The Legacies of President John F. Kennedy

By 1961, people with mental retardation had received the attention of the most powerful person in the nation, President John F. Kennedy, who had a sister with mental retardation. Kennedy convened a presidential commission to study the state of the art and to assess the current needs of people with mental retardation. Two of the commission’s recommendations were to increase, through research, the scientific understanding of the causes of mental retardation, and to train professionals in treating children with mental retardation. President Kennedy then appointed a panel on mental retardation. The panel’s recommendations included establishing research centers to expand the knowledge base about mental retardation, constructing university-affiliated facilities to treat children and to train providers, and providing additional money for training providers within these UAFs. Recommendations from the panel were quickly transformed into legislation, some that addressed research needs and some that dealt with training needs.

In 1962, the National Institute of Child Health and Human Development (NICHD) was established to investigate the biological, social, and behavioral bases of human development.¹⁰ The MCH research program, section 512 of Title V of the SSA, was formally established in 1963. The program was to support studies that would advance MCH and crippled children’s services.¹¹ Although the Children’s Bureau had been conducting research since its inception in 1912, the health services research aspect of the MCH research program was at that point codified in law to distinguish it from research conducted by the NICHD.¹² In 1963, Congress also established UAFs through Title I, Part B of P.L. 88-164. This major infusion of construction dollars served as the impetus for many universities to become active in research on mental retardation and developmental disabilities.¹³ By 1969, the federal government had invested $9.1 million in training and core support for UAFs. Ninety percent of those dollars came from the Children’s Bureau. Because such a large portion of the funding came from the Bureau, much of the training focused on children.¹⁴

Understanding Mental Retardation

In the 1960s and 1970s, knowledge about children with mental retardation increased dramatically. The Children’s Bureau, NICHD, the Department of Education, and others all conducted studies on the topic. Once it was discovered that phenylketonuria (PKU) was an inherited form of mental retardation caused by an inborn error of metabolism,¹⁵ researchers struggled to develop a screening test for the disorder. In 1961, Dr. Robert Guthrie, with Children’s Bureau funding, developed a simple blood-screening test for PKU.¹⁶ In most cases, placing newborns identified as having PKU on a special diet prevented them from becoming mentally retarded.

Dr. Guthrie not only developed the PKU screening instrument but was also instrumental in encouraging states to conduct universal new-born-screening tests. Said Eunice Kennedy Shriver, “When Dr. Robert Guthrie developed the screening test for PKU he didn’t just write it up and go on to the next experiment. He went public. He knocked on doors, buttonholed state legislatures, spoke to parents’ groups, organized coalitions until every state passed laws mandating PKU screening and country after country adopted the Guthrie test.”¹⁷ Following the development of the Guthrie test, Dr. Guthrie and others developed screening tests for other inborn errors of metabolism, such as galactosemia and maple syrup urine disease (MSUD). In 1969, a vaccine for German measles, or rubella, was developed, and children were immunized against this preventable cause of mental retardation as well.

Researchers also focused their attention on issues other than prevention, and the concept of developmental disabilities began to emerge. Researchers and clinicians slowly began to view mental retardation and other neurodevelopmental disabilities not as diseases to be cured but rather as delays and differences in development that could be overcome or ameliorated through interventions such as education, stimulation, and opportunities for interaction with other children.¹⁸ For example, some children initially thought to have mental retardation actually had learning disorders that could be addressed through intensive education. This emphasis on diagnosis and management

BUILDING THE FUTURE

recalled the experience of the Children’s Bureau D & E clinics of the 1950s. It was also becoming increasingly clear that with intensive intervention, children could maximize their developmental potential, and families could improve their quality of life.

By the 1980s and 1990s, families and clinicians were partnering to prevent, when possible, developmental disabilities from occurring and, through early and continuous interventions, to lessen the effects of those that could not be prevented. By the late 1980s, screening tests, diet changes, or treatment for galactosemia, PKU, and cretinism were preventing an estimated 1,000 people per year from developing mental retardation.¹⁹ Fetal alcohol syndrome, fragile X syndrome, and childhood lead poisoning are now understood to be highly prevalent, preventable causes of mental retardation in chil-dren.²⁰ NICHD, MCHB, and others advanced the study of mental retardation through research on the brain, inherited metabolic diseases, and molecular biology. LEND projects developed best practices for serving children with neurodevelopmental disabilities and conducted extensive research on the most effective clinical interventions. For example, LEND projects collaborated on studies of the neurodevelopmental consequences of HIV infection in children and of the effects of HIV clinical treatments on children.

Developmental Disabilities Today

Research and experience have shown that child development can be viewed along a spectrum. Some children develop at a pace similar to that of their peers, while children with developmental disabilities experience delays in their development. Many children who receive early intervention to address delays in development can be saved unnecessary hospitalizations, can function more effectively, and are more likely to achieve their potential.²¹ Early intervention requires health professionals who are knowledgeable about children with disabilities and can (1) help families understand the nature of the child’s disability, (2) offer a medical diagnosis when possible, (3) assess the child’s functional level, and (4) assist the family in learning about and accessing a wide variety of services.

COMMUNITY-BASED, COORDINATED, INCLUSIVE SYSTEMS OF CARE

For at least the first half of this century, children born with mental retardation and other neurodevelopmental disabilities had one of two fates. They were either institutionalized or remained in their homes, infrequently venturing out into public places. Even until very late in this century, children with special health care needs were not entitled to the same services as other children. As parents and health professionals learned more about the causes and the prognoses for children with developmental disabilities, they began to advocate for family-centered, community-based, coordinated, and culturally competent services. From the 1970s through the 1990s, parents, health professionals, and policy-makers came together to express their desire to establish new systems of care for children with special health care needs and to train providers to deliver services in these new systems.

In 1970, the Developmental Disabilities Act was passed. What made this particular piece of legislation so important to children with special health care needs was not necessarily the money it provided, but the spirit of the legislation and the manner in which coalitions came together to ensure its passage. UAF directors were active participants in determining the language of the act, insisting that “mental retardation” be dropped and that the term “developmental disabilities” be used instead. They wanted this new legislation to reflect the current state of the art in the service arena, and they wanted policy-makers to acknowledge this change as well.²² With the passage of P.L. 94-142, the Education of All Handicapped Children Act, in 1975, Congress implemented the developmental concept that all children, regardless of their disability, had the potential and the right to learn. Congress also asserted that children with disabilities had the same rights as all other children to free and appropriate education in the least restrictive environment possible. The law also encouraged states to expand early intervention services to preschool children ages 3 to 5. In 1986, Congress passed P.L. 99-457, which expanded the Education of All Handicapped Children Act by mandating community-based, family-focused, comprehensive, interdisciplinary services for infants and toddlers ages newborn to 2 years with developmental disabilities. This legislation’s intent was to ensure that children received intervention services at the youngest age possible. It was hoped that P.L. 99-457 would improve the delivery of early-intervention services, which were viewed at the time as inadequate and unco-ordinated.²³ In 1989, the Omnibus Budget Reconciliation Act amended the MCH Services Block Grant (Title V of the SSA) to require each state to promote family-centered, community-based, coordinated care for CSHCN, and to facilitate the development of community-based systems of services for these children.²⁴ In 1991, the Individuals with Disabilities Education Act (IDEA) called for services that were coordinated, family focused, and community based. When IDEA was reauthorized in 1997, families were included as an integral part of eligibility evaluation and planning team meetings for their CSHCN, further strengthening their role.

During the 1980s and 1990s, rights for people with disabilities were not only prominent in legislation but were also emphasized by advocates, including Surgeon General C. Everett Koop. Dr. Koop held a series of Surgeon General’s conferences focusing on CSHCN and their families. In these conferences, Koop outlined steps in a national agenda to promote family-centered, community-based, coordinated care. Families were also demanding that services be delivered in settings where their children spent their time, by health professionals knowledgeable about the latest research and clinical interventions, and in a culturally competent way. Parents developed effective partnerships with organizations representing health professionals and others advocating change. Consumer and family involvement were highlighted in legislation and priorities for agencies such as MCHB and the Administration for Developmental Disabilities. Training programs’ interest in involving parents as partners also reflected this change. While in theory these legislative changes ensured that children with developmental disabilities had access to services, in fact, comprehensive, coordinated services remain elusive.²⁵ By providing interdisciplinary long-term training, by developing exemplary clinical service models, and by reaching out to

BUILDING THE FUTURE

the community through consultation, technical assistance, and continuing education, MCHB’s LEND program has made significant strides toward developing comprehensive, coordinated services for children with developmental disabilities and for their families.

THE LEND PROGRAM’S APPROACH TO INTERDISCIPLINARY LEADERSHIP TRAINING

LEND has roots in the early clinical research and demonstration projects funded by the Chil-dren’s Bureau in the 1950s and 1960s, which emphasized the importance of an interdisciplinary approach to clinical services and training. President Kennedy’s Panel on Mental Retarda-tion’s recommendations, which were included in the authorizing legislation for UAFs, remain enduring features of LEND programs. They include the following items: (1) an emphasis on training leaders and on training faculty and others who would train future leaders; (2) the provision of a continuum of innovative services to the community, from assessment and treatment services to other services such as child care and preschool; and (3) the communication of findings, not only from research to practice, but also among disciplines.²⁶ Another panel recommendation that has endured at some LEND sites is the collocation of research, clinical, and demonstration projects at one site. This allows (1) the latest research advances to inform practice and

(2) clinical researchers to explore those areas that they observe as needing further research. This research/demonstration/training model has been a part of the MCH Training Program since its beginning and is an important aspect of LEND.

THE EVOLUTION OF THE LEND PROGRAM

For the past 35 years, UAFs and then univer-sity-affiliated programs (UAPs) have been at the forefront of training the next generation of leaders, providing groundbreaking clinical services, and involving families and communities in improving services for children with developmental disabilities. UAFs emphasized the construction of facilities to treat people with mental retardation and to train providers. Over time, UAFs became UAPs, emphasizing clinical programs and long-term interdisciplinary training. UAP projects were the first widespread interdisciplinary service and training models in the country. They also advanced the developmental disabilities field through the creation of the field of neurodevelopmental pediatrics and of special care dentistry. UAP funding has come from a variety of sources, of which MCHB is only one. In 1994, to clarify the MCH Training Program’s mission, MCHB redirected its investment in UAPs specifically toward LEND projects, most of which are located in UAPs.

Even though some of the UAPs’ roots have remained constant, LEND has clearly been an innovator in the developmental disabilities field. Even the program’s name has evolved over its 40-year history to reflect new knowledge in the field and the development of new service-delivery models. The LEND program’s name emphasizes the leadership training component with which MCHB is most concerned. Fifield and Fifield describe three generations of UAFs over time: (1) from 1963 to 1974, centers emphasized clinical services, diagnosis and treatment centers, interdisciplinary leadership training, and collocation of expertise; (2) from 1975 to 1986, programs emphasized community-based services and developmental concepts; and

(3)

from 1987 to 1994, programs emphasized consumer empowerment, independence, and inclusion.²⁷

In 1994, UAP directors were asked to identify the ways in which their programs had changed over time. Most said that their programs had moved from (1) being completely child centered to also focusing on youth and adults as children age out of the existing system of care,

(2)

from being center-based to also being community- and home-based systems of care, and

(3)

from being direct service providers to placing more emphasis on family support and systems change.²⁸ These shifts are also occurring in public health, as public health professionals move away from providing direct health care services and toward being involved in public health functions of assessment, assurance, and policy development.

THE LEND PROGRAM TODAY

It is currently estimated that 12.6 million children in the United States, or 18 percent of those under the age of 18, have a special health care need (for example, a chronic physical, developmental, behavioral, or emotional condi-tion).²⁹ The LEND program primarily focuses on children who have disorders of the brain or central nervous system. The children may have been born with these disorders, or the disorders may have been caused by injury or illness. The spectrum of neurodevelopmental and related disabilities include mental retardation, cerebral palsy, spina bifida, brain injuries, fetal alcohol syndrome, hearing loss and communication disorders, learning disabilities, behavior disorders, autism, and other disorders.

Hallmarks of the LEND program include long-term interdisciplinary training, clinical expertise, research, and outreach to the community through consultation, technical assistance, continuing education, and the broad dissemination of research findings. A discussion of each of these follows.

