The Touchpoints approach to well-child care for infants and young children, based on the work of T. Berry Brazelton, M.D., is a means of improving the practice of a variety of professionals who work with young children and their families--pediatricians, office receptionists, nurse practitioners, child development specialists, early interventionists, eligibility workers and child care providers--anyone who, as part of the system of child and health care, can play a role in supporting parents in the job of caring for their children. The Touchpoints approach, articulated over the course of the last four years at the Touchpoints project and now embodied in two training models, consists of two major components--a particular view of early development and an emphasis on the relational aspects of practice.

Touchpoints' view of early development describes the development of the child in the context of the family as a discontinuous process in which there are predictable spurts and regressions in development (e.g., disruptions in the child's sleeping routines as related to cognitive and motor advances at 9 months). We have further outlined, based upon Dr. Brazelton's original work, the major developmental themes and opportunities for practice at each predictable Touchpoint in the first three years of life. This model is seen as an alternative to conceptions of development that are represented by a continuous series of milestones that are internal to the child.

The behavioral disorganization that results from temporary regression in a child's development can extend throughout the family. This may have positive or negative implications for the child and family. Increased energy for development can result from the reorganization that occurs in response to such disorganization, or a pattern of failure to resolve behavioral disorganization can be established. Hence, the Touchpoints developmental model also recognizes that the child's development is intimately related to the meaning the child's caregiver applies to various developmental events within the context of caregiving. That is, we maintain that along with and strongly affecting the process of development in the child there is a parallel process in the parent. Touchpoints practice requires an understanding of both of these processes.

The second major component of Touchpoints is relational. Knowledge about the forces of development and awareness of parent's inner lives are the foundation of the approach. However, without thorough consideration of how relationships with families are made and maintained, such understanding is of little practical use. It is only through the relational aspects of practice that this developmental understanding can be put at the service of children and families. At the core, Touchpoints is a means by which practitioners join parents in the system of care around a child. We enter into a collaborative alliance with the parents in which both professional and parental expertise is acknowledged.

The relational model describes how the alliance with the child and parent(s) is established. Elements of this model include a number of maxims or principles which have emerged from our work on describing a responsive and competent model of care. Use of each of these principles of practice is emphasized in our practitioner training.

Principles of Touchpoints practice

• Value and understand the relationship between you and the parent
• Use the behavior of the child as your language
• Value passion wherever you find it
• Focus on the parent child relationship
• Look for opportunities to support mastery
• Recognize what you bring to the interaction
• Be willing to step outside of your disciplinary boundaries

The Touchpoints Project aims to affect practice at two levels. First, we want professionals to refine their own skills through adoption of the Touchpoints developmental and relational models. Second, we want to affect the systems, such as hospitals, agencies, and communities, within which professionals work. Touchpoints faculty, including T. Berry Brazelton, John Hornstein, Constance Keefer, Maureen O'Brien, Ann Stadtler, and Edward Tronick, train both individual practitioners and teams of practitioners from community sites at separate trainings.

During the training week we focus on helping practitioners understand and use the Touchpoints principles. Through facilitated role play, live and videotaped family-practitioner interactions, presentations, and discussions, providers learn clinical applications of the Touchpoints model. They receive curriculum materials covering child development information and communication strategies around each Touchpoint. And, in the subsequent year of follow-up, which consists of a site visit as well as frequent communication and consultation, we support these practitioners as they teach other practitioners in their community about the Touchpoints model.

Enriching work with individual families through the Touchpoints approach

Adopting the Touchpoints approach to practice can take many forms. As a result of Touchpoints training, a nurse practitioner may focus more on the agenda that a parent brings to a well-child visit, a pediatrician may be more able to use the baby's behavior as a means to establish a relationship with a parent, and a child development specialist may provide more meaningful documentation to other practitioners working with a family. At the community level, practitioners from various disciplines may use Touchpoints as a foundation upon which to construct a common philosophy for service delivery and begin to use a common language in establishing greater continuity of care for families.

As we work with community sites around the country we continue to elaborate and refine the approach, as well as discover new elements of practice that are affected by its adoption. Community sites currently include Greenville, SC; Napa, CA; Decatur, IL; Mercer County, PA; Schaumburg, IL; San Mateo, CA; Minneapolis, MN; Austin, TX; and The Dalles, OR, Racine, WI, Grand Haven, MI, and Gallup, NM. A vignette from Decatur, Illinois illustrates practitioners' use of the Touchpoints approach and principles of practice to enrich their work with families.

The Baby TALK program in Decatur, Illinois is designed to serve all parents of infants and young children in their community of more than 100,000 residents. Initially supported by education grants as a means to promote child development and parent child interaction through reading, and staffed primarily by educators, Baby TALK has become increasingly integrated with the health care system. Baby TALK's involvement with parents begins with their participation in prenatal classes and newborn assessments. Baby TALK staff visit every new baby born in Decatur. They continue the relationship through a presence at clinics, pediatric practices, parent groups, and libraries.

