Predicting School-Age Behavior

Problems: The Role of Early

Childhood Risk Factors

Tracy Magee
Sister Callista Roy

Purpose. To examine the impact of early childhood risk factors on school-age child behavior. Identifying
the relationships of risk factors in early childhood contributing to behavior problems in school age-children can effectively target interventions during pediatric primary care encounters.
Methods. An 8-year longitudinal, retrospective secondary analysis using a sample of children (N = 721)
from the National Longitudinal Survey of Youth 1979 (NLSY79).
Results. A logistic regression model prediction was significant (R2 = 0.62, p < .001) though modest with
overall behavior problems predicted at 62.5% with sensitivity problems. Adjusted odds ratios indicate a
young boy with a difficult temperament was two times more likely to have behavior problems at school
age. The same boy with a less able mother was eight times more likely to have problem behavior at
school age.
Implications for practice. There are significant risk factors in early childhood that predict school-age
behavior problems even in a non-clinical sample. All families deserve ongoing behavioral screening and
assessment.

childs preschool years are a

time of great developmental
change. Children are learning which behaviors are
acceptable and which behaviors are
not. Often behaviors that are perceived as problematic during this time
resolve without intervention. Research
suggests, however, that a significant
number of preschool children with
problem behaviors are at risk for more
serious behavior problems in the
future (Caspi et al., 2003; HawkinsWalsh, 2001).
Current research attempting to
explain childhood behavior problems
offers a variety of risk factors encompassing biologic, socio-emotional,
and environmental influences. Unfortunately, with so many risk factors
identified, the ability to adequately
assess children and families is hindered. The purpose of this study was

Tracy Magee, PhD, RN, CPNP, is an

Assistant Professor, University of Illinois at
Chicago College of Nursing, Chicago, IL.
Sister Callista Roy, PhD, RN, FAAN, is a
Professor and Theorist, Boston College,
William F. Connell School of Nursing,
Boston, MA.
Acknowledgment: Preparation of this
manuscript was made possible by the
Harris Scholar Foundation.

to test a conceptual framework based

on the transactional model to determine what early childhood risk factors
predict which child will have behavior
problems at school age. By more fully
understanding the risk factors for
behavior problems in children, nurses
can begin planning effective and efficient interventions to promote child
development as well as advocating for
the needs of children and families.

Background
According to retrospective studies,
disruptive and violent adolescents
have often had behavior problems
during the preschool years (Keenan &
Wakschlag, 2002). In spite of this,
behavior problems in young children
have not been well described.
Campbell (1995) describes preschool
behavior in two dimensions; internalizing and externalizing. Examples of
internalizing behaviors are depression,
withdrawal, and anxiety; examples of
externalizing behaviors are attention,
self-regulation, aggression, and noncompliance. It is generally accepted
that behavior problems with the severity and consistency to alter normal
development are considered to be
clinically significant (Keenan &
Wakschlag, 2000).
Patterson, Mockford, Barlow,
Pyper, and Stewart-Brown (2002)

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

suggest that in the United Kingdom 1

in 5 children under the age of 6 has
behavior that is disruptive to the family. The most current data in the United
States suggest that about 10% of
young children have problem behavior with that number increasing to 25%
for children in poverty (Joseph &
Strain, 2003).

Theoretical Framework
The Transactional Model of Child
Development was first articulated by
Sameroff and Chandler (1975) and
developed from studies that showed
negative developmental outcomes
could not be entirely explained by the
presence of biologic insult, unless the
insult was severe enough to leave
clear biologic damage. The developmental outcomes could only be
explained by understanding the transaction between the content of the
childs behavior and the context of
that behavior (Parker, Greer, &
Zuckerman, 1988).
The transactional model describes
the development of the infant or child
as occurring within the context of the
environment and that the environment
transacts with the infant over time to
produce developmental outcomes
(Sameroff & Mackenzie, 2003). To
predict an outcome, both the childs
individual characteristics and the
37

characteristics of the environment

must be assessed. The conceptual
model for this study reflects the transactional model (see Figure 1) and
consists of the three constructs
mother, environment and child that
continuously transact.

