecting the chron ic

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sequelae of congenital defects, neurological abnormalities, and met­abolic abnormalities; the complex of disease and illness in childrenrelated to environmental factors such as poverty, housing, nutrition,under- or overstimulation, sensory deprivation, failure to thrive,abuse, etc.; the developmental disorders in children manifested in awide spectrum of behavioral symptoms and reflecting a wide scopeof etiological causes.

3. The pattern of medical care required by the patterns of diseaseand illness in children) if such care is to be comprehensive andcontinuous:

In keeping with the changes anticipated in the predominant pat­terns of disease and illness, the pediatric professions will be requiredto pay more attention to the nature of the disease, illness, or disorderas the chronicity of the disease or illness or disorder predicates theneed for long-range medical programs, as distinct from short-rangeepisodic care. Such long-range medical programs will require atten­tion to the nature of studies, staff, and equipment required for therehabilitation of the child, in addition to that required for the diag­nosis and treatment of the disease or illness or disorder; the co­ordinated efforts of the various pediatric specialties brought into playin the course of providing services; the spectrum of allied healthprofessions and technicians needed for the short- and long-rangeprovision of medical care; and attention to the various communityagents who will also be called into play for support of the long-rangemanagement of the child.

4. The pattern of human care required by the child during theprovision of medical care for his disease and illness) as a means ofaiding him to cope successfully with the disease and illness:

In the past two decades, medical care for the disease and illnessof a child has immeasurably increased the capacity of a child tosurvive. If in the next decade the end point of medical care forchildren is to become the increased capacity of each child to thrivewithin his developmental potential, and not simply survive, increas­ing attention will of necessity be paid to the developmental needs ofchildren, whether in health or illness. The pediatric professions andthe health service industry will be required in the provision ofmedical care for the disease or illness to consider the pattern of pastdevelopment of the child, the meaning of the disease or illness to this

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past development and its implications for future development; thereactions, feelings, and needs of children at a time of illness; themeaning of the disease or illness to the child and his family; thenature of the family equilibrium and the effect of the child's illnesson this equilibrium. The pediatric profession and health serviceindustry, in their considerations of developmental needs of children,will entertain a whole host of possibilities as a means of providinghuman care through medical care. The possibilities for care of sickchildren are legion, but lack will have impact on the nature of phys­ical plant required, the scope of programs needed, and the spectrum ofstaff necessary, i.e., "motel" accommodations for parents in order tomaintain tie of child and family; child-care homemakers as a bridgebetween the hospitalized child and family; home-care staff and pro­gram for relating the home to the child to the disease or illness tocomprehensiveness and continuity in medical care; play programs,school services, recreational facilities; day and partial hospitalization;medical foster homes; parent coping programs, etc.

5. The network system pattern which will be required for thedelivery of health services to children:

During the past decade, and at an ever faster pace, increasing em­phasis has been given to an identification of the parameters for anorganized system of health care delivery. Though the exact form ofthe system or systems for health care delivery will yet emerge duringthe next decade, the parameters have been generally identified. Anexamination of these parameters would reveal the utilization ofvarious mechanisms which (at least) provide for the decentralizationof services of a generalist nature to a defined population area, group,or characteristic; a centralization of specialized services to supportthe generalist decentralized services; a scope of services which arecomprehensive in nature so that equal attention can be given to thehealth, promotion, and maintenance of health, prevention, andearlier identification of disease or illness, and the diagnoses and treat­ment of disease or illness of the given population; a spectrum to theseservices which insures continuity in the provision of the services; asystem of information and data collection and analyses on popula­tion, patients, providers and programs (services) for purposes ofplanning, evaluations, studies, epidemiology, program comparisons,cost accounting; a quality control system to assure accountability of

610 M eyer Sonis

providers and standards for services rendered ; a method or patternof payment for services rendered which can offer compromise solu­tions between pluralism and universality, choice and mandate, con­trolled entree and assured access, private and public.

Of gr ea t significance for the delivery of health services to childrenhas been the past and con tinued search for a common denominatormechanism to the various target population possibilities, i.e., chil­dren, youth, aged individuals, families, minority group, majoritygroup, poor, nonpoor, breadwinning, urban, rural etc. During thenext de cade, and as the form or forms for a system of health caredelivery emerges, increased attention will be required of the pediatricprofessions and health service industry to those mechanisms whichcan insure a network system of health services for a target populationin their developing years, as distinct from a target population in theirproductive or declining years .

6. The pattern of medical care for children requested and /orutilized by the community at large:

In the planning and implementation of a system or systems fordelivery of total health services to children during the next decade,there is no doubt th at increased attention will be paid to the voiceof the consumer. In so doing, the provider of services will be requiredto consider the various formal and informal routes by which the laychild caretaking community reflects the vacuums and inadequaciesin the health services available; expresses dissatisfaction with the levelof care provided child ren ; and seeks and forges its own network ofservices from the nonsystem which exists.

7. Th e pattern of collective child care provided by the community}as this care may posit ively or negatively influence the developmentof children} the pattern of disease or illness or trauma in children}and the effective delivery of total health servi ces to children:

If the health services for children are to achieve more than the endpoint of survival of children, the pediatric professions and healthservice industry will be required to place more emphasis on the psy­chosocial aspects of medical car e. Consideration of the ecology ofthe community will be required to ascertain the capacity of the col­lective comm unity to promote the health of children ; prevent disease,illness, and trauma; identify children at earlier ages who are highrisk for developmental disorders; participate with the health service

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industry in meeting the developmental needs of children while ill;support the primary caretaker of children in the task of childbearingand rearing. Thus, the ecology of the community will be more thanthe air and water children breathe and drink, and the space theyplay in, but also the extent to which integrated social, welfare, edu­cational, correctional, and protection services can be made available.Thus, for example, consideration will be given to the nature of edu­cational services which are required for the child and his family:remedial programs; diagnostic services; periodic health survey; ser­vices for the handicapped, retarded, and disturbed; vocational plan­ning; family life curriculum; guidance counselors; adult classes; util­ization of school facilities for family and community activities, i.e.,library, playground, gymnasium, pool, auditorium.

