child is born too soon and weighs so little that she barely fills the palm of her father's hand. What care does she need to thrive? How does one change the lifestyle and diet of a chubby 12-year-old boy who spends his evenings mesmerized by television, mindlessly munching junk food? And how can violence in the family shape the character of a whole community? Harvard School of Public Health researchers are investigating these and hundreds of other questions at the core of keeping children healthy, fit, and able to fulfill their potential. Their contributions have touched nearly every phase of a child's life, from fetal development to adolescence.

A HEALTHY START
Good prenatal care as the key to reducing high rates of infant mortality has been a much-repeated maxim for decades. Yet, after 25 years of evaluating numerous prenatal interventions, Department of Maternal and Child Health Chair Marie McCormick draws a much more complex picture. Decreasing rates of infant mortality in the United States reflect the development of high-tech interventions to sustain the lives of increasingly more immature infants rather than the impact of prenatal programs, she explains. In her evaluation of Healthy Start, a national program to reduce infant mortality rates in America's highest risk communities, McCormick has determined that prenatal interventions do help to reduce illness in the infant and improve the mother's health. "We need to stop kidding our- selves about what is effective and what isn't," she says. "Each type of program should include rigorous assessment to determine which interventions actually have an impact."

One intervention that has made a "whopping difference" in both the development of the premature, low birthweight infant and its mother is the Infant Health and Development Program (IHDP), says McCormick. This long-term study measures the impact of three years of regular home counseling on how to enhance an infant's development, two years of free daycare center programs, and participation in a parental support group. Of the over 1,000 infants and their families in the study, the mothers of 377 infants received the three-year intervention; the other group was closely scrutinized, and mothers were referred to all appropriate community services. At age three, the first group of infants had significantly higher IQs, fewer behavioral problems, and no major illness; their mothers were less depressed and less likely to smoke. After five years, the differences between the intervention and control groups lessened. However, in follow-up studies with this group at adolescence, researchers found that although IQs were now similar, those in the early intervention group showed less delinquency and were more likely to finish school. "The critique of 'Cadillac' home interventions is that they are too expensive, but now we can show the cost of the programs may be weighed against the cost of jail days," she concludes. "It's a good argument for universal access to early childhood interventions and ongoing support throughout childhood, especially for disadvantaged families with biologically more vulnerable infants."

READING, WRITING, AND FITNESS
More than 20 percent of children and youth are overweight and already carry risk factors for America's most debilitating chronic diseases--from heart disease to diabetes. In response to these alarming statistics, researchers at Harvard have taken the lead to devise innovative school curriculums designed to improve the fitness and nutritional status of students. Eat Well & Keep Moving was designed for elementary school children by Lilian Cheung, director of health promotion and communication at the Department of Nutrition, and colleague Steven Gortmaker, whose research at the Department of Health and Social Behavior focuses on reducing the risks for illness and death in children. Gortmaker and colleagues Karen Peterson, Jill Carter, and Jean Wiecha, also developed Planet Health, a similar program for middle school students designed to fit inexpensively within existing school curricula and empower students to make healthier decisions about diet and activities.

Eat Well & Keep Moving was first implemented in six schools in Baltimore in 1995. Cheung and her colleagues found that students in the program ate less fatty foods and more fruits and vegetables, watched less television, and improved their knowledge of nutrition and physical activity. In addition, Cheung gives an enthusiastic account of the program's impact on the wider community--from school-sponsored Eat Well & Keep Moving nights with educational games and cooking demonstrations--to a walking club supported by teachers, parents, and watchful shopkeepers that reclaimed a whole neighborhood considered too dangerous for outdoor play. In times when schools focus on test scores and student performance in core areas, the program's interdisciplinary nature is a distinctive asset. Its popularity with school staff and innovative funding through the USDA's Food Stamps Nutrition Education Fund has led to widespread national interest and the prestigious Dannon Institute Award for Excellence in Community Nutrition.™ "Through the participants' incredible enthusiasm, these programs reach beyond our imaginations and develop a life of their own," says Cheung.

Planet Health's flexible integration into a wide range of school curricula has also been the key to the program's success. "In the past this information either came through the health teacher or not at all," says Gortmaker. Now, students in language arts class may write their own Public Service Announcements to promote eating five daily servings of locally grown produce, learn about the chemical composition of fruits and vegetables in science class, and chart and analyze their television habits in math class. The benefits of this creative approach was demonstrated in a randomized control study involving ten Boston-area middle schools. Researchers found girls were less obese and ate more fruits and vegetables; both boys and girls were more informed about healthy diets and activities and watched less television. Gortmaker elaborates, "Reducing inactive time in children isn't hard to do--kids aren't having fun all the time they're watching hours of TV. They need suggestions for alternative activities and clear limits on their TV time--a set in their room can add 50 minutes of television watching a day." The success of the program has led to its adoption in cities throughout the U.S. and in other countries. Both Planet Health and Eat Well & Keep Moving are now published and available nationally.

TROUBLED TEENS
To determine the origins of psychiatric disorders, drug use, and criminal behavior in adolescents requires a detailed examination of "multiple spheres of influence," says Stephen L. Buka, associate director of the Project on Human Development in Chicago Neighborhoods, involving both public health and medical school researchers at Harvard. "The earlier focus on the psychology of the mother and child was too narrow a perspective." The large-scale Chicago project has proven to be a gold mine of information on the health and well-being of adolescents, as researchers study families, peer groups, schools, and neighborhoods, integrating both social and behavioral sciences.

The multiple studies of residents in 80 neighborhoods have led to startling findings. Homicide, suicide, motor vehicle accidents, and intentional injuries have replaced biological illnesses as the most common causes of death in adolescents. Illnesses in adolescents are often the result of drug use, emotional problems, sexually transmitted diseases, and environmental asthma. Yet Buka and colleagues have also found "protective" factors that shield some children. "If children have a sense of community, trust, and a sense of participation in their school and neighborhood, they have fewer adolescent problems," he says. "As a result of these studies, schools are developing programs to foster these characteristics as early as possible." Colleague Beth Molnar's work on the relationship between family violence and violence within the community also highlights the complex network of interactions that shapes the lives of residents and the character of a community. In this seven-year study of 7,000 Chicago neighborhood families, Molnar found more parent to child physical aggression--anything from spanking to severe injuries--in highly disadvantaged, violent communities.

According to Buka, adding to the complexity of the picture is that the origins of some of these problems may even reach into the prenatal period of the child's development. Studies have found that exposure to nicotine in utero or to tranquilizers and sedatives during labor may change related receptors in the fetus, making it easier for him or her to become addicted to these substances later on. He concludes, "We have found that poor behaviors don't spring out full force at age 16--they have developmental origins. In our research, we want to determine the pathways that lead from risk to consequence so that we can intervene and reduce the key factors that threaten the health of individuals, families, and the community,"--a perspective that is probably shared by all of Harvard's scientists whose work helps children to grow and flourish.

Gabriele Amersbach