Risk Factors
Child. Current research suggests
that individual characteristics such as
gender, developmental level, and temperament may play significant role in
behavior problems. For example,
boys exhibit more externalizing behaviors (aggression) and girls exhibit
more internalizing behaviors (depression) (Campbell, 1995). Bongers,
Koot, van der Enle, and Verhulst
(2003) found that in children 4 years
old to 11 years old, the number of
internalizing problems did not differ
between boys and girls. However, by
adolescence, girls were more likely to
show internalizing behaviors such as
somatic complaints and social withdrawal. In addition, Baker and colleagues (2003) studied 205 families
with 3-year-old children with and without developmental delays and found
that parents of children with developmental delays rated their children as
higher than their non-delayed peers
on both internalizing and externalizing
behaviors. Finally, temperament has
been linked to behavior problems
from early childhood through to adulthood (Caspi et al., 2002).
Mother. It is generally accepted
that parental characteristics and parenting styles influence child behavior,
especially problem behavior (Barry,
Dunlap, Cotten, Lochman, & Wells,
2005; Gadeyne, Ghesquiere, &
Onghena, 2004). For example, adolescent mothers are thought to be
more likely to have lower educational
attainment and live in poverty, which
sets up both mother and baby for a
whole host of additional risk factors
(Logsdon, Birkimer, Ratterman,
Cahill, & Cahill, 2002). In addition,
externalizing behaviors have been
linked to poor quality parenting, particularly harsh and punitive discipline
(Deater-Deckard & Dodge, 1997).
Brenner and Fox (1998), in a study of
more than 1,000 mothers of children
between the ages of 1 and 5 years,
found that discipline was the strongest
predictor of behavior problems even in
very young children.
Environment. Research strongly
suggests a link between quality of
the home environment and school
achievement (Bradley, Corwyn,
Buchinal, McAdoo, & Garcia, 2000),
impaired cognitive development, and
38

Table 1
Variable Selection
0-2 Years

2-4 Years

3-6 Years

7-9 Years

Temperament

Maternal Education

Home
Environment

Behavior
Problems

Development

Average Family Income

Parenting Ability

Ethnicity
Gender

impaired physical development including height, weight, and anemia

(Malat, Oh, & Hamilton, 2005).
Virtually all of the research involving
children and family income concludes
that low family income puts a family
at risk for a host of negative affects,
including poorer health (Howard
& Lindsey, 2002), developmental
delay (Caughy & OCampo, 2006),
maternal depression (Petterson &
Albers, 2001), and violence (GrahamBermann & Seng, 2005).

Methods
Data source. Data for this study
were drawn from the National Longitudinal Survey of Youth 1979 Children
and Young Adults (NLYS-Child), an off
shoot of the National Longitudinal
Survey of Youth 1979 (NLSY79). The
NLSY79, initiated by the Department
of Labor, Bureau of Labor Statistics,
consists of a sample of 12,686 young
men and women who were between
14 and 22 years of age in 1979 and
who have been interviewed biennially
since the surveys inception (U.S.
Department of Labor, Bureau of Labor
Statistics, 1979). Over-representation
of African Americans, Hispanics, and
economically disadvantaged nonblacks and non-Hispanics provide statistical power for subgroup analysis,
and population weights are available
to draw national inferences.
In 1986, the National Institute of
Child Health and Human Development (NICHD) began to sponsor supplemental surveys to collect data
about the children of female respondents of the NLSY79, providing a battery of cognitive, socio-emotional,
and physiological assessments as well
as family background, home environment, and health information. Data
are collected from either the mother or
the child depending on the childs age.
Mother records and child records are
linkable via the mothers identification
number. To date more than 12,000
children of the female respondents of
the NLSY79 have been interviewed.
Data from the 1992-2000 NLYS-Child