Interdisciplinary Leadership Training and Clinical Expertise

The LEND program provides clinically based graduate and postgraduate leadership training for health professionals in the fields of neurodevelopmental and related disabilities. Faculty and trainees in LEND programs represent 12 disciplines: pediatrics, nursing, nutrition, social work, speech pathology, audiology, psychology, pediatric dentistry, occupational therapy, physical therapy, health administration, and par-ents.³⁰ Trainees learn in an interdisciplinary clinical setting, because providing effective diagnosis and intervention services to children and families with complex needs requires assessment and treatment recommendations by many disciplines. The interdisciplinary team brings all of these skilled providers together.

Trainees study with faculty who provide state-of-the-art diagnosis, evaluation, and treatment services. For example, in case conferences, trainees interact regularly with clinicians and fellow trainees from a variety of disciplines. Trainees learn about the interdisciplinary team process and the roles of other disciplines in assessing a case.³¹ Beyond these clinical areas of expertise, LEND programs have evolved over time to include an emphasis on public health approaches: health services assessment, quality assurance, and policy development. LEND programs partner with families, state and local CSHCN programs, and others to assess the current CSHCN populations, to ensure that CSHCN receive high-quality services in the most appropriate environment, and to develop and improve policies targeted to CSHCN and their families.

Community Linkages

LEND faculty and trainees are actively engaged in providing consultation and technical assistance to community-based agencies and in providing continuing education to practitioners who may not have been formally trained in serving children with special health care needs. LEND faculty and trainees continually educate health professionals from many disciplines about the complex needs of children with developmental disabilities. For example, in their work with state Title V agencies, LEND programs helped to develop standards of care and appropriate monitoring for children with special health care needs.

Family Involvement

LEND programs include family members on their faculties, partner with families to provide training and clinical services, and use feedback from families to assess the quality of their services. LEND programs also advocate for systems changes with families and help provide families with a road map of the services to which their children are entitled.

Dissemination of Findings

LEND projects disseminate findings through traditional academic channels, such as peer-reviewed journal articles and presentations at national professional meetings. They also develop manuals on family-centered and interdisciplinary training, Web sites targeted to families of children with developmental disabilities, and rural telecommunications networks.

The support of the MCH Training Program has been critical to the development and ongoing functioning of the LEND programs. UAPs, of which most LEND programs are a part, are funded from a variety of sources, including the Administration for Developmental Disabilities, foundations, state governments, clinical income, state general funds, and other funds, but MCHB dollars are a critical contribution in that they focus efforts on training leaders. Within a changing health care climate, in which managed care companies may hesitate to authorize interdisciplinary evaluations and academic medical centers are in financial straits, LEND is struggling to continue to provide interdisciplinary training and service provision.

The adolescent health and LEND program	It is unlikely that the services available to ado-
case studies demonstrate MCHB’s highly signif	lescents and to children with developmental dis
icant role, and that of the agencies that preced	abilities today would exist if the MCH Training
ed it, in supporting the development of the	Program had not supported their development.
fields of adolescent health and neurodevelop-	The impact of a relatively small investment has
mental disabilities over nearly half a century.	been substantial. This small investment has had
The resources provided for training physicians	a ripple effect on the field, with past trainees
and others in adolescent health gave a core	developing their own clinical, training, and fel
group of people the knowledge base they need	lowship programs.
ed to advance the field. The program’s support	The effects of other training priorities not
for conferences gave these pioneers an opportu	profiled here have also been well documented.
nity to share their ideas and their enthusiasm,	Each was initiated to address an important
which led to yet more innovations in the field.	problem, and the program priorities’ different
Collaboration across neurodevelopmental dis-	emphases have changed with society. The MCH
ability specialties (both in service provision and	Training Program has been effective and flexible
in training) fostered by the program’s interdisci	enough to result in ongoing improvements in
plinary requirement has helped develop a more	the health of children throughout the nation.
complete view of children with developmental
disabilities and how to meet their needs.

Bickel H, Gerrard J, Hicksman EM. 1953. Influence	Evans J, Adolescent Health Branch Chief. 1999,
of phenylalanine intake on phenylketonuria.	October 22. Personal communication. Rockville,
Lancet ii.	MD: Maternal and Child Health Bureau.
Birenbaum A, Cohen HJ. 1998. Managed care and	Fifield M, Fifield B. 1995. The Evolution of University
quality health services for people with develop-	Affiliated Programs for Individuals with Develop
mental disabilities: Is there a future for UAPs?	mental Disabilities: Changing Expectations and
Mental Retardation August:325–329.	Practices [report submitted to the Administration
Boggs EM. 1971. Federal legislation. In Wortis J, ed.,	on Developmental Disabilities]. Silver Spring,
Mental Retardation: III (pp. 103–127). New York,	MD: AAUAP.
NY: Grune & Stratton.	Gephart J, former nursing consultant. 1999, March
Braddock D. 1987. Federal Policy Toward Mental	15. Personal communication. Rockville, MD:
Retardation and Developmental Disabilities. Balti-	Maternal and Child Health Bureau.
more, MD: Paul H. Brookes.	Guthrie R. 1961. Blood screening for phenyl-
Braddock D. 1973. Mental Retardation Funds: An	ketonuria. Journal of the American Medical Asso-
Analysis of Federal Policy. Unpublished doctoral	ciation 178.
dissertation. University of Texas at Austin.	Guthrie R, Edwards J. 1990. Prevention of mental
Buck PS. 1992. The Child Who Never Grew.	retardation and developmental disabilities. In
Rockville, MD: Woodbine House.	Pueschel S and Mulick J, eds., Prevention of
Bureau of Health Professions. 1999. Performance	Developmental Disabilities. Baltimore, MD: Paul
Measurement System. In Bureau of Health Pro-	H. Brookes.
fessions [Web site]. Cited June 3, 1999; available	Hauser-Cram P, Upshur C, Krauss MW, Shonkoff J.
at http://www.hrsa.dhhs.gov/bhpr/perfsys1.htm	1988. Implications of Public Law 99-457 for early
#Goal 1.	intervention services for infants and toddlers with
Comerci GD, Witze DB, Scire AJ. 1987. Adolescent	disabilities. The Social Policy Report of the Society
medicine education in pediatric residency pro-	for Research in Child Development (3)1–15.
grams following the 1978 Task Force on pediatric	Hutchins V. Chair, Division of Policy. 1999, October
education report. Journal of Adolescent Health	14. Personal communication. Arlington, VA:
Care 8:356–364.	National Center for Education in Maternal and
DeGraw C, Fagen M. 1996. Site Visit Report: Clinical	Child Health.
Training Unit, Center on Human Development	Hutchins V. 1994. Maternal and Child Health
and Disability, The University of Washington.	Bureau: Roots. Pediatrics. 94(5):695–699.
Washington, DC: Center for Health Policy	Hutchins V. 1993. Federal policy for early child-
Research, The George Washington University	hood: Evaluation of services for children with
Medical Center.	disabilities. In Gallagher JJ and Fullagar PK, eds.,
Deisher B, former Director, LEND Program. 1999,	The Coordination of Health and Other Services for
September 21. Personal communication. Seattle,	Infants and Toddlers with Disabilities: The Conun-
WA: University of Washington.	drum of Parallel Systems (pp. 6–19). Chapel Hill,
Emans SJ, Bravender T, Knight J, Frazer C, Luoni M,	NC: Carolina Policy Studies Program, University
Berkowitz C, Armstrong E, Goodman E. 1998.	of North Carolina at Chapel Hill.
Adolescent medicine training in pediatric resi-	Insley V, former Chief of Social Work. 1999, June
dency programs: Are we doing a good job? Pedi	29. Personal communication. Rockville, MD:
atrics 102(3):588–595.	Maternal and Child Health Bureau.

Lundberg EO. 1917. A Social Study of Mental Defectives in New Castle County, Delaware. Children’s Bureau Publication no. 24. Washington, DC: Government Printing Office.

Mackenzie RG, Fisher MM. 1998. The Society for Adolescent Medicine’s role in promoting education. Journal of Adolescent Health 23(6)(Supple-ment):135–142.

Masland R, Sarason S, Gladwin T. 1958. Mental Subnormality. New York, NY: Basic Books.

Maternal and Child Health Bureau, Division of Science, Education, and Analysis. 1998. Leadership Education Excellence in Caring for Children with Neurodevelopmental and Related Disabilities, Application Guidance. Rockville, MD. Maternal and Child Health Bureau, Division of Science, Education, and Analysis.

National Institutes of Health. 1999. National Institutes of Health [Web site]. Cited November 1, 1999; available at http://www.nih.gov/welcome/ nihnew.html.

New England Serve. 1999. New England Serve [Web site]. Cited October 12, 1999; available at http://www.neserve.org/.

Newacheck PW, Strickland B, Shonkoff JP, Perrin JM, McPherson M, McManus M, Lauver C, Fox H, Arrango P. 1998. An epidemiologic profile of children with special health care needs. Pediatrics 102(1):118–119.

Papai J, former Chief, Research and Training Branch. 1999, October 29. Personal communication. Rockville, MD: Maternal and Child Health Bureau.

Rauh JL, former adolescent health grantee. 1999, March 2. Personal communication.

Schmickel R. 1988. Overview: Etiological models of retardation. In Kavanagh J, ed., Understanding Mental Retardation: Research Accomplishments and New Frontiers. Baltimore, MD: Paul H. Brookes, pp. 19–20.

Shriver EK. 1988. Twenty-five years of accomplishments in mental retardation. Foreword to Kavanagh J, ed., Understanding Mental Retardation: Research Accomplishments and New Frontiers. Baltimore, MD: Paul H. Brookes.

Story M. 1999, July 6. Personal communication. Minneapolis, MN: University of Minnesota.

Treadway WL, Lundberg EO. 1919. Mental Defect in a Rural County: A Medico-Psychological and Social Study of Mentally Defective Children in Sussex County, Delaware. Children’s Bureau Publication no. 48. Washington, DC: Government Printing Office.

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Mental Defectives in the District of Columbia: A Brief Description of Local Conditions and the Need for Custodial Care and Training. Children’s Bureau Publication no. 13. Washington, DC: Government Printing Office.

West P, Branch Chief. 1999, August 26 and September 1. Personal communication. Maternal and Child Health Bureau and Health Resources and Services Administration, Region X, Seattle, WA.

1. Papai.	16. Guthrie 1961, p. 863.
2. Mackenzie and Fisher.	17. Shriver,p.xiv.
3. Emans et al.	18. Fifield and Fifield, p. 25.
4. Comerci et al.	19. Schmickel.
5. Emans et al.	20. Guthrie and Edwards.
6. Buck.	21. Birenbaum and Cohen.
7. Boggs.	22. Fifield and Fifield, p. 25.
8. Masland et al.	23. Hauser-Cram et al., p. 115.
9. U.S. Department of Labor; Lundberg; Treadway	24. Hutchins, 1993.
and Lundberg.	25. Hutchins, 1993.
10. Braddock D, 1987, p. 120.	26. Fifield and Fifield, pp. 6–7.
11. Braddock D, 1973, p. 85.	27. Fifield and Fifield, p. 14.
12. Hutchins. Personal communication.	28. Fifield and Fifield, p. 58.
13. Fifield and Fifield, p. 10.	29. Newacheck et al.
14. Fifield and Fifield, pp. 17–18	30. Maternal and Child Health Bureau, p. 13.
15. Bickel et al., p. 313.	31. DeGraw and Fagen.

