NBAS, TOUCHPOINTS AND... TOBACCO:
Improving the child's health: lessons from Brazil
Mario Becker, M.D., M.P.H., M.Sc.
Pediatrician and psychotherapist
Ex-Fellow, Child Development Unit - Boston Children's Hospital
Coordinator: Tobacco Prevention, Treatment, and Control Programs
Campinas and Hortolândia Public Health Departments - State of São Paulo, Brazil
The NBAS and Touchpoints, have much in common. There are similarities ranging from their shared theoretical concepts to their approach to evaluation and intervention. Because they have so much in common, I suggest that we view them as part of the same evaluation and intervention family, in terms of their origins (Dr. Berry Brazelton, the Child Development Unit) and their clinical and research uses.
The relationship between the NBAS and Touchpoints began to be clear to me when I first contacted Berry Brazelton and the CDU staff at Longwood Avenue back in 1981. My first contact with Dr. Brazelton and his colleagues was in those surroundings, although I had been sensitized to this approach through Berry's scientific papers and family-oriented publications back in Brazil. Staying in and around the CDU from 1984 through 1996 as a Fellow in the 80's and, later, as medical director and evaluation coordinator of the "Healthy Connections" program at Boston Children's Hospital I observed some correlations between the NBAS, Touchpoints, and family lifestyles. The extraordinary opportunity created by the CDU/Harvard Medical School/University of Massachusetts Smith-Richardson Fellowship empowered us with the knowledge and experience that we needed as health professionals to positively impact families with children. Although the fellowship focused on mother-infant early attachment using the NBAS, it clearly introduced us to the Touchpoints concepts and its evaluation/intervention uses.
Healthy Connections a program that was conceptualized, designed, and started at the Children's Hospital, Boston in 1991_focused on lowering preventable infant morbidity and mortality rates in specific Boston neighborhoods by enhancing access to and utilization of primary health care and prevention programs. Healthy Connections articulated clinical and administrative contacts between Boston Children's Hospital primary care programs, newborn services (at Beth Israel, Brigham and Women's Hospitals, Martha Eliot Health Center), and community-based organizations. For the 2,337 mother-infant dyads served, our program showed statistically significant improvements on five variables:
- Parents were more likely to keep their 1 month appointments;
- Parents were also more likely to keep their 2 month appointments;
- There was a reduction in emergency department visits prior to the first pediatric primary care appointment;
- More perinatal forms were filled at the first pediatric primary care appointment;
- There was a higher six-month immunization rate.
Now, what has this and NBAS/Touchpoints to do with... tobacco? To oversimplify it: where there's smoke, look for fire. In the Healthy Connections study, we discovered that the first stages of development, which include predictable and universal developmental spurts and regressions, as summarized in the Touchpoints approach, provide health care professionals with a remarkable opportunity to respond to emerging questions and concerns brought by families.
The consumption of tobacco products by family members tends to be a family stress marker in the U.S. and in Brazil, whether the consumption is passive or active, at home, work, or elsewhere. This is even more the case when the mother eats poorly during pregnancy. Malnutrition in the developing fetus adds to its vulnerability to this insult. These babies can be at high risk for abuse or neglect and for failure to thrive. In our pediatrics, psychotherapy, and tobacco-related experience, fetus, child, and adolescent passive smokers, with their tobacco-related multiple health consequences, are related to distress in varying degrees in family dynamics. Sometimes some of these children or adolescents are already active smokers themselves. This important window into family attitudes, practices, and behaviors is frequently brought home to us during prenatal and well-child visits, although rarely in explicit ways. As a result, Touchpoints-based approaches have been used in programs we have created in the Campinas (state of São Paulo, Brazil) area in tobacco prevention, treatment, and control programs.
I suggest we ask about tobacco smoking during routine and emergency medical visits. These are unique opportunities for families: they are looking for our advice in their search for better child health outcomes, mainly during developmental spurts and regressions like the ones described in the Touchpoints model. It is a brief intervention lasting around three minutes beginning with prenatal appointments. This approach may start with questions like: "Who smokes at home or near it?" or "Does your child stay near people who smoke?" These contacts, when families are hoping for a warm and interested response to their child-related concerns by the doctor, may result in a life-long benefit for all family members by inducing their reflection about smoking. Raising the issue of tobacco use with the families brings the message home to them that, "yes, this is a very important component for your child's health" and may induce the family to transition from contemplation to action. Our professional position has the potential for changing family behaviors, when we, as health professionals, establish a trusting and respectful relationship with the families. Left unchanged, these behaviors have long-lasting, devastating health consequences. Tobacco is the only product that, when used as recommended by advertisements, is lethal. Extending our professional involvement into passive and active tobacco use is definitely another benefit to families, which, in our work in Brazil, was inspired by the NBAS and Touchpoints models.
- Brazelton, T. Berry, and J. Kevin Nugent. Neonatal Behavioral Assessment Scale. London, England: Mac Keith Press, 1995.
- Brazelton, T. Berry. Touchpoints: Your Child's Emotional and Behavioral Development. Cambridge, MA: Addison-Wesley, 1992.
- Brazelton, T. Berry, and Joshua D. Sparrow. Touchpoints Three to Six: Your Child's Emotional and Behavioral Development. Cambridge, Mass.: Perseus, 2001.
- Becker, Mario, Judith S. Palfrey, and Paul H. Wise. Evaluation of a Program to Improve the Transition from Birth Hospital to Primary Care. Ambulatory Child Health. 1998; 4:189.
- Bra zelton, T. Berry, and Joshua D. Sparrow. Mastering Anger and Aggression — The Brazelton Way. Cambridge, Mass.: Da Cappo Press, 2005.
- Brazelton, T. Berry, and Joshua D. Sparrow. Toilet Training - The Brazelton Way. Cambridge, Mass.: Da Cappo Press, 2004.
- Becker, Mario. Active and Passive Tobacco Use: Early Preventive Interventions with the Pregnant Woman, the Child, and the Adolescent (Tabagismo Ativo e Passivo: Intervençes Preventivas Precoces com a Gestante, a Criança e o Adolescente). 6th International Symposium on Tobacco Treatment. Rio de Janeiro, Brazil: November 9, 2002.
- Rosemberg, José. Nicotine: Universal Drug (Nicotina: Droga Universal). São Paulo, Brazil: SES/CVE, 2003.
- Centers for Disease Control and Prevention. Management of Nicotine Addiction. Washington, DC: US Government Printing Office, 2000.
- Rigotti, N. A., Arnstein, J. H., McKool K. M. et al. Efficacy of a Smoking Cessation Program for Hospital Patients. Archives of Internal Medicine. 1997; 157:2653.
For references and further information please contact:
author at firstname.lastname@example.org