and NLSY79 were analyzed for this

study using the Center for Human
Resource Research Database Investigator Software (Mott, 1995).
Sample. Our sample consisted of
521 child-mother-environment triads
where the child was between 7-9
years old at the 1998 survey and had
a complete battery of assessments,
specifically, children with temperament scores, motor-social scores, and
HOME-SF score. Table 1 summarizes
our selection schema.The survey year
1994 reflects the first assessment year
in which all children in the sample
were at least 1 year old and best represents the early child hood years
(birth to 4 years old) of the sample.
The maternal and environmental variables reflecting conditions that may
change from survey-to-survey year
were taken from the 1994 and 1996
assessments. The demographic characteristics of the child-mother-environment triad are summarized on
Table 2.
Outcome measure. The Behavior
Problems Index (BPI) was created for
the NLSY79. The BPI proposes to
measure the frequency, range, and
type of behavior problems for children
ages 4 and over (Mott, 1995). The
items for the BPI are summed into an
overall score and six sub-scores that
reflect six dimensions of child behavior. The BPI poses 28 questions to the
mother about her childs behavior. The
questions have been dichotomized,
summed, and normed against a
national sample by age. The resulting
index is scaled to have an index of 100
with a standard deviation of 15 in the
national population. A higher score on
the BPI reflects more disruptive
behavior. The total BPI has an alpha
coefficient of 0.86. Behavior was
dichotomized using the sample mean
as the cut off (problem behavior v normal behavior).
Predictors. Model predictors gathered from the literature reflect the
transitional model, which includes the
mother, child, and environment. Child
risk factors are gender, temperament,

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

Table 2
Sample Characteristics
Child
Age
Birth Weight
Prematurity

Mean

SD

97.6 months

44.6

118.6 ounces

21.2

38.5 weeks
N

Environment
Average Total Family Income
per Year
(1994-1996)

1.9
%

Ethnicity

721

Black

150

20.8

Hispanic

163

22.8

Non-Black, Non-Hispanic

406

56.4

Gender

721

Male

355

49.3

Female

365

50.7

Chronic Illness

688
37

5.0

Requires medication

31

4.0

Requires special equipment

13

1.0

SD

$37,093

36,903

Household with more than

one wage earner

721

Type of Adults in Household

with Mother

706

54.7

Partner

44

6.1

Grandmother

35

4.9

Grandfather

19

2.7

Number of Family Members in

Household
< Three

Requires health care provider

Median

706 (respondents)
26

4.7

Three

131

18.6

Four

281

39.8

Five

152

21.5

> Six

116

15.4

Number of Children under 18

Years Old in Household

428

Prenatal Drug Exposure

688

Cigarette use

150

21.8

Alcohol

200

29.0

Marijuana

0.7

Less than two

114

26.6

Cocaine

.07

Two

145

33.9

Mother

Mean

SD

Three

99

23.1

Age

29.4 years

2.7

Four

44

10.3

Education

13.1 years

2.5

Five or more

26

6.1

Ethnicity

721

Black

150

20.8

Hispanic

163

22.8

Non-Black, Non-Hispanic

406

56.4

Married

509

70.0

Occupation

721

Professional

318

44.2

51

1.6

Sales Worker/Clerical

119

6.9

Craftsman

146

20.5

Manager

Armed Forces

0.7

40

6.8

0.1

Service Worker

86

9.1

Private Household

10

0.1

Operatives/Laborers
Farmers

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

and motor/cognitive development; mother risk factors are

age at the birth of the child, education, and parenting ability; and environmental risk factors are income and home
environment (see Table 3). Ethnicity was used as a controlling variable rather than a predictor and as such is not
included in the conceptual framework.
Statistical analysis. SPSS Version 12.0 (Chicago) was
used to perform statistical analysis. Descriptive statistics
computed on all study variables and examined for missing
data, marked skewness and outliers, were used to summarize the data. By examining the residual histogram and partial plot for the outcome variable, the assumptions of normality, linearity and homoscedasity were assessed and
assumptions were not violated. A Pearsons coefficient of
skewness (mean-median/standard deviation) was computed for the continuous variables. Square root transformation
corrected positive skewness of parenting ability and home
environment and family income. A binary logistic regression
analysis was performed on the outcome variable of behavior problem and 10 predictor variables that were entered
simultaneously was one block. Sample size created ample
power for the number of predictor variables entered (Cohen,
1988). Multicollinearty was examined and found not to be a
problem with the predictors used in the regression model
(Tabachnick & Fidel, 2001).

39

Table 3
Predictors
Concept

Description

Rationale for Inclusion

Measure

Mean

SD

Child Gender

Sex of Child

Boys exhibit more externalizing

behaviors (aggression) and girls
exhibit more internalizing
(depression).