Noma Anderson, Ph.D.	Phyllis Magrab, Ph.D.
School of Communications	Georgetown University Medical Center
Howard University	Washington, DC
Washington, DC
	Lisa Paine, C.N.M., Dr.P.H.
Robert Blum, M.D., Ph.D.	Department of Maternal and Child Health
University of Minnesota	Boston University School of Public Health
Leadership Education in Adolescent Health	Boston, MA
Minneapolis, MN
	Deborah Perry, M.A.
Anita Farel, Dr.P.H.	Doctoral student
Department of Maternal and Child Health	Washington, DC
University of North Carolina at Chapel Hill School
of Public Health	Gregory Redding, M.D.
Chapel Hill, NC	Pediatric Pulmonary Division, CH-68
	University of Washington School of Medicine
Millie Jones, M.P.H.	Children’s Hospital and Regional Medical Center
Bureau of Family and Community Health	Seattle, WA
Madison, WI
	Nancy Striffler
Margaret Teng Lee, M.D.	Georgetown University Medical Center
Health Resources Branch	Washington, DC
HHS/HRSA, New York Office
New York, NY	Herbert Zimiles, Ph.D.
	Arizona State University
	Tempe, AZ

KEY
Adol Hlth	Adolescent Health
Beh Ped	Behavioral Pediatrics
Comm Dis	Communication Disorders
HBC	Historically Black Colleges
LEND	Interdisciplinary Leadership Education in
	Neurodevelopmental and Related Disabilities
Nurs	Nursing

Nutri	Nutrition
Ped Dent	Pediatric Dentistry
Ped OT	Pediatric Occupational Therapy
Ped PT	Pediatric Physical Therapy
PPC	Pediatric Pulmonary Centers
SPH	Schools of Public Health
SW	Social Work
CE	Continuing Education

Grantee (State Total)

Adol

Beh

Comm

HBC

LEND

Nurs

Nutri

Ped

Ped

Ped

PPC

SPH

SW

CE

Hlth

Ped

Dis

Dent

OT

PT

Alabama (5)

University of Alabama at Birmingham

X

X

X

X

X

Arkansas (1)

University of Arkansas

X

California (9)

Drew University

X

University of California, Berkeley

X

University of California, Los Angeles

X

X

X

University of California, San Francisco

X

X

X

University of Southern California

X

Colorado (2)

University of Colorado

X

X

Connecticut (1)

Yale University

X

District of Columbia (3)

Georgetown University

X

Howard University

X

X

Florida (6)

University of Florida, Gainesville

X

2X

University of South Florida, Tampa

X

X

University of Miami

X

Georgia (1)

Morehouse School of Medicine

X

Hawaii (2)

University of Hawaii

X

X

Grantee (State Total)

Adol

Beh

Comm

HBC

LEND

Nurs

Nutri

Ped

Ped

Ped

PPC

SPH

SW

CE

Hlth

Ped

Dis

Dent

OT

PT

Illinois (5)

University of Chicago

X

University of Illinois, Chicago

X

3X

Indiana (3)

Indiana University

X

X

X

Iowa (2)

University of Iowa

X

X

Kansas (1)

University of Kansas, Kansas City

X

Louisiana (1)

Tulane University

X

Maryland (7)

Johns Hopkins University

X

X

X

2X

University of Maryland, Baltimore

X

X

Massachusetts (14)

Brandeis University

X

Boston University

X

X

X

X

2X

Children’s Hospital, Boston

X

X

X

2X

Harvard University

X

Massachusetts General Hospital

X

Michigan (1)

University of Michigan, Ann Arbor

X

Minnesota (7)

University of Minnesota, Minneapolis

X

2X

X

X

2X

Missouri (1)

University of Missouri, Columbia

X

Nebraska (2)

University of Nebraska, Omaha

X

X

North Carolina (6)

University of North Carolina at Chapel Hill

X

X

X

X

X

X

New Hampshire (3)

Dartmouth College

X

2X

New Mexico (3)

University of New Mexico, Albuquerque

X

X

X

New York (7)

Albert Einstein College of Medicine

X

Montefiore Medical Center

X

Mount Sinai School of Medicine

X

University of Rochester

X

X

X

Westchester Inst. for Human Development

X

Ohio (9)

Case Western Reserve University

X

X

X

Grantee (State Total)	Adol Hlth	Beh Ped	Comm Dis	HBC	LEND	Nurs	Nutri	Ped Dent	Ped OT	Ped PT	PPC	SPH	SW	CE
Children’s Hospital, Cincinnati	X
University of Cincinnati					X									X
Ohio State University					X									2X
Oklahoma (3)
University of Oklahoma			X		X					X
Oregon (1)
Oregon Health Sciences University					X
Pennsylvania (6)
MCP Hahnemann University										X
Children’s Hospital of Philadelphia		X
University of Pennsylvania, Philadelphia					X									X
University of Pittsburgh					X								X
Puerto Rico (1)
University of Puerto Rico, San Juan												X
Rhode Island (1)
Rhode Island Hospital		X
South Carolina (1)
University of South Carolina, Charleston							X
South Dakota (1)
University of South Dakota, Vermilion					X
Tennessee (7)
Meharry Medical College				X
University of Tennessee, Chattanooga														X
University of Tennessee, Memphis					X									X
Vanderbilt University			X		X									X
Texas (2)
Children’s Hospital of Texas	X
University of North Texas, Denton														X
Vermont (1)
University of Vermont, Burlington					X
Virginia (1)
Virginia Commonwealth University					X
Washington (7)
University of Washington, Seattle					X	X				X	X	X		2X
West Virginia (1)
West Virginia University, Morgantown					X
Wisconsin (3)
University of Wisconsin– Madison					X				X		X
TOTAL	7	9	3	4	35	6	6	2	3	3	7	13	3	37

The MCH Training Program seeks to contribute to the creation of leaders in the MCH professions by providing public and nonprofit institutions of higher learning with funding for MCH leadership training under the Title V discretionary grant authority. Through these grants, MCHB funds 14 broad training project priorities. Nine of these—Behavioral Pediatrics, Communication Disorders, Nursing, Nutrition, Pediatric Occupational Therapy, Pediatric Dentistry, Pediatric Physical Therapy, Social Work, and Historically Black Medical Colleges—are discipline specific; four of these—Adolescent Health, Pediatric Pulmonary Centers (PPCs), MCH Training in Schools of Public Health, and Leadership Education in Neurodevelopmental and Related Disabilities (LEND)—are interdisciplinary; and one is a Continuing Education Program Priority. Below is a historical overview of the federal financial commitment to improving MCH.

1920s

1921. The Sheppard-Towner Act is passed. This program was administered by the Children’s Bureau. It provided funds to states to improve children’s health and reduce infant mortality.

1929. The Sheppard-Towner Act was repealed because it was opposed by many influential entities including the Catholic Church, the Public Health Service, and the American Medical Association. The Children’s Bureau developed a plan of action for MCH programming so it would be prepared when funds were made available again.

1930s

1935. In the face of the Great Depression, diminishing health resources, and the declining health of mothers and children, President Franklin Delano Roosevelt signed into law the Social Security Act. The Children’s Bureau was charged with administering Title V of the act, which funded states to support initiatives that improved MCH.

Moneys were divided into A and B funds. The A funds were distributed based on a formula that took into account the number of live births (rural infants were counted twice for urban infants) and on indicators of need. The A funds also required a match. The B funds were based on states’ economic need; every state received a minimum award plus the amount it was entitled to under the formula. The Children’s Bureau reserved a quarter of the B funds (known as the RB funds) for discretionary purposes. The RB funds could fund discretionary research and training without approval from Congress. (Previously, many studies conducted by the Children’s Bureau had to be approved by Congress.)

1938–39. Congress voted to allow B funds to be used for “crippled children’s” programs. This led to the establishment of two RB funds: MCH RB funds to be used for discretionary programs and Crippled Children’s Services RB funds to be used for “crippled children’s” programs. By 1938, nearly all states had a “crippled children’s” program to provide for the social, emotional, and physical needs of this population. These programs represented the first health care programs supported on a continual basis by federal grants-in-aid funds.

1940s

1943. The Emergency Maternity Infant Care Program (EMIC) was established. Funds under this program supported the development of a service-delivery system that provided free and comprehensive maternal and infant health care for wives and infants of the four lowest grades of serviceman. EMIC represented the most extensive public health care program to date.

1947. The first federally funded training projects were established in schools of public health at Harvard University, the University of California at Berkeley, the University of North Carolina, and Johns Hopkins University. Training was targeted to health professionals who had completed a terminal degree.

1950s

Funds were set aside for programs that target children referred to as “mentally retarded.” These funds, designated as MCH, MR, and CCS MR funds, supported diagnosis and evaluation clinics, which found that nearly half of the children in their care were developing more slowly than their peers because of environmental factors and did not need to be treated in institutions. This decade also brought to light new information about infant mortality rates and risks.

1960s

1961. President Kennedy established the Commission on Mental Retardation. The commission came out with 93 recommendations, most of which were implemented. Funds were set aside for training on mental retardation.

1962. Legislative changes to Title V allowed grants to be awarded directly to universities. Previously, all grants had to pass through the states.

1963. University-affiliated facilities (UAFs)—research, service, and training centers for people with mental retardation—were established.

1963–65. The Maternal and Infant Care (MIC) and Children and Youth (C & Y) projects were established to provide comprehensive child and reproductive health care services to low-income women and children. Funds could go to medical schools, nonprofit hospitals, and universities. Funds were also made available to conduct research on MCH issues other than those being addressed by the National Institutes of Health.

1965–66. The Children’s Bureau provided funding for training in UAFs.

1967. Along with the MIC and C & Y projects, new family planning, dental care, and intensive infant care programs became known as the program of projects for the states. Each state was required to have at least one project in place by 1975.

1969. Congress dismantled the Children’s Bureau. Health programs formerly administered by the Children’s Bureau were now handled by the Public Health Service.

1970s

Nearly 40 percent of the Title V appropriation was designated for the program of projects (administered directly by the federal government), 10 percent went to research and training, and 50 percent was distributed to the states according to a formula.

1976. A legislative change gave states control of program of projects funds. States now directly administered 90 percent of the funds.

1980s

1981. The Title V program was converted into a block grant to the states that was administered by the Office of Maternal and Child Health. Eighty-five percent of the funds were distributed to the states under a formula. States were required to match each $4 of federal funds with $3 of cash or in-kind contributions. The remaining 15 percent of the Title V funds supported discretionary grants, including Special Projects of Regional and National Significance (SPRANS).

1989. Community Integrated Service Systems (CISS) program was established by P.L. 101-508, OBRA ’89. Projects were funded at 12.5 percent of the Title V appropriation above $600 million. The CISS program supports the development and expansion of integrated community-level services that serve to reduce infant mortality and improve the health of mothers and children.

1990s

MCHB, created in 1990, administers the Title V program. In FY 1999, the MCH Leadership Training Program constituted over 35 percent of total SPRANS spending.

1994. University-affiliated programs (UAPs) became Leadership Education in Neurodevelopmental and Related Disabilities (LEND) to emphasize leadership training.

1996. The welfare reform legislation of 1996 created a new program related to abstinence, which was also administered by MCHB. A total of $50 million a year for the period FY 1998–2002 was set aside to fund states’ support of abstinence education.

DEFINITION

In the MCH context, the term “continuing education” (CE) describes a number of formal education methods that differ from the requirements of long-term education funded by the MCH Leadership Training Program. The CE priority is supported wholly or in part by federal funds. The funds may be allocated training funds or any of the other discretionary funds within the Title V federal budget (which include funds for research, genetics, hemophilia, MCH improvement projects, community-integrated service systems, or abstinence education). Similar CE activities initiated and conducted by the individual states and funded through their federal Title V allocation or state matching funds are not included in this discussion.

The primary goal of the MCH CE training priority is to enhance the knowledge and skills of health professionals and other individuals involved in providing care to mothers and children in the varied settings in which services are available to this population.

Continuing education may take any of the following forms:

• Short-term educational experiences are usually sponsored by an institution of higher learning (IHL) for health professionals from agencies. These experiences can take place during rotations for professional interns or residents in training, for long-term trainees from other programs within the university, or for students from other professional schools. The length of the educational experience may range from a week to several months and may use either a standard or an individually designed curriculum.

• Institutes are usually 1 or 2 weeks long. They are sponsored by an IHL and are staffed by that IHL’s faculty and by guest faculty. Their curriculum incorporates the most recent information on a specific topic, and they are generally marketed to a defined agency audience.

• Conferences are usually 2 to 5 days long. Their curriculum is designed to appeal to diverse audiences. They may be sponsored by an IHL, a state, or a nonprofit organization. The sponsoring agency is frequently responsible for an MCH-funded discretionary project, and the conference is part of the project’s dissemination plan.

• Workshops are, in effect, small-scale conferences. Their purpose is usually to develop implementation plans based on new findings or methods. Participants then share these plans within their agencies and with fellow professionals. Workshop sponsors are similar to conference sponsors. Attendees participate in activities rather than just observe.