8. The pattern of medical education which can best produce themedical manpower for the delivery of total health services to children:

During the past decade significant changes have taken place in thecurriculum content and format of medical education. These changeshave not yet been consolidated into a specific pattern of medicaleducation from which generalizations can be made. It would seemthat the next decade will produce the more generalized pattern formedical education as the medical professions and health service in­dustry seek solutions to the issues now existing. These solutions, orcompromise solutions, will require considerations of the ultimatedirection of the health service industry and the preparation of thephysician for his place in this system of health care delivery; medicalmanpower needs and distribution; the nature of curriculum requiredto produce a developmentally focused, health-oriented physician,who is capable of assuming his or her place as a member of an ex­tended team for delivery of comprehensive and continuous medicalcare; the realignment of service as an equal partner to teaching andresearch; the nature and extent of responsibility to be taken by themedical profession for the psychosocial aspects of medical care; theobligations on the medical profession for continuous education andquality control of its profession; the future implications of currenttrends in medical education (specialization at earlier ages, continueddepartmental compartmentalization, emphasis on disease and pathol­ogy, separation of psychosocial aspects of medical care from the main­stream of medical care) for the delivery of health services.

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9. Th e patt ern of edu cation and train ing which can best producethe allied health human po wer required for th e delivery of totalhealth services to children :

During the past decade, and under circumstances and issues similarto those facing the medical profession, there have been significantchanges in the educational programs of those professions traditionallyviewed as health-related: nursing, social work, physical therapy, etc.Of signal importance, however, to the delivery of health services tochildren has been the more recent development of the past few years,namely, the academic institutionalization of educational programs forthe allied health professions in a School of the Health-Related Pro­fessions or School of Allied Health Professions wherein the futurehuman power for delivery of health services is provided an identitywhich is distinct from that of the past traditional allied healthprofessions.

At the present time, though there is agreement am ong the medicalprofession and educators on the need for a health orientation anddevelopmental focus in medical care, there are indications thatchanges in medical education will not take place fast enough or insufficien t breadth to produce such physicians in quantity. At thepresent time, though the traditional allied health professions suchas nursing or social work are prepared to assume an increased respon­sibility in this area, there are also ind ications that changes in theireducational programs will not take place fast enough or in sufficientbreadth.

In the decade to come in creasing emphasis will be given to thethrust for new identities, professions, and technicians to emerge fromwithin the newer academic institutions such as "Schools of theHealth-Related Professions" or "Schools of the Allied Health Pro­fessions. " In the development of these new professions and spe­cialties the conjoint effort of the medical professions and traditionalallied health professions will be required in the planning and imple­mentation of curriculum and programs to produce pediatric asso­ciates, nurse practitioners, child-care specialists; child developmenttechnicians, physician aides, psychological associates, and child-carehomemakers. The development of these new professions should pro­vide the opportunity for a common curriculum on child develop-

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ment for utilization by the medical profession, the traditional healthprofessions, and the new professions.

10. The pattern of administrative organization of the health ser­vice industry required for distribution and delivery of comprehensiveand continuous. health services to children:

Despite the delays and detours which have taken place and willcontinue to take place in the implementation of a system or systemsfor delivery of health services, all indications suggest that the decadeto come will bring an increasing emphasis on the nature of admin­istrative organization required of the health service industry. Whetherthe ultimate configuration of the health servi ce industry will providefor a partial or total system, consideration will be required by thepediatric professions of a translation of stated principles into theadministrative language of costs, comparisons, evaluation, data, andsystems.

For all of us in the health professions, it becomes increasinglyclear that we can either passively face a major revolution in healthcare or actively provide the leadership for an evolution of such care.This is a fact. I t is even further to the point to state that the time hascome when those of us in the health professions must affirm the beliefthat it is now the right of every citizen, including the child, to havethe best of health.

For those of us now designated to assume responsibility for thehealth and care of children, the mandate given us is quite clear: ourconcerns should be all children, and not simply those in our im­mediate care ; our interest should lead us to all factors which canimpede the healthy development of children ; our partners in achiev­ing the goal, of necessity, will be professions and technicians yetundreamed of; and we cannot accept any shortcuts to excellence.

REFERENCES

COMMITTEE REPORTS, U.S. CO NGRESS (1970-71), R epo rt on H ealth, Education,and W elfa re, and Organiwtion of H ealth Care Delivery . Washington, D.C.: Govern­ment Printing Office.

FEIN, R . W . & WEBER, G . I. (1971), Fin ancing Medical Ed ucation. New York : McGraw­Hill.

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HEALTH MANPOWER SOURCE BOOK 21 (1970), Allied Health Manpower Supplyand Requirements 1950-1980. Washington, D.C.: U.S. Department of Health, Edu­cation, and Welfare.

NATIONAL CENTER FOR HEALTH STATISTICS (1970), Report of the T'uientiethAnniversary Conference of the United States National Committee on Vital andHealth Statistics, Series 4, No. 13. Rockville, Md.: U.S. Public Health Service.

REDICK, R. W. & GOLDSMITH, H. F. (1971), 1970 Census Data Used to IndicateAreas with Different Potentials for Mental Health and Related Problems. NIMH,Mental Health Statistics, Series C, No. 13. Washington, D.C.: U.S. GovernmentPrinting Office.