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115 Presentation PREPARING PHYSICIANS TO CARE FOR AT-RISK CHILDREN ROBERT J. HAGGERTY, M.D. President William T. Grant Foundation 515 Madison Avenue New York, New York 10022-5403 THE question, "Who are the children at risk?" is relatively easy to answer. But the answer is a bit daunting because the numbers are so large. They are the poor, of course, and this group has been increasing in numbers over the past decade. It now stands at at least 15 percent of our population. They are clearly minorities, including many immigrants. They are those with chronic physical illness, some 10 to 15 percent of aU children. And I would add a group not usually considered children, but who are still dependent and in great need, the group identified by the WiUiam T. Grant Foundation's Commission on Youth and America's Future as "the forgotten half": older adolescents between 15 and 24 who do not graduate from high school and who, in today's world, are at very high risk of economic and family failure. FinaUy, children at risk include the many with emotional and developmental problems. In the 1988 National Health Interview Survey1, four percent of children from age three to 17 were identified as having a developmental delay. This is 2.4 mUlion chUdren. Those with learning problems formed 6.5 percent of the total population, or 9.4 million children. Those with problem behaviors were 135 percent of the population or seven miUion, and those with asthma, which is only one of the chronic physical diseases, numbered 3.2 million. If one takes into account chUdren with problem behaviors (such as school-age pregnancy and substance abuse), runaways, foster children, and the homeless, the total is probably nearly half of all children. Of course, all of these groups overlap to a great degree, and as Michael Journal of Health Care for the Poor and Underserved, Vol. 2, No. 1, Summer 1991 116 Preparing Physicians Rutter in England and others have shown2, the total risk grows geometrically as you add these separate risks together. One of the major problems in addressing the needs of these children is that different agencies and disciplines currently deal with different parts of the total problem. And yet any one child may face two, three, or four of these burdens, and be forced to deal with two, three, or four agencies. Indeed, my message is that the large numbers of children involved, and the overlap in the problems besetting them, mandate that we develop integrated programs for children, not separate programs for each problem. The implications for the education of professionals who will work in such programs are obvious. Principles for preparing physicians One of the greatest needs is to prepare the physician—and all other members of the helping/service professions—to work together in a coordinated fashion, dealing with the whole child, and not just with one of his or her many problems. I would propose that the preparation of physicians to care for at-risk children adhere to four principles: 1. Full active participation in the care of such children is essential. Medicine is not a spectator sport, and cannot be learned only from books. We have known for a long time that active participation is an important aspect of effective learning. 2. Such participation in active learning must take place in an effective service program. The surest way to turn off young physicians is to place them in a program where they become frustrated because the program is not accomplishing its goals. Thus the development of effective programs is the second principle. 3. It has been demonstrated many times that in order for programs to be effective, they must be comprehensive, they must coordinate services across agencies and disciplines, and they must be flexible and intensive. All of these words sound good, but as Elizabeth Schorr has demonstrated in Within Our Reach3, they are very difficult to achieve. Meharry Medical College's "I Have A Future" Program, which goes into housing projects to reduce teen pregnancy and substance abuse, is an example of such a comprehensive and coordinated program. 4. Evaluation of such programs to measure their effectiveness is...

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