• Task forces and work groups are convened to provide guidance or to develop models or recommendations for new and emerging issues or methodologies. Sponsors may be similar to conference or workshop sponsors, or they may

be professional organizations. These groups’ products are frequently used for CE activities in the other forums.

• In-service education, another form of CE, is usually designed for the employees of the sponsoring agency or, occasionally, of a group of similar agencies.

In recent years, most CE courses have developed a method for providing participants with CE credits. This helps meet the needs of the health professionals attending the various forums and, of course, is a marketing tool for the sponsoring agency.

BEGINNINGS

From 1921 to 1929, the period of the Shep-pard-Towner Act, federal funds were provided to states to improve MCH services. States discovered their need for professionals trained to work with mothers and children. They used a portion of the Sheppard-Towner funds to purchase CE in the form of in-service and short-term training for staff nurses.

When Title V was enacted as part of the SSA in 1935, the concept of teamwork gained favor as state agencies came to realize that no single professional group could meet the needs of mothers and children, and that a variety of professional personnel had important contributions to make. Professionals providing care had to become a team before mothers and children would receive the maximum benefit of their pooled knowledge. As a result, the states decided to include social workers and physical therapists among the health professionals for whom short-term training was to be provided. The states also collaborated with medical societies to train obstetricians and pediatricians. Courses were conducted at medical centers where field experience could supplement lectures.

The 1939 amendment of the SSA required states to appoint all full-time personnel under a merit system. This gave the Children’s Bureau an opportunity to work with the states in developing standards. These standards would ensure the quality of service being delivered. The Bureau provided the states with in-service education and technical assistance to accomplish this objective.

Long-term pre-service training programs were first funded in 1947 at schools of public health. From the experience it gained during the Sheppard-Towner era and during the first years following the SSA in the late 1930s, the Chil-dren’s Bureau recognized that thousands of health practitioners needed training if children and women were to receive adequate care. As a result, the Bureau required that these programs provide CE for both public and private administrators and practitioners.

In 1948, the Children’s Bureau gave several schools of social work long-term grants. Each grant included provisions for short-term training through workshops, during which social workers in the states could meet and exchange ideas. For example, in 1948, the Bureau gave the Illinois Crippled Children’s Services’ Program a grant to hold workshops for social work faculty members responsible for health content in schools of social work. The workshop lasted 3 weeks: during the first week, an overview and orientation was provided for the entire group; during the middle week, each participating faculty member worked with a social worker in a state health department; and during the last week, all the participants met as a large group to share and learn from their experiences. These educational experiences promoted a preventive approach to care and emphasized roles other than direct service, especially program consultation.

Workshops, forums, and multiregional conferences for social workers have continued to inform health professionals about emerging issues and the latest advances in the MCH field; to add to the dialogue between practitioners and academics; and to enhance skills and contribute to the dissemination of new information. Other MCH disciplines have used similar models to accomplish these objectives.¹

CATEGORIES OF CONTINUING EDUCATION PROJECTS

MCHB’s CE program has many components, is funded from both within and outside the training fund allocation, and has a variety of funded sponsors. The categories of CE are described below. These five categories, along with a few examples, suggest the breadth and complexity of this program.²

1. Continuing Education as a Component of Long-Term Training Grants

Short Course: Nutritionist-Enriched Early Intervention Teams, Frances Stern Nutrition Center, Boston

This project, which was funded from 1992 to 1995, provided a course sensitizing early intervention (EI) team members to nutrition-related problems and helped both team members and parents develop nutrition-related case management skills. It aimed to better integrate nutrition services into EI programs by increasing the number of teams that included a nutritionist as a consultant or team member. According to the project plan, by the year 2000, all EI sites would include nutritionists on staff or as consultants. Project-developed annual workshops provided EI team participants with individualized tutoring and supervision, and involved them in case-oriented team-building activities. It also offered them collegial support from professionals in their own and other disciplines, and gave them opportunities to function as a team.

Community Health Nursing Competency Enhancement Project, Department of Pediatrics, University of Maryland, Baltimore

This project, which was funded from 1992 to 1995, developed and implemented a training program, the goal of which was to enhance community health nurses’ (CHNs) case management competency and to enable them to participate more effectively in the MCH care system. Although case management is an essential component of CHNs’ role, it had not been well recognized as a critical component of practice, nor had it been defined as a nursing intervention in the Maryland system of care at that time. The project developed and tested a prototype curriculum for case management. Topics included case management, health care system reform, decision making, communication, culturally sensitive communication, team building, outcome measures, standards and regulations, and negotiation and conflict resolution.

The project was a cooperative venture with in-kind contributions from the state Title V Agency’s Office of Child Health. It used the expertise of the University of Maryland nursing and medical faculty in conjunction with the expertise and experience of the state health department. Approximately 200 CHNs were trained in case management and health care system improvement.

2. Continuing Education as a Component of Other Special Projects of Regional and National Significance (SPRANS) Grants

Many of the SPRANS and the CISS grants include CE as one of their objectives. Grantees with a dissemination component frequently provide CE through conferences, workshops, and other activities, as well as through print and electronic publications. The CE activity may be directed to a community, state, regional, or national audience, depending on the scope and on the innovative results of the project.

3. Freestanding Continuing Education Projects

Task Force on Opportunities for Women in Pediatrics (American Academy of Pediatrics)

In 1980, about 10 percent of all U.S. physicians were women. Although about 30 percent of practicing pediatricians in the country were female, women were underrepresented on academic faculties, and there were almost no women among AAP officers and leaders. It was clear that if trends persisted, in a few years, 50 percent of the nation’s pediatricians would be women. The fact that female physicians received lower pay, were less likely than their male counterparts to occupy faculty and organizational positions, and were promoted less often than male physicians, and the fact that there were thus fewer prominent role models for young women physicians, were concerns.

MCH funded an AAP task force to explore these issues.

The task force report, issued in 1982, confirmed the impressions and made several recommendations that were quickly put into practice. Among them were (1) AAP should appoint a committee to identify issues of concern to AAP’s women members (including education, academic promotion, establishing practices, midcareer options, and retraining) and to implement long-range plans to further the progress of women physicians in their training, their careers, and their role in the AAP; (2) AAP should provide leadership training and career workshops; (3) AAP should encourage medical schools to appoint a faculty member to serve as a liaison between the school and organizations addressing the concerns of women students and physicians; and (4) AAP should support the increased availability and flexibility of quality part-time training and retraining programs to assist women physicians.

Healthy Generations/Healthy Futures Evaluation Findings: A Dissemination Conference, University of North Carolina at Chapel Hill

This project evaluated the Healthy Generations (HG) Program, an initiative of MCHB, and the Healthy Futures (HF) Program, an initiative of The Robert Wood Johnson Foundation. It examined their component interventions in three broad areas: (1) changes in capacity, accessibility, and competence of the perinatal health care system; (2) changes in timing, content, and coordination of prenatal, delivery, and postpartum services received by pregnant women and their children; and

(3) changes in infant mortality and other indices of poor birth outcomes. Both programs had the same primary goal: to reduce the infant mortality rate through an array of state-based efforts to upgrade and expand access to health care systems, and to permanently incorporate these changes into the perinatal health care system. Eleven southern states were funded from 1988 to 1992 (five through MCHB and six through The Robert Wood Johnson Foundation) to implement a range of state-specific interventions.

The annual dissemination conferences provided a forum for presenting the major findings of the HG/HF evaluation with a select regional and national audience, and for discussing these findings. The goal of the conferences was to discuss the efficacy and the impact of the HG/HF programs and their component interventions. The conferences were organized around four topics:

• Overall efficacy of the HG/HF programs

• Efficacy of specific program interventions

• Effective public prenatal care clinic practices

• Lessons learned—implications for state and national policy

The evaluation findings from this major, regional infant mortality reduction effort were disseminated in a timely manner to state and national MCH program directors and policy-makers to improve current and forthcoming perinatal initiatives. Conference proceedings were published, providing a record of the conferences and their recommendations.

Bright Futures Resource Center for Curricula, Children’s Hospital, Boston

The purpose of this project is to develop a 3year content plan for pediatric residency curricula based on Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, behavioral pediatrics, and adolescent medicine, and to write learner-centered cases that highlight and integrate the health supervision guidelines of Bright Futures. The project plans to disseminate the new curricula through the training of faculty in other programs and through the World Wide Web.

Web Site for Developmental and Behavioral Pediatrics, Children’s Hospital, Columbus

The project’s purpose is to improve the health care delivered by pediatricians and family practitioners through innovative continuing medical education (CME) experiences in developmental and behavioral pediatrics. Through the World Wide Web, the project aims to strengthen traditional residency training and to overcome geographic barriers to participation in customary CME activities. The project will develop new methods of long-distance learning, increase interaction among physicians, and promote advances in the management of patients through interactive electronic forums.

4. Institutes

Maternal and Child Health Leadership Skills Training Institutes

MCH Leadership Skills Training Institutes were held at San Diego State University from 1985 to 1994 and have taken place at the University of Alabama, Birmingham, since 1995. These institutes emerged in response to the need for a national CE program to improve administrative and leadership skills for state Title V staff members working in key program positions.

Management and program development skills were among the most frequently cited

BUILDING THE FUTURE

needs for nondegree training and CE needs. Among the specific areas identified were planning, needs assessment, evaluation, quality assurance, interagency collaboration, conflict resolution, resource development, and cultural competence. CE was offered that taught and reinforced the history and philosophy of MCH, emphasized interdisciplinary functioning in programs, and gave participants the skills needed to improve the administration of programs and leadership in the MCH field. An introductory institute addressed the basic needs of program staff members in all Title V state programs. For the first 3 years, the institute was held at a variety of venues across the country. Eventually, for logistical, efficiency, and planning purposes, Denver was chosen as the insti-tute’s permanent site. Hawaii and Puerto Rico were represented at the institute, but Pacific jurisdictions, which received training specific to their needs from an earlier grant to the University of Hawaii, were not. Later, an advanced MCH institute with a more specific focus for MCH program staff was also set up.

Three to five MCH Child Health Leadership Skills Training Institutes are offered each year. Institute faculty includes federal MCHB personnel, state Title V directors, university professors, and private consultants. State Title V directors select the participants/trainees.

A History and Philosophy Manual was created by the project in 1989. The manual includes text descriptions, timelines, overhead transparencies, slides, and a bibliography. The institutes have been using it since 1990. Between 1989 and 1994, 744 participants were trained in 21 institutes; between 1995 and 1998, 352 participants were trained in 10 institutes.^3,4

Two CSHCN institutes are also sponsored by MCHB but are funded outside the MCH Training Program. AAP now administers the Power of Pediatricians CSHCN Institute, targeted to community pediatricians, and the Institute for Child Health Policy administers a state Title V/CSHCN Agency Institute targeted to state CSHCN policymaking. Institutes focus on family-centered, community-based, coordinated care for children with special health care needs. They pay particular attention to new roles and responsibilities, service provision, care coordination, and development of community infrastructure.

5. Collaborative Office Rounds

In the fall of 1988, in response to the increasing emphasis on the mental health aspects of primary health care for children and adolescents, the MCH program convened a small meeting of pediatricians and child psychiatrists to consider ways to enhance coordination in education. The meeting resulted in the recommendation that the Collaborative Office Rounds (COR) discussion group approach be implemented. Ten COR projects, which were sponsored jointly by pediatrics and child psychiatry medical school departments/sections, were launched in the fall of 1989. Later, COR groups were incorporated as an essential element in the behavioral pediatric training projects supported by MCHB.

The COR program supports small discussion groups that meet at regular intervals over sustained periods to address the mental health aspects of pediatric care. Initially, COR participants were expected to be primarily practitioners, but COR has shown promise with fellows and residents as well. Most group participants are pediatricians. The groups are jointly led by pediatricians and child psychiatrists. Although they vary in a number of ways, all are concerned with the day-to-day psychosocial issues that confront primary care providers serving children, adolescents, and their families.⁵

Summary

MCHB, through a variety of grant mechanisms, supports a national CE training priority. The educational activities this priority comprises have been an integral component of MCH for more than three quarters of a century. During these years, MCH’s comprehensive CE program has updated and enhanced the knowledge and skills of health professionals and other individuals involved in providing care to the nation’s children and families.