Male or Female

721

Early
Temperament

Temperamental
Characteristics:
Activity, Predictability,
Fearfulness, Sociability,
Negativity, Positive
Affect, Compliance,
Difficulty

Temperament has been linked to

behavior problems in later childhood (Paterson & Sanson, 1999),
adulthood (Caspi et al., 2003) and
has been linked to maternal
depression (Beck, 1996), which
indirectly influences later behavior.

Assessment: How My
Infant/Toddler Usually
Acts Difficult
composite 1992
(k = 49, = .94)

721

46.2

12.7

Development

Age Appropriate Motor

and Social
Developmental Level

Children with developmental

delays were rated higher by their
parents than their non-delayed
peers on both internalizing and
externalizing behaviors (Baker et
al., 2003).

Motor and Social

Development (MSD)
1992, from NLSY79,
[US Mean 100.6
(14.2), Sample mean
101.2 (15)]

645

76.9

58.2

Maternal Age

Age in Years

Adolescent mothers also are

more likely to have lower educational attainment and live in
poverty, which sets up both
mother and baby for a whole
host of additional risk factors
(Hess, Papas, & Black., 2002).

Age of Mother at Birth

of Child

721

29.4

22

Maternal
Educational
Level

Average Highest
Grade of Schooling
Completed

Lower maternal education has

been associated with higher
Behavior Problem Index Scores
(Kahn, Wise, & Finkelstein,
1999).

Average Highest
Grade Completed by
Mother in 1992-1994

705

13.0

2.5

Parenting Ability

Ability of Mother to
Provide Positive or
Nurturing Interaction
as Measured by the
HOME Scale,
Emotional Stimulation
Subscale

It is generally accepted that parents and parenting style influence child behavior (Barry et al.,
2005).

HOME Scale
Emotional Stimulation
Subscale 1994 and
1996 (k= 23, =.88)

645

136.8

51.3

Total Family
Income

Financial Resources of Poverty has been associated

the Family (1992-1994) with impaired cognitive development and impaired physical
development including height,
weight and anemia (Malat et al.,
2005).

Average Net Yearly

Income 1992-1994
HOME Score
Cognitive Stimulation

455

42,108

36,903

Home
Environment

Physical Quality of
Home, as Measured
by HOME-SF
Cognitive Stimulation
Subscale (Bradley et
al., 2000).

Subscale 1994 and

1999 (k=13, = .81)

645

180.6

66.7

40

Research strongly suggests a

link between age appropriate
toys and books in the home and
school achievement (Bradley et
al., 2000). Poverty has been
associated with impaired cognitive development and impaired
physical development including
height, weight, and anemia
(Malat et al., 2005).

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

Table 4
Summary of Binary Logistic Regression of Behavior Problems (N = 526)
Step 1

Variable

S.E.

Wald

df

Significance

Child Ethnicity

-.109

.123

.794

.373

.896

Gender

-.511

.199

8.007

.005*

.600

Development

-.005

.033

.019

.890

.995

Temperament

.023

.008

7.786

.005*

1.023

-.003

.045

.004

.95

.997

.001

.015

.003

.954

1.001

Mother Age
Education
Parenting Ability

Exp(B)

-.653

.348

4.607

.032*

.594

Income

.001

.001

1.776

.183

1.001

Home Environment

.471

.347

1.841

.175

1.602

*p < .050

Results
The success of prediction was significant (R2 = 0.62, p < .001), though
modest, with overall behavior problems predicted at 62.5% with sensitivity of 76%, specificity of 45%, positive
predictive value of 63% and negative
predicative value of 60%. These findings indicate that the model had the
tendency to miss children with significant problem behaviors (see Table 4).
The significant predictors were
gender (p < .011) with a beta weight
of -.511 and an odds ratio of .600,
temperament (p < .005) with a beta
weight of .023 and an adds ratio of
1.023, and parenting ability (p < .480)
with a beta weight of .653 and an odds
ratio of -.594. This analysis indicated
that young toddlers with difficult temperament regardless of gender were
2.3% times more likely to exhibit later
behavior problems. However, young
boys were 40% more likely to exhibit
problem behavior at school age.
Mothers with less parenting ability
were 41% more likely to have children
with school-age behavior problems.
No environmental risk factors were
found to be statistically significant.
The adjusted odds ratio indicated that
a young boy with a difficult temperament was two times more likely to
have behavior problems at school
age; whereas if that same boy had a
less able mother, he was eight times
more likely to have behavior problems
at school age.