Endnotes

1. Insley V, former Chief of Social Work (retired). 1999, August 18. Personal communication and assorted papers. Rockville, MD: Maternal and Child Health Bureau.

2. Most of the material in the examples cited was obtained from the MCH database located at the National Center for Education in Maternal and Child Health, a research program of Georgetown University’s Graduate Public Policy Institute.

3. Oglesby A (retired). 1999, September. Personal communication. San Diego, CA.

4. Alexander G. 1999, September. Personal communication. Birmingham, AL: University of Alabama, Birmingham, School of Public Health.

5. Fishman M, Kessel W, Heppel D, Brannon E, Papai J, Bryn S, Nora AH, Hutchins VL. 1997. Collaborative office rounds (COR): Continuing education in the psychosocial/developmental aspects of child health. In Pediatrics Electronic Pages [online journal] 99(4):e5. Cited November 4, 1999; available at http://www.pediatrics.org/cgi/ content/full/99/4/e5.

PROGRAM HISTORY AND STRATEGY

Adolescents have been of particular concern to the Children’s Bureau, and later to the Maternal and Child Health Bureau (MCHB), since the Children’s Bureau’s inception; however, special training was first funded in the 1950s, with adolescent-medicine fellowship training of pediatricians at five sites. This initiative was in response to new research that demonstrated two important facts:

(1) adolescents have special health care needs, different from those of children or adults; and (2) adolescents, as a group, have a high rate of health problems. In the

1960s, the Children’s Bureau continued to support improvements in adolescent health by sponsoring the Adolescent Seminars, a series of conferences. These meetings helped to clarify and articulate adolescent health issues.

With a clear problem identified and with growing support for adolescent health from the medical and public health communities, the Maternal and Child Health (MCH) Training Program expanded its fellowship training support of physicians in 1967. During the next three decades, and up to the present time, organizations such as the Society for Adolescent Medicine, an interdisciplinary group formed out of the Adolescent Seminars with MCH Training Program support, have advocated for the health needs of adolescents while emphasizing the concept of holistic care. Other groups also identified adolescent health needs; for example, the 1976 Task Force Report on Pediatric Education, sponsored by the American Academy of Pediatrics, concluded that the lack of training in adolescent health represented a serious gap in child health services. National data documented “new morbidities” (e.g., injuries, mental and emotional disorders, developmental problems, other complex emotional and behavioral issues) that greatly affected the health of adolescents; however, health professionals received little training on how to address these problems. At the same time, other MCH training programs were beginning to demonstrate the value of interdisciplinary training. Thus, in 1976, a new interdisciplinary adolescent health training program was established to train not only physicians, but also persons from the fields of nursing, nutrition, psychology, and social work. The goal was to develop a cadre of leaders who would secure improved care and services for adolescents through policy, research, training, and clinical care. This program has continued to the present, with relatively minor modifications. Initially, nine interdisciplinary programs were funded; however, over the years, the number has been reduced to its current level of seven.

PROGRAM CHARACTERISTICS

The purpose of the Leadership Education in Adolescent Health (LEAH) program is to prepare trainees in a variety of professional disciplines for leadership roles in the public and academic sectors and to ensure high levels of clinical competence. Training is designed to integrate biological, developmental, mental health, social, economic, and environmental issues within a public health framework. The seven interdisciplinary programs consist of the following components: (1) preparation that focuses on

PROGRAM HISTORY AND STRATEGY

Children’s health has dramatically improved over the course of this century. Once-prevalent causes of death such as childhood diseases and infections have been effectively prevented or treated through safer milk supplies, immunizations, antibiotics, and technological advances. Pediatricians who once spent most of their time treating acute illnesses are now faced with “new morbidities” in children, such as injuries, mental and emotional disorders, developmental problems, and

other complex issues. The field of behavioral pediatrics evolved from the need for increased collaboration between professionals in the fields of pediatrics, psychology, and psychiatry to address children’s needs. In 1986, the behavioral pediatrics program was established to prepare pediatric residents to address these “new morbidities.”

PROGRAM CHARACTERISTICS

The behavioral pediatrics training program focuses on (1) supporting fellows in behavioral pediatrics to help prepare them for leadership roles as teachers, researchers, and clinicians; and (2) providing pediatric practitioners, residents, and medical students with essential biopsychosocial knowledge and clinical expertise. The purpose of the program is to enhance behavioral, psychosocial, and developmental aspects of general pediatric care.

Fellows are expected to gain clinical expertise in the practice of behavioral pediatrics and to develop leadership attributes that extend beyond clinical acumen and skills.

HIGHLIGHTS

Faculty and Fellows. Training grant funds support faculty who demonstrate leadership and expertise in behavioral pediatrics teaching, scholarship, and community service and fellows who have completed training to be board-eligible in pediatrics.

Curriculum. The 3-year fellowship program curriculum includes course work and clinical exposure to psychosocial and biological sciences, growth and development, adaptation, injury prevention, disease prevention, and health promotion. Projects are also required to cosponsor, with child psychiatry, an ongoing Collaborative Office Rounds (COR) group as a training experience for fellows and a continuing education experience for community providers.

Continuing Education and Technical Assistance. Grantees must also provide continuing education activities for practicing physicians and are encouraged to offer technical assistance and consultation to pediatric residency training programs that are in the early stages of developing their own behavioral program components.

PROGRAM PROFILE

• In FY 1999, the Maternal and Child Health Bureau funded nine grants in behavioral pediatrics, with annual grant awards totaling $1.2 million.

• The grant awards, including some supplementary awards, range from $110,000 to $261,000, with a mean award amount of $132,000.

Present Grant Recipients

STATE	GRANTEE
CA	University of California,
	San Francisco
MA	Boston University
	Children’s Hospital, Boston
MD	Johns Hopkins University
	University of Maryland, Baltimore
NY	Montefiore Medical Center
OH	Case Western Reserve University
PA	Children’s Hospital of Philadelphia
RI	Rhode Island Hospital

BIBLIOGRAPHY

Friedman SB. 1985. Behavioral pediatrics: Interaction with other disciplines. Journal of Developmental and Behavioral Pediatrics 6(Suppl. 4):202–207.

Proceedings of the National Conference on Behavioral Pediatrics [entire supplement]. 1985. Journal of Developmental and Behavioral Pediatrics 6(Suppl. 4):179–240.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Leadership Education in Behavioral Pediatrics: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Communication disorders can severely impede healthy child development and result in significant disabilities. Many of these conditions are chronic and progressive and place significant burdens on the child, the child’s family, and society. In the early

1990s, to meet the needs of children with communication disorders, the Maternal and Child Health Bureau (MCHB) began supporting centers of excellence in communication disorders. These grants were awarded to institutions of higher learning for the purpose of training speech-language pathologists and audiologists to provide comprehensive services to children and their families, and to promote the advancement of the field through information and knowledge dissemination. Currently, MCHB grant funds are supporting centers of excellence that are advancing health professionals’ skills in caring for children with communication disorders. This training is based upon the principles expressed in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, the flagship publication of MCHB’s Bright Futures Initiative.

PROGRAM CHARACTERISTICS

The primary objective of the communication disorders program is to provide a national focus on leadership through the following: (1) graduate training of speech-language pathologists and audiologists for leadership roles in education, service, research, administration, and advocacy; (2) development and dissemination of curricula, teaching models, and other educational resources to enhance maternal and child health (MCH) content in communication disorders training programs; and (3) continuing education, consultation, and technical assistance in communication disorders, geared to the needs of the MCH community.

HIGHLIGHTS

Graduate Education. Students enrolled in the training program receive training in several areas, including the following: (1) a multidisciplinary/ interdisciplinary approach to care management of young children, especially those at risk for communication disorders; (2) leadership programs such as apprenticeships and seminars; and (3) enrichment programs designed to establish and maintain mechanisms to bring together trainees from varied disciplines to share ideas and knowledge.

Faculty Development. This MCH program supports faculty from a variety of disciplines by helping them to develop and to enhance curricula, teaching models, and other educational resources for the purpose of improving pediatric content in health care programs at all levels of higher education. Faculty are also supported and encouraged to use both qualitative and quantitative analytic techniques and advanced technology for learning on-site and in remote areas.

Continuing Education. Communications disorders projects provide MCH consultation and technical assistance that is geared to the needs of the MCH community, including health professionals, policy-makers, and parents. These projects have brought courses and in-service training to hundreds of practicing professionals in hospitals, clinics, universities, private-practice offices, and public schools. Nationally recognized experts often serve as facilitators. Examples of the offerings include grand rounds, guest lecture series, consultant lectureships, and symposia.

PROGRAM PROFILE

• In FY 1999, MCHB funded three programs in communication disorders, with annual grant awards totaling $434,000.

• The grant awards range from $133,000 to $167,000 per year, with a mean award of $145,000.

Present Grant Recipients

STATE	GRANTEE
DC	Howard University
OK	University of Oklahoma
TN	Vanderbilt University

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Center for Leadership in Communications Disorders Education: Application Guidance.

Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Despite strides that have been made during the past few decades, minorities—in particular African Americans—continue to have a poorer health status than the general population. Because minority physicians often provide care for minority populations, the Maternal and Child Health Bureau (MCHB) made it a priority to increase the number of minority physicians being trained in an effort to improve the health outcomes for this population. Maternal and child health (MCH) training grants to departments of

obstetrics/gynecology, pediatrics, and family medicine in historically/predominantly black colleges and universities were first funded in the early 1990s. The funding of these institutions was initiated to serve a dual purpose: (1) the primary intention of these grants is to make possible or enhance the education and training of residents in obstetrics, adolescent gynecology, family practice, and pediatrics for the provision of primary care in community-based settings; and (2) the secondary purpose of these grants is to use the MCH mentorship program to stimulate the interest of African-American and Hispanic high school and college students in MCH-related health professions.

PROGRAM CHARACTERISTICS

This training program has two components: the MCH residency program and the MCH mentorship program. The MCH residency program encourages the development of interdisciplinary programs to enhance the ability of obstetricians, family practitioners, and pediatricians to address primary health care issues. The MCH mentorship program provides high school and college students with course work and clinical experiences to enhance their understanding of the health of children and families.

HIGHLIGHTS

The MCH Residency Program. Residents are exposed to a variety of health care settings and programs to enhance their ability to provide primary care to unserved and underserved populations. These settings and programs include private-practice offices, public health facilities, and community-based programs such as the Healthy Tomorrows Partnership for Children Program and the Community Integrated Service Systems projects. The residency program also encourages the development of interdisciplinary programs to enhance the ability of obstetricians, family practitioners, and pediatricians to address patients’ primary health care issues. It also supports activities and mechanisms to recruit residents into MCH scholarship and practice.

The MCH Mentorship Program. This program provides a 6-week session to high school and undergraduate college students, particularly inner-city youth. The students are exposed to a variety of didactic and clinical experiences that are designed to enhance their understanding of the MCH field. These experiences include seminars, observation, and, in some cases, assistance in the provision of services. Upon completion of the program, students submit a personal statement in which they reflect on their experience, as well as a formal paper on a topic related to what they learned during the session.

PROGRAM PROFILE

• In FY 1999, MCHB funded four MCH projects in historically or predominantly black colleges and universities, with annual grant awards totaling about $686,000.

• The grant awards range from $163,000 to $191,000 per year, with a mean award of $171,000.

Present Grant Recipients

STATE	GRANTEE
DC	Howard University Child
	Development Center
CA	Charles R. Drew University
GA	Morehouse College
TN	Meharry Medical College

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1996. Graduate Medical Education in Obstetrics/Gynecology, Pediatrics, and Family Practice in Historically/Predomi-nantly Black Medical Schools: Application Guidance.

Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Children with special health care needs (CSHCN) have been of particular concern to the Children’s Bureau, and later to the Maternal and Child Health Bureau (MCHB), since the Children’s Bureau’s inception. In the early 1950s, the chief of the Chil-dren’s Bureau made it a priority to learn more about children with mental retardation. The Bureau initially supported four demonstration projects that developed interdisciplinary clinical services for children with mental retardation. By 1957, states were developing new diagnostic,

consultation, and education (D & E) clinics. In several of these clinics, health professionals found that up to half of the children initially diagnosed as having mental retardation did not. In 1960, the Children’s Bureau began providing grants to institutions of higher learning to train interdisciplinary teams to serve children with mental retardation.

The 1960s and 1970s were periods of rapid advancement in knowledge about children with mental retardation. In 1963, President Kennedy established the first University Affiliated Facility (UAF) to research and treat mental retardation, as well as train providers of services to persons with mental retardation. The Children’s Bureau supported training for persons providing services in the newly constructed UAFs. By 1969, most training and core support of UAFs were provided by the Children’s Bureau; as a result, much of the training focused on children. Training and research about children with mental retardation advanced hand in hand. It was discovered that some forms of mental retardation— those caused by phenylketonuria (PKU) and rubella (German measles), for example—were preventable; other forms could be dramatically improved through early and continuous intervention services, such as those provided at UAFs.

By the 1980s and 1990s, families and clinicians were partnering to prevent developmental disabilities, when possible, through early intervention, and to lessen the effects of those that could not be prevented entirely. Early intervention requires health professionals who are knowledgeable about children with disabilities, who can help families understand the nature of the child’s disability, who determine a medical diagnosis when possible, who assess the child’s functional level, and who assist the family in learning about and accessing a wide variety of services. Increasingly, health professionals now strive to provide these services in a family-centered, community-based, coordinated fashion. By 1987, the UAFs had become university-affiliated programs (UAPs), reflecting the fact that they were much more than the physical facilities initially supported by the legislation. In 1994, MCHB changed the name of its grant program from UAPs to Maternal and Child Health Leadership Education in Neurodevelopmental and Related Disabilities (LEND). LEND grants provide interdisciplinary training to enhance the clinical expertise and leadership skills of health professionals dedicated to caring for children with disabilities.

PROGRAM CHARACTERISTICS

The purpose of the LEND program is to improve the health of children who have, or are at risk for developing, neurodevelopmental or related disabilities by preparing trainees from a wide variety of professional disciplines to assume leadership roles and to ensure high levels of clinical competence. LEND program objectives include the following:

(1)

advancing the knowledge and skills of the full range of child health professionals to improve health care delivery systems for children with developmental disabilities; (2) providing high-quality education training for health professionals; (3) providing a wide range of health professionals with the skills needed to foster a community-based partnership of health resources and community leadership; and

(4)

promoting innovative practice models that enhance cultural competency, partnerships between disciplines, and family-centered approaches to care.

Funds are available to support programs that focus on these objectives at the regional level, including programs with an expanded scope that address both regional and national needs. Regional projects focus on identifying the special needs of children and families that are specific to a clearly defined area of the country. Projects of regional and national significance, on the other hand, focus on a particular region’s specific needs and serve as a national resource. Both the regional and national programs collaborate regularly with the myriad of health, education, and social service agencies serving children with developmental disabilities. LEND training projects also function as regional and national resources by conducting continuing education activities, providing technical assistance and consultation, and developing and disseminating educational materials.

HIGHLIGHTS

Faculty. The LEND program provides clinically based graduate and postgraduate leadership training for health professionals in the fields of neurodevelopmental and related disabilities. Faculty and trainees in LEND projects represent 12 disciplines, including developmental pediatrics, nursing, public health social work, nutrition, speech-language pathology, audiology, pediatric dentistry, psychology, occupational therapy, physical therapy, health administration, and, most recently, parents of children with neurodevelopmental disabilities. The project director must be a board-certified pediatrician with training in child development.

Trainees. The trainees enrolled in the program are working toward a graduate degree or are enrolled in a postgraduate program in one of the represented disciplines, with an emphasis on infants, children, and adolescents with special health care needs. The LEND program itself is part of a freestanding unit within the university; it draws trainees and faculty from individual departments or colleges within the university. Degrees for the trainees are conferred by their home departments or colleges.

Curriculum. The LEND program curriculum includes graduate education at the master’s, doctoral, and postdoctoral training levels, with an emphasis on developing a knowledge and experience base that includes the following: (1) knowledge of all aspects of neurodevelopmental and related disabilities,

(2)

knowledge of the family environment, and

(3)

acquisition of interdisciplinary team skills.

Course content and philosophy aim to prepare trainees to assume leadership roles in the development, improvement, and integration of health care systems for children with special health care needs in culturally appropriate, community-based, family-centered settings. Traineeships include classroom course work, clinical skills building, mentoring, and outreach to the community through clinics, continuing education, consultation, and technical assistance.

By providing interdisciplinary long-term training, by developing exemplary clinical service models, and by reaching out to the community through consultation, technical assistance, and continuing education, the LEND program has made significant strides toward developing comprehensive, coordinated services for children with developmental disabilities and for their families.

PROGRAM PROFILE

• In FY 1999, the LEND program funded 35 projects, with annual grant awards totaling about $18.2 million.

• The grant awards range from $300,000 to $1.2 million per year, with a mean award amount of $520,000. For additional information about the LEND

projects, please visit http://www.aauap.org.

Present Grant Recipients

STATE	GRANTEE
AL	University of Alabama at Birmingham
AR	University of Arkansas
CA	University of California, Los Angeles

CO University of Colorado Health Sciences

Center DC Georgetown University FL University of Miami HI University of Hawaii IA University of Iowa IN Indiana University KS University of Kansas MA Children’s Hospital, Boston

Massachusetts General Hospital MD Johns Hopkins University MO University of Missouri NE University of Nebraska NC University of North Carolina at

Chapel Hill NH Dartmouth College NM University of New Mexico NY Albert Einstein College of Medicine

University of Rochester Westchester Institute for Human Development

OH University of Cincinnati

Ohio State University OK University of Oklahoma OR Oregon Health Sciences Center PA Children’s Seashore House

University of Pittsburgh SD University of South Dakota TN University of Tennessee, Memphis

Vanderbilt University Medical Center VA Virginia Commonwealth University VT University of Vermont WA University of Washington WI University of Wisconsin-Madison WV West Virginia University

BIBLIOGRAPHY

Fifield M, Fifield B. 1995. The Evolution of University Affiliated Programs for Individuals with Developmental Disabilities: Changing Expectations and Practices. Washington, DC: Administration on Developmental Disabilities.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1998. Leadership Education Excellence in Caring for Children with Neurodevelopmental and Related Disabilities: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Public health nursing has traditionally been the backbone of maternal and child health (MCH) services. Nurses’ training was first supported by the Children’s Bureau with funds made available through the Sheppard-Towner Act of 1922. In supporting

training for nurses at the state level, the Children’s Bureau was attempting to lower the high infant mortality rate. Although the health of children and families has improved since the first nurse-train-ing projects were initiated, unmet health care needs still exist that threaten the well-being of the MCH population. The Maternal and Child Health Bureau (MCHB) nursing training program continues to fund training projects in public and nonprofit institutions of higher learning. The goal of these projects is to prepare MCH nursing leaders for key positions in education, service, research, administration, and advocacy.

PROGRAM CHARACTERISTICS

The nursing program has two components: leadership education in maternity nursing and leadership education in pediatric nursing.

The maternity nursing component provides funds to train nurses and nurse midwives in two domains: faculty development and continuing education and development. Faculty development comprises leadership education for maternity-nursing and nurse-midwifery faculty, to enhance the level of scholarship, research, and leadership skills in the field.

Continuing education focuses on leadership development, scholarship, clinical practice, academics, and specific issues such as clinical assessment of health risk factors and access to primary care.

The pediatric nursing component provides funds to train nurses in three domains: graduate education, faculty development, and continuing education and development. Graduate education focuses on leadership development, scholarship, clinical practice, and academics for graduate pediatric nurse trainees. The faculty development and continuing education domains focus on enhancing scholarship, research, education, and skills of MCH nurse trainees.

HIGHLIGHTS

Faculty/Trainees. Participating faculty have demonstrated leadership skills, expertise in materni-ty/obstetrical nursing, nurse midwifery, and pediatric nursing, and experience in integrating nursing services in local and state health care systems. The trainees supported by these projects are registered nurses working toward a graduate degree in nursing with an emphasis on the MCH population.

Curriculum. The nursing training program curriculum includes graduate education at the master’s and doctoral levels with an emphasis on preventive, diagnostic, treatment/management, and follow-up care for the MCH population. Course content and philosophy aim to prepare trainees to assume leadership roles in the development, improvement, and integration of nursing in health care systems. Nurse training sites also function as regional/national resources for the health professional community by hosting workshops and by providing technical assistance and consultation in an effort to improve services in the field and to enhance trainee education.

PROGRAM PROFILE

• In FY 1999, MCHB funded six nursing training program projects, with annual grant awards totaling about $953,000.

• The grant awards range from $53,000 to $213,000 per year, with a mean award amount of $159,000.

Present Grant Recipients

STATE	GRANTEE
CO	University of Colorado Health
	Sciences Center
MA	Boston University
MN	University of Minnesota (2 grants)
OH	Case Western Reserve University
WA	University of Washington

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1998. Leadership Education Excellence in Maternal and Child Health Nursing: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Many of the improvements in maternal and child health (MCH) throughout this century can be attributed to better nutrition and food safety—for example, safe milk supplies and the discovery of vitamins and their use to prevent diseases such as rickets. As the knowledge base about the science of nutrition expanded, professionals were needed to provide nutritional services, to conduct further research, and to educate other providers and families about the benefits of improved nutrition. Current areas of concern include the increasing

rates of obesity among children, adolescents, and adults; low intakes of fruits and vegetables, calcium-rich foods, and folic acid; and higher than recommended intakes of high-fat foods. Inadequate food resources, low rates of breastfeeding, and iron deficiency in young children and pregnant women may also be of concern in low-income populations.

The vital role of nutritionists—and the need to provide special training for them in public health concepts and philosophy—has been recognized since the initiation of the MCH Training Program. Graduate training programs in public health nutrition were first funded by Title V in 1943, as the critical need for nutritionists trained in public health was identified. Training in nutrition was also integrated into the MCH interdisciplinary training programs since their inception. Nutritionists were trained in the special needs of mothers and children and the population-based focus of public health.

Currently, Maternal and Child Health Bureau (MCHB) grant funds are awarded to establish and enhance centers of excellence to improve MCH by promoting the healthy nutrition of the mother, child, and family. These centers are actively engaged in three domains: graduate leadership education, faculty development, and continuing education. Some centers focus on long-term as well as short-term training, while others focus exclusively on continuing education.

PROGRAM CHARACTERISTICS

The primary objectives of the nutrition training program are to enhance MCH nutrition’s contributions to primary health care and public health, reduce barriers to needed health services, reduce health status disparities for underserved and special populations, and ensure quality of care. Because many other training priorities include nutrition services, the particular focus of the nutrition training program is to work closely with the other Title V programs to provide training and to develop MCH-related programs. Nutrition training programs also develop faculty and student leadership skills and have been leaders in the development and promotion of innovative practice models in MCH nutrition.

The nutrition training program is divided into two areas: leadership education in public health nutrition and leadership education in pediatric nutrition.

Leadership Education in Public Health Nutrition. This component provides long-term graduate education and short-term continuing education in MCH nutrition through graduate programs that are members of the Association of Graduate Programs in Public Health Nutrition, Inc., and have curricula consistent with guidelines recognized by that group. Students are trained in core public health principles, epidemiology, environmental approaches to population intervention, and the development and evaluation of nutrition-related, cost-effective interventions for specific populations. Training is also provided in identifying and designing outcome evaluations and in evaluating the potential physiological and biochemical mechanisms linking diet and nutritional status with risk or disease status.

Leadership Development in Pediatric Nutrition. Long-term and short-term training and continuing education in pediatric nutrition are provided to clinical as well as public health pediatric professionals in the health care community. This training can be in the form of practica of 3 weeks’ to 3 months’ duration, 1-week intensive courses, or 1-day continuing education. Each course is designed to provide both clinical and public health approaches to working with the pediatric population. Areas of emphasis include specialized neonatal intensive care training, training in the area of children with special health care needs, and training in breastfeeding promotion and maternal nutrition.