Discussion
The current study provided a retrospective yet longitudinal look at identified risk factors of childhood problem
behaviors. The study sought to test a
conceptual model based on early
childhood risk factors identified by an

exhaustive review of the literature. In

the study, the sample proved to
resemble a middle class, not-at-risk
population. Using this sample, the
model was only moderately (62%)
successful in identifying children who
have problem behaviors at school age
and had a propensity to miss children
with significant behavior problems.
Even in this non-clinical population, significant predictors of later
behavior problems were identified in
very young children. Gender, temperament, and parenting ability in
early childhood were significant predictors of behavior problems in later
school age. In addition, the transaction of these predictors dramatically
increased the risk of later behavior
problems for a young toddler. A
young toddler having all three predictors or risk factors, male gender,
early difficult temperament and a less
able parent was eight times more
likely to have behavior problems at
school age.
This research corroborates the
growing body of evidence describing
the transactional nature of child development in which the bidirectional
affects of individual risk factors are
identified (Feldman, Eidelman, &
Rotenberg, 2004; Robison, Frick, &
Sheffield, 2005; West & Newman,
2003). For example Barry and colleagues (2005) found maternal mental health was significantly related to
behavior problems in boys even when
controlling for SES and income. In
contrast, Wake and colleagues (2006)
found that negative infant behavior
was significantly related to poor
maternal mental health. Our finding
can be better understood by examining the characteristics of the study
sample in comparison to previous

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

research and by examining current

thinking in measuring socioeconomic
factors, particularly poverty, in children.
The current study sample consisted of primarily middle income families
that did not appear to have characteristics generally thought to be associated with poverty or low socioeconomic
status. For example, almost 50% of
the mothers in this sample reported
some college education and 54% of
families were two-income households
with a median income of $38,777.00,
well above the poverty line in 1994
(U.S. Census Bureau, 2000). Even
though this sample appeared to have
few of the well-documented risk factors, child gender, temperament, and
parenting ability were still significant
predictors of behavior problems, indicating that these variables cross
socioeconomic boundaries.
Given the presence of significant
predictors even in this middle class
sample, more research is needed to
identify and meet the needs of all families, not just families with known risk
factors. Much attention has been given
to young, single, urban, poor mothers,
and virtually no attention has been
given to low income or middle class
mothers living in rural areas. Much
attention has been given to the role of
poverty and community violence in
urban American, and little or no attention has been given to families who
make just enough money to get by living in suburban America.
Limitations. National data sets
have inherent limitations as do secondary analyses. The major disadvantage of secondary analyses is that
research questions are being asked of
a data set that was not collected to
specifically answer that question. The
41

researcher has no control over original

data collection and is dependent on
the original researchers decisions
about data collection and storage
(Magee, Lee, Giuliano, & Munro,
2006). In addition to the limitations
associated with large data sets and
with secondary analyses, this
research has two major limitations.
The first limitation is in the measurement of temperament. Studies of very
young children require parental report
of temperament and of the outcome;
therefore, the measures are not independent of each other. In the current
study, temperament was assessed for
negativity or difficulty during the first 2
years of life, and behavior problems
were assessed between 6 to 9 years of
age. The length of time between each
measure increases the chance that the
measures are independent of each
other, but given the bidirectional
effects of parenting and temperament,
independence is not assured.
A second limitation of this study is
the under-representation of families
from lower income levels. Previous
research suggests that environment,
particularly the aspect of the home
environment, which is influenced by
income, is significant to child development and to parent-child interactions.
All income levels need to be well represented in research concerning children and parents
Future research. Given that previous research has highlighted the
importance of environment on the developing child (Caughy & OCampo,
2006) and on the development of a
parent (Beeber & Shandor, 2003;
Brooks-Gunn, Klebanov, Smith, &
Lee, 2001), further research is needed
to more fully understand how the
home environment acts or interacts on
both the child and the parent. For
example, does the home environment
mediate or moderate the effects of a
negative community environment?
What factors must be present in the
home to promote child development
and enhance parenting ability? Given
the unique role of poverty on child
behavior and development (Eamon,
2000, 2001), more research is needed
to describe the role of family income
on the child, the parent, and the environment. To suggest that only the
child who lives in poverty are at risk
for negative behavioral and developmental outcomes contradicts anecdotal evidence and clinical experience. Finally, while research points to
the negative implications of poverty,
children who live in poverty may have
positive experiences associated with
poverty.
42