HIGHLIGHTS

Faculty/Trainees. Faculty who participate in the nutrition training program have demonstrated leadership skills in all areas of MCH nutrition, including establishing professional standards and guidelines in nutrition. Examples of faculty contributions include the development of guidelines and the credentialing test for a pediatric nutrition specialty through the American Dietetic Association, development of competencies for graduate programs in public health nutrition, working with the Association of State and Territorial Public Health Nutrition Directors to develop the handbook Moving to the Future: Developing Community-Based Nutrition Services, and participating in the Maternal and Child Health Interorganizational Nutrition Group to produce Call to Action: Better Nutrition for Mothers, Children, and Families. Additionally, faculty and trainees have been involved in the development and writing of both Bright Futures in Practice: Nutrition and Bright Futures in Practice: Physical Activity. Students and trainees are primarily from the nutrition discipline but also include nurses, social workers, and physicians. Faculty and students/trainees provide technical assistance to other Title V programs as well as to the health care/public health community.

Continuing Education. A strong component of the nutrition training program is continuing education, which is provided to a variety of health disciplines to enhance their knowledge and skills in the area of MCH and public health nutrition. In addition to traditional courses and workshops, the nutrition grantees provide cutting-edge continuing education through the use of new distance education technologies, including regional and national satellite teleconferencing, videotape instruction with accompanying materials, and Web-based and computer-based educational and resource programs.

PROGRAM PROFILE

• In FY 1999, MCHB funded six MCH centers of excellence in nutrition, with annual grant awards totaling about $1.1 million.

• The grant awards range from $99,000 to $310,000 per year, with a mean award of $176,000.

Present Grant Recipients

STATE	GRANTEE
AL	University of Alabama,
	Birmingham
CA	University of California,
	Los Angeles
IN	Indiana University
MN	University of Minnesota
NC	University of North Carolina at
	Chapel Hill (with subcontract to
	University of Tennessee)
SC	Medical University of South
	Carolina

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1998. Leadership Education Excellence in Maternal and Child Health Nutrition: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY health (MCH) population; (2) development and Major advances in the treatment of oral disease in dissemination of curricula, teaching models, and children have significantly improved children’s oral other educational resources to enhance the MCH health in the United States. Fluoridation of water content of dentistry training programs; and (3) con-

supplies, regular tooth brushing and dental visits, and application of dental sealants have reduced the incidence of caries in children. However, children in low-income families and other children who are at high risk for developing health problems continue to suffer disproportionately from oral disease. Access to dental treatment and preventive care is limited for these high-risk populations for many reasons. One reason is the lack of dental health professionals who have been specially trained to serve a pediatric population in general, and children with special health care needs (CSHCN) and other high-risk populations in particular. In 1965, the Children’s Bureau (now the Maternal and Child Health Bureau [MCHB]) initiated the pediatric dentistry program to address these gaps in training and to serve as a regional and national resource for other pediatric dentistry programs.

PROGRAM CHARACTERISTICS

Through the pediatric dentistry leadership grant, dentists receive specialized training in prevention and treatment services for the pediatric population and in dental public health and leadership. The purpose of the pediatric dentistry program is to facilitate a national focus on leadership in the field through the following activities: (1) postdoctoral training of dentists in the primary care specialty of pediatric dentistry for leadership roles in education, service, research, administration, and advocacy related to oral health programs for the maternal and child tinuing education, consultation, and technical assistance in pediatric oral health.

Trainees and faculty provide services to the general pediatric population as well as to children with special health care needs, including children with behavioral problems. Clinical services include comprehensive dental treatment and are provided in a variety of settings, including university-based dental clinics, group homes, local community health clinics, and school-based centers. High-risk populations are targeted for the provision of clinical services; these populations include developmentally disabled children, children of migrant farm workers, Native American children, and children from low-income families.

HIGHLIGHTS

Faculty/Trainees. Participating faculty have demonstrated leadership, expertise, and skills in pediatric dentistry. Faculty have experience in communi-ty-based services that provide population-based care as well as in integrating pediatric dentistry services with local and state health care systems. The trainees enrolled in the program are working toward a graduate degree in public health or pediatric dentistry.

Curriculum. The program curriculum includes graduate education at the master’s level or above with an emphasis on preventive, diagnostic, treat-ment/management, and follow-up care for the MCH community, with a particular emphasis on CSHCN. Course content and philosophy is focused on preparing graduates to assume leadership roles in the development, improvement, and integration of pediatric dentistry in community-care systems. The training program also aims to be responsive to the cultural, social, and ethnic diversity of the community in the development and integration of services. Training sites function as regional or national resources for the health professional community to improve services and enhance trainee education.

PROGRAM PROFILE

• In FY 1999, MCHB funded two pediatric dentistry training projects, with annual grant awards totaling $463,000.

Present Grant Recipients

STATE	GRANTEE
IA	University of Iowa
NC	University of North Carolina at
	Chapel Hill

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Center for Leadership in Pediatric Dentistry Education: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

The goals of occupational therapy as a health discipline are to prevent disability and handicap and to promote, restore, and maintain health through occupation. Since its inception, the goal of the Maternal and Child Health Bureau (MCHB) pediatric occupational therapy training program has been to prepare master’s and doctoral students for future leadership roles in the field of occupational therapy, particularly as it relates to mothers and children. The program focuses on both increasing access to developmental programs for children with disabilities and developing culturally competent, community-based systems of care for children and mothers.

PROGRAM CHARACTERISTICS

The purpose of the pediatric occupational therapy program is to facilitate a national focus on leadership in the field through the following activities: (1) post-professional graduate training of occupational therapists for leadership roles in education, service, research, administration, and advocacy in programs providing services for the maternal and child health (MCH) population; (2) the development and dissemination of curricula, teaching models, and educational resources to enhance the MCH content in occupational therapy training programs; and (3) the provision of continuing education, consultation, and technical assistance in pediatric occupational therapy that addresses the needs of the MCH community.

HIGHLIGHTS

Faculty/Trainees. Participating faculty have demonstrated leadership skills and experience in integrating pediatric occupational therapy services in local and state health care systems. Trainees enrolled in the program are working toward a postprofessional graduate degree with a pediatric focus. In addition to completing other course work, students participate in special seminars covering topics such as leadership development, grant writing, and the social and economic challenges currently faced by mothers and children. Trainees also gain both disci-pline-specific and leadership skills in a variety of ways, which include developing and conducting research projects; teaching undergraduate courses and attending seminars on faculty development; and collaborating with public health and community service agencies to provide technical assistance.

Curriculum. The program curriculum includes graduate education at the master’s or doctoral levels, with an emphasis on occupational therapy within the context of family and community systems. Course content and philosophy aim to prepare graduates to assume leadership roles in integrating pediatric occupational therapy into state and local systems of care in community-based settings, especially those that provide MCH services and that target children with special health care needs. Training sites function as regional or national resources for the health professional community to improve services and enhance trainee education. Grantees also develop curricula, teaching models, and other educational resources, which are shared with other occupational therapy programs.

PROGRAM PROFILE

• In FY 1999, the MCHB pediatric occupational therapy training program funded three occupational therapy projects, with annual grant awards totaling $398,000.

• The grant awards range from $126,000 to $140,000 per year, with a mean award amount of $133,000.

Present Grant Recipients

STATE	GRANTEE
CA	University of Southern California
MA	Boston University
WI	University of Wisconsin–Madison

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Center for Leadership in Pediatric Occupational Therapy Education: Application Guidance. Rockville, MD: U.S. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

Advances in medical technology, increased survival rates for low-birthweight infants, enhanced understanding of developmental risk factors, and improved identification methods have resulted in increased numbers of children with disabilities and special health care needs. Limited fiscal and human resources, geographic characteristics, and changing demographics present challenges in addressing the needs of mothers and children in today’s rapidly changing health care environment. These factors have heightened the need for a greater number of pediatric physical therapists to assume leadership roles in improving the functioning, level of independence, and quality of life for children who have, or are at risk for developing, disabilities. The Maternal and Child Health Bureau (MCHB) pediatric physical therapy training program was designed to prepare pediatric physical therapists to assume leadership positions in developing and improving culturally competent, family-centered systems of care for children and families.

PROGRAM CHARACTERISTICS

The purpose of the training program in pediatric physical therapy is to facilitate a national focus on leadership in the field through the following activities: (1) postprofessional graduate training of physical therapists for leadership roles in education, service, research, administration, and advocacy in programs providing services for the maternal and child health (MCH) population; (2) the collaboration of the projects and other MCH, Title V, and community agencies; (3) the development and dissemination of curricula, teaching models, and educational resources to enhance the MCH content of physical therapy training programs; and (4) the provision of continuing education, consultation, and technical assistance in pediatric physical therapy that addresses the needs of the MCH community. The Pediatric Physical Therapy training projects serve as regional

and national resources for health professionals, families, commu-nity-based agencies, and institutions of higher learning.

HIGHLIGHTS

Trainees. Postprofessional program curricula at both the mas-ter’s and doctoral levels emphasize public health and MCH issues such as family-centered care; incorporate clinical, teaching, and research experiences; include focused mentoring in pediatric physical therapy; and provide interdisciplinary training opportunities. Trainees develop leadership skills in professional, academic, administrative, policy, and research capacities in their positions of responsibility within professional organizations, institutions of higher learning, or community agencies. Additionally, skills in advocacy, policy development, mentoring, program development, and outcome evaluation are developed.

Faculty. The faculty train pediatric physical therapists for leadership roles, advocate for the MCH population, provide regional continuing education for a variety of health care professionals, integrate pediatric physical therapy into local and state health care systems, provide service to their professional associations, and conduct and disseminate research to improve the practice of pediatric physical therapy.

Faculty collaborate with state Title V agencies, public health and community agencies, and other institutions of higher learning to develop curricula centered on the needs of the MCH population.

PROGRAM PROFILE

• In FY 1999, the MCHB pediatric physical therapy program funded three projects, with annual grant awards totaling $398,000.

• The grant awards range from $123,000 to $149,000 per year, with a mean award amount of $133,000.

Present Grant Recipients

STATE	GRANTEE
OK	University of Oklahoma
PA	MCP Hahnemann University
WA	University of Washington

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Center for Leadership in Pediatric Physical Therapy Education: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

For much of this century, children with respiratory disorders did not live beyond infancy. As more children survived because of improved treatments, training was required to ensure that children with respiratory conditions were diagnosed appropriately and received the best care possible. To provide children with respiratory disorders with effective treatment and ongoing care, the federal government funded 13 pediatric pulmonary centers (PPCs) in 1967. In 1973, the federal Office of Maternal and Child Health (OMCH) took over the administration of the PPC grants. OMCH recognized the importance of training multidisciplinary teams to address the complex needs of children with pulmonary conditions, and it changed the grants’ focus to include multidisciplinary training of physicians, nurses, respiratory therapists, nutritionists, and social workers. Another area of emphasis added to the PPCs was a population-based, public health focus.

Throughout the 1980s and 1990s, several additional shifts occurred in the field of pediatric pulmonary medicine. Newborns were now surviving as a result of technological interventions. Chronically ill children were entitled to receive an education in the same settings as their peers. Comprehensive care moved from hospitals into homes and schools. In response to these shifts, PPCs changed their emphasis as well. Rather than focusing exclusively on medical interventions, centers now provide family-centered, culturally appropriate, developmental, and psychosocial support of children and their families. Interdisciplinary team members also work with the public health system at local, regional, and national levels to achieve these goals.

Currently, more than 7 million children in the United States have lung-disabling conditions, including asthma and cystic fibrosis. Respiratory conditions are the cause of most hospitalizations for children ages 1 through 9 in the United States and are also responsible for many days of missed school. The Maternal and Child Health Bureau (MCHB) pediatric pulmonary centers training program is designed to do the following: (1) improve the health status of children with acute and chronic respiratory conditions; (2) develop and sustain community-based systems of care; and (3) advance knowledge in the pediatric pulmonary field.

PROGRAM CHARACTERISTICS

The purpose of the interdisciplinary pediatric pulmonary centers training program is to prepare health professionals for leadership roles in the development, enhancement, or improvement of commu-nity-based care for children with chronic respiratory diseases and for their families. These PPCs provide interdisciplinary training of health professionals, engage in active partnerships with state and local health agencies and health professionals, and serve as models of excellence in training, service, and research related to chronic respiratory conditions in infants and children.

HIGHLIGHTS

Faculty/Trainees. PPC traineeships are available in pulmonary medicine, nursing, nutrition, pharmacy, respiratory therapy, and social work. The program trains at both the graduate and postgraduate levels in the primary program setting as well as in diverse community settings. Faculty engage in relevant research. Both faculty and trainees provide consultation and technical assistance to develop or to improve community-based services. Additionally, the program collaborates with state Title V programs to improve community capacity by integrating services and resources, conducting needs assessments, and jointly developing continuing education and consultation efforts.

Curriculum. The program prepares trainees for leadership by providing not only clinical training, but also curriculum that includes a broad public health perspective consisting of, among other things, the development and implementation of systems of care, advocacy, public policy formulation, and legislation. PPCs also provide ongoing continuing education activities through community-based workshops and seminars, conferences, and other activities designed to enhance skills or disseminate new information.

PROGRAM PROFILE

• In FY 1999, MCHB funded seven PPCs, with annual grant awards totaling $2.2 million.

• The grant awards range from $282,000 to $349,000 per year, with a mean award amount of $308,000.

Present Grant Recipients

STATE	GRANTEE
AL	University of Alabama at
	Birmingham
FL	University of Florida
LA	Tulane University
NM	University of New Mexico
NY	Mount Sinai School of Medicine
WA	University of Washington
WI	University of Wisconsin–Madison

For additional information about the PPCs, please visit http://salud.unm.edu/asthma/ppc.htm.

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. n.d. Maternal and Child Health Bureau Division of Systems, Education and Science Maternal and Child Health Training Program Announcement of Grant Availability: Pediatric Pulmonary Centers. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

The maternal and child health (MCH) training grants to schools of public health were the first long-term training programs funded by the Children’s Bureau, beginning in 1947. The program was initiated to help establish an MCH concentration within schools of public health. The developing MCH state agencies required a work force that was knowledgeable about public health principles and that focused on children and families.

Currently, the Maternal and Child Health Bureau (MCHB) funds grants that support the development and enhancement of MCH content, expertise, and training in 13 schools of public health. The grants also foster the availability of such resources to all parts of the country. The schools of public health MCH training programs have demonstrated their ability to advance the field of MCH and to help achieve MCH-related health objectives.

PROGRAM CHARACTERISTICS

The objectives of the MCH training programs in schools of public health are as follows: (1) to educate future leaders and to assist current leaders in solving MCH public health problems; (2) to discover and test solutions to these problems by conducting applied research at the local, state, and national levels; and (3) to improve the health status of women, children, and families through participation in community activities. The programs are interdisciplinary in focus, with faculty from many professional disciplines working as a team to provide training. Schools of public health MCH training programs use a com-petency-based curriculum designed to train students to become leaders in public health practice, research, planning, policy development, and advocacy. The curriculum focuses on the development of scientific and analytic skills, as well as on the development of skills in management, communication, and advocacy.

HIGHLIGHTS

Trainees. According to the Association of Teachers of Maternal and Child Health, more than 550 students are supported annually by the MCHB funds through stipends and traineeships. The students in these training programs participate in a variety of activities aimed at preparing them to become leaders in the MCH field. These activities include assisting in community-based health agencies, conducting community-based training sessions, producing educational materials, and conducting evaluations on the effectiveness of MCH community-based programs. In addition, students participate on local and national task forces, advisory panels, and commissions.

Faculty. Faculty from the schools of public health MCH training programs train public health professionals for leadership roles; provide technical assistance and consultation to local, state, and national organizations; develop and disseminate new knowledge; provide continuing education to practicing public health professionals; and advocate for the MCH population. Faculty in the training programs include nurses, social workers, obstetricians, pediatricians, nurse-midwives, nutritionists, economists, psychologists, sociologists, epidemiologists, and health services researchers.

PROGRAM PROFILE

• In FY 1999, MCHB funded 13 general MCH training programs in schools of public health with annual grant awards totaling about $4.5 million.

• The grant awards range from $243,000 to $402,000 per year, with a mean award amount of $318,000.

Present Grant Recipients

STATE	GRANTEE
AL	University of Alabama at
	Birmingham
CA	University of California, Berkeley
	University of California,
	Los Angeles
FL	University of South Florida
HI	University of Hawaii
IL	University of Illinois at Chicago
MD	Johns Hopkins University
MA	Boston University
	Harvard University
MN	University of Minnesota
NC	University of North Carolina at
	Chapel Hill
PR	University of Puerto Rico
WA	University of Washington

BIBLIOGRAPHY

Association of Teachers of Maternal and Child Health. Fall 1998. Maternal and child health training in U.S. schools of public health: What is it? Who does it? Who benefits? ATMCH Newsletter.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Maternal and Child Health Bureau, Division of Systems, Education, and Science. n.d. Maternal and Child Health Training Program Announcement of Grant Availability: MCH Training in Schools of Public Health. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

The vital role of social workers—and the need to provide special training for them in public health concepts and philosophy—has been recognized since the initiation of the Title V program, when continuing education training was provided. Training for social workers was also integrated into the interdisciplinary training programs, which were funded from their inception by the maternal and child health (MCH) program.

Social work training, as a separate priority, was first developed in the mid-1950s when the critical need for social work faculty trained in public health was recognized. At that time, a doctoral program was established—the only one in the nation that helped students who had a master’s of social work (M.S.W.) degree to obtain a master’s of public health (M.P.H.) degree along with a Ph.D. in social work. This program, located within a school of public health, is still viewed as key to producing faculty with public health and MCH perspectives for schools of social work.

Grants to schools of social work—which have ranged in number from as many as 20 in the 1970s to only 3 in FY 1999—have been awarded on a competitive basis to encourage the training of social workers in MCH concepts at the master’s level and also to support continuing education for social workers at the regional level. The continuing education and consultation aspects of these grants are viewed as equally important for long-term training. The regional conferences focus on new and emerging issues that have been identified by national leaders. Examples of topics from these conferences over the years include family planning, perinatology, prevention, mental health, parenting, adolescent health, violence as a public health issue, and evaluation. The workshops provide an important opportunity for field workers, administrators, and teachers to gain new knowledge and stay current with the national MCH agenda. In short, the social work training program aims to establish centers of excellence that promote public health training for social workers who can then become leaders in their field. These centers also serve as regional resources in continuing education.

PROGRAM CHARACTERISTICS

The social work training program has: (1) gradu-ate-level social work programs that integrate MCH content into their health concentrations, and (2) one program that provides postgraduate training to persons who have already received an M.S.W., leading to an M.P.H. degree and a doctorate in social work. These social work programs offer students a wide range of interdisciplinary field experiences in various MCH settings. Because there are so few training grants relative to the need for trained social workers in this area, the programs are all required to disseminate curriculum materials, teaching models, and other educational resources to social work education programs around the nation. In this way, the training program’s work has more influence.

HIGHLIGHTS

Trainees. The social work training program has successfully recruited many qualified minority can-didates for long-term training. Graduates have become faculty in schools of social work, pursued careers in policy and research, or become local leaders in direct service.

Faculty. Project directors have an M.S.W. degree as well as a doctorate. They are demonstrated leaders with expertise in public health social work practice, program development, and administration. Other MCH faculty actively participate in the program in a variety of ways. Faculty engage in applied and clinical research and must provide technical assistance and consultation to Title V agencies in addition to their teaching and advising functions.

Curriculum. The curriculum includes the following areas, as applied to mothers, children, and families: epidemiology; social factors relating to health; community needs assessment; program planning and evaluation; program management and accountability; policy change strategies; and effects of ethnicity, culture, and gender on access to health services. The curriculum also includes field training.

PROGRAM PROFILE

• In FY 1999, MCHB funded three social work projects, with total annual awards amounting to $400,000.

• The grant awards range from $117,000 to $160,000 per year, with a mean award amount of $133,000.

Present Grant Recipients

STATE	GRANTEE
MD	University of Maryland, Baltimore
NC	University of North Carolina at
	Chapel Hill
PA	University of Pittsburgh

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1997. Maternal and Child Health Center for Leadership in Public Health Social Work Education: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

PROGRAM HISTORY AND STRATEGY

In recognition of the need to continuously build and enhance the knowledge and skills of persons caring for the maternal and child health (MCH) population, all MCH training programs, beginning with the first long-term training grants to schools of public health in 1947, have been required to provide a continuing education component. In addition to the continuing education component of these long-term training projects, the Maternal and Child Health Bureau (MCHB) has separately funded short-term continuing education training grants. The primary objective of this program is to advance the knowledge and skills of MCH professionals so that they can enhance their effectiveness in primary, secondary, and tertiary health-care delivery settings (such as homes, ambulatory care facilities, managed care facilities, private practice offices, community-based facilities, and hospitals). By developing a communi-ty-based partnership of health resources and community leadership, the training program is designed to help prepare health professionals to assist children and their families in achieving their developmental potential.

PROGRAM CHARACTERISTICS

The term continuing education comprises a number of methods of formal education that may take the following forms: (1) short-term educational experiences that can range in length from a week to several months and that utilize either a standard curriculum or one that has been individually designed;

(2) institutes, which usually focus on a specific topic and are marketed to a particular target audience;

(3)

conferences, which generally have a one-time curriculum intended for diverse audiences; (4) workshops, which are generally smaller and more limited in scope than conferences;

(5)

task forces and work groups, which are convened to provide guidance, models, recommendations, or consultation for new and emerging issues or methodologies; and (6) in-service education, which is usually designed for the employees of the sponsoring agency or, occasionally, a group of similar agencies.

In recent years, many continuing education courses have begun offering educational credit for participants.

HIGHLIGHTS

Centers of Excellence. First funded in the early 1990s, the primary objective of these centers is to advance the knowledge and skills of pediatric health professionals so that they can enhance their effectiveness in primary, secondary, and tertiary health care delivery settings. These centers are designed to help prepare health professionals to assist children and their families in achieving their developmental potential by forging a community-based partnership of health resources and community leadership.

MCH Leadership Skills Training Institutes. These institutes offer continuing education and training to increase leadership skills for key management per-sonnel in state Title V MCH programs in the United States. Each year, approximately two institutes on planning, implementing, and evaluating programs and two institutes on systems are offered to state Title V program staff members. These institutes integrate content material from both MCH and children with special health care needs programs and address general leadership and administrative skills topics.

Collaborative Office Rounds (COR). The COR program supports small discussion groups that meet at regular intervals over sustained periods of time to address the mental health aspects of pediatric care. The groups are jointly led by pediatricians and child psychiatrists, and participants include practitioners, fellows, and residents. Although they vary in a number of ways, all groups are concerned with the day-to-day psychosocial issues that confront primary care providers serving children, adolescents, and their families.

Distance Learning. MCHB currently funds dis-tance-learning continuing education projects in three institutions of higher learning. The primary objective of these projects is to enhance the reach of their continuing education offerings beyond the institutions’ walls. Thanks to innovations such as audiotapes and videotapes, telephone conferencing and videoconferencing, satellite linkages, and the World Wide Web, the distance learning projects are able to reach increasingly broad audiences across states, regions, and the nation.

PROGRAM PROFILE

• In FY 1999, MCHB funded 37 continuing education programs around the country, with annual awards totaling about $2.1 million.

• The grant awards range from $12,000 to $410,000 per year, with a mean award amount of $55,130.

Present Grant Recipients

STATE	GRANTEE
AL	University of Alabama at
	Birmingham
CA	University of California,
	San Francisco
CT	Yale University School of Medicine
FL	University of South Florida
	University of Florida (2 grants)
IL	University of Chicago
	University of Illinois at Chicago
	(3 grants)
MA	Children’s Hospital, Boston
	(2 grants)
	Boston University School of Public
	Health
	Boston Medical Center
	Brandeis University
MD	Johns Hopkins University
	(2 grants)
MI	University of Michigan
MN	University of Minnesota (2 grants)
NC	University of North Carolina at
	Chapel Hill
NE	University of Nebraska Medical
	Center
NH	Dartmouth College (2 grants)
NM	University of New Mexico
NY	University of Rochester
OH	Case Western Reserve University
	University of Cincinnati
	Children’s Hospital, Columbus
	(2 grants)
PA	Joseph Stokes Research Institute,
	University of Pennsylvania

TN Vanderbilt University University of Tennessee, Memphis University of Tennessee, Chattanooga

TX University of North Texas

WA Children’s Hospital and Medical Center, Washington University of Washington

BIBLIOGRAPHY

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 1998. Leadership Education Excellence in Continuing Education and Development: Application Guidance. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.