Implications and
Recommendations for Nursing
For nurses to affect positive
change, more attention to normal
growth and development across the
life span must be given in nursing education. As the new morbidities of
poverty, stress, and parental health
issues such as depression, threaten
child health and development (Hagan,
2001; Haggerty, 1995; Zuckerman &
Parker, 1995), nurses must be ready
to face the challenge.
Temperament. Building on the
work begun by Kang and Barnard
(Kang & Barnard, 1979; Kang, Barnard, & Oshio, 1994) and the Nursing
Child Assessment Satellite Training
(NCAST), which uses infant behavior
at feeding to assess infant-parent
interaction, the concept of temperament can be used as an organizing
vehicle to promote goodness of fit
between parent and child and as an
intervention to increase parenting
competence and ability. Preliminary
reports of the Temperament Project, a
temperament-based intervention designed to facilitate parenting operated
by the Oregon Mental Health and
Developmental Disability Services
Division, showed a significant reduction in behavior problems of preschool
children after the intervention (Koroloff, 1991).
Temperament can be useful for
operationalizing family and patient
teaching. For example, planning care
for a child who is slow to warm up will
be different than planning care for an
easy child. Helping parents identify
the temperamental style of their child
will facilitate not only normal parentchild relationships but can affect parenting a child with a chronic illness.
For example, parents of a temperamentally difficult child who has asthma and needs frequent nebulizer treatments will benefit from a nurse who
can help identify the temperamental
style of the child, and who can offer
clear suggestions that facilitate the
medical treatments.
Primary care. Mounting evidence
indicates behavior problems in childhood are a result of transaction
between child, parent, and environment. The current pediatric health
care paradigm recognizes only the
child as a client (Hagan, 2001).
Zuckerman and Parker (1995) have
demonstrated the positive child effect
of meeting maternal needs; however
this transactional model has not been
embraced by the larger pediatric community (American Academy of
Pediatrics, 2001). This study supports
the concept that addressing the needs

of the family, mother and father as well

as child, benefits the whole family.
Concrete applications of this study
such as (1) systematic assessment of
child behavior, parent concerns and
home environment during well child
exams; (2) offering parenting groups
for parents with young children; and
(3) making use of parent handouts
that address behavioral issues, are all
easily incorporated into clinical practices and can be made available to all
families. This study strengthens the
support for assessment of all families
not just for families at known risk.
Advocacy. Rogers (1992) wrote:
For nurses, [the] focus consists of a
long-established concern with people
and the world they live in. It is the natural forerunner of an organized,
abstract system encompassing people
and their environments (p. 28).
Armed with the knowledge that the
first years of life are biologically and
emotionally important, nurses, individually and as a profession, must
advocate on behalf of todays children
as they are tomorrows adults. Issues
such as clean water, adequate housing, and access to health care and free
and appropriate education, are no
longer just child issues.
As science progresses, the link
between childhood and adulthood is
forming. Nursing is a diverse yet holistic perspective that understands the
complex and interconnected aspects
of the person and environment. The
nursing care of children requires care
of the child and his or her family and
the context in which the families live.
Issues such as adequate housing,
parental substance abuse, and community and domestic violence are as
important for the health care community as car seats and immunizations.
The discipline of nursing, with its
unique ability to describe phenomena,
as well as to intervene, using multiple
paradigms, could have a profound
impact at the forefront of these issues.

Conclusion
The early years of life are important
in the development of young children.
Parents in the 21st century face many
challenges. Issues such as poverty,
stress, and health issues affect the
health and development of children
and have been linked to behavior
problems in childhood. The current
pediatric health care system has not
been effective in meeting the changing needs of family. Given the hesitancy of pediatric clinicians to venture
into family issues, this study gives credence to and legitimizes the assessment of child, parents, and communi-

PEDIATRIC NURSING/January-February 2008/Vol. 34/No. 1

ty by the pediatric health care community. The transactional model identifies the bidirectional effects among
child, parent, and environment. To
effectively meet the needs of children,
pediatric clinicians must concern
themselves with family issues. It is the
aim of pediatric primary care to facilitate a happy healthy child.

References
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