Thousands of interactions such as the following vignette from Baby TALK's warmline telephone resource for parents, take place each year. Jan Mandernach, a Touchpoints trained educator at Baby TALK reported:

I thought of you [at Touchpoints] on Thursday when I received a Warmline call. The mother called asking about infant vision. "When will my one-month-old's eyes focus?" Before my acquaintance with you and your group I would have dutifully talked to her about newborn eye control, etc. Instead, I asked a few more questions and realized that there were significant issues there. Eventually I learned that she had nursed her two year old until the delivery of her new baby and couldn't bear to nurse him because she feared making the toddler feel rejected. So she's bottle feeding the baby and weaning the toddler at the same time, both of which are obviously very foreign to her. She feels that she is failing to mother both of them, and doesn't feel like a mother to the new baby at all. I realized that her questions about infant vision were related to her frustration on not making eye contact with the one-month old. She confided that the only communicating that her infant does is crying, and I suspected that there is a lot of that. She described herself to me as suffering from postpartum depression.

Needless to say I was on the phone with this mom for some time, concluding with my sending a letter and some materials and my own promise to call her back later this week. After our conversation, I looked up our documentation of our encounter with her on the OB unit ("Very receptive, but concerned about sibling adjustment and feeding issues"), and our documentation of our three-week Outreach phone call ("Cheerful, but concerned about sibling as well as issues of bottle feeding")

Why did she just now let down her guard enough to talk about the real issues? I have to conclude that her honesty with me was the result of her previous two encounters with Baby TALK through which she was convinced that someone was generously interested in her and her children. And I'm sure that I was willing to press a little bit deeper with her because of your work. When I said to her, "It almost sounds like you don't think that you are a good mother to your baby because you aren't breastfeeding him," she really opened up and I think we got some things done. I would never have said that before Touchpoints.

This interaction illustrates many of the principles we promote through Touchpoints training. In particular, it demonstrates valuing passion wherever you find it, focusing on the parent child relationship, and using the behavior of the baby as your language. Jan recognized early in this interaction that this mother's concerns were greater than those requiring knowledge about visual acuity in infancy. How did she know this? She probably did react, in part, to the mother's tone of voice. But, she also recognizes that many seemingly straightforward questions about development can represent deeper concerns. It was through her follow-up questions and the ensuing discussion that she unearthed intense feelings about the children.

What is important here is Jan's willingness to follow the passion. She sensed that there were larger issues and she let the conversation bring her to where the mother's real concerns were. All too often practitioners--whether they are pediatricians, child care providers or educators--end such discussions before they begin. They give a short speech about development and move on. Perhaps they are afraid of the emotions that they might unearth or of extending beyond the boundaries of their expertise. She did neither. She stayed within the bounds of her expertise as an educator, and she was able to manage the emotions that she encountered. The end result was an interaction which was probably more satisfying and productive for both the parent and the practitioner.

This interaction illustrates a second principle: focusing on the parent-child relationship. An implicit goal for Jan was to support the health of this relationship. As she was collecting data about eye contact and feeding, she was attending to the implications of these developmental and behavioral indicators for the parent-child relationship. It's as if she were following two tracks simultaneously. In many sports the best players are not only aware of what they are doing with the ball or puck, but at another level they are conscious of where all the other players are and where they are in relation to the goal. The goal here is to support the parent-child relationship, and the means is to use developmental information as the language through which this goal is achieved.

This last point is perhaps the most universal of all the Touchpoints principles. It is knowledge about the behavior of the child from which the practitioner derives credibility. It is the behavior of the child that is of utmost interest to the parent. And, it is the place at which parent and practitioner can focus their joint attention most effectively. Jan uses her knowledge of eye contact and feeding not as a demonstration of her advanced knowledge of development but as a means through which she and the parent can better understand the child and the issues facing this mother.

The next interaction between Jan and this mother will be based upon their shared history of addressing these issues. Having acknowledged the mother's self doubt in the first interaction, Jan may begin to focus more quickly upon another of the Touchpoints principles: support mastery wherever you can. Furthermore, Jan's efforts will lead to a stronger connection between this mother and the care system as a whole. This mother is not as alone in her parenting as she was before she called the Warmline.

Touchpoints groups

The Touchpoints approach applies not only to one-on-one interactions but also to group settings. In fact, the Touchpoints faculty has always valued parents in the development of our curriculum materials and conducted parent focus groups from the beginning of the Project (Stadtler, O'Brien, & Hornstein, 1995). Through organizing groups of parents with children of the same age (touchpoint), we reflect on and refine our thinking regarding the themes of the various touchpoints. The groups let us hear the voice of the developing parent, as well as giving us an opportunity to examine group dynamics, facilitative strategies, and the logistics of organization that best support collaboration between the parents and professional group leader.

As a way to practice pediatrics in a time-efficient and cost-effective manner, group well-child care is becoming a popular concept in primary care. Ralph Myers, a pediatrician from Napa, California, began group well-child care before coming to Touchpoints training. He initially saw group visits as a way to provide enhanced care, because he would have more time with his families and could provide them with much more support and information. After Touchpoints training, he sees less need to impart information and views the group instead as an opportunity to collaborate with parents, focus on their concerns, and use a valuable resource in his practice--parents.

By facilitating a group and focusing on common issues, Ralph helps parents learn how they can find support from him and from other parents. He uses the children's behavior--which they all can see, since both parents and children are present in his groups--to focus on developmental issues. Through the discussion of the child's behavior, he comes to what is meaningful to the parents. The information covered is at least as plentiful as before, but the needs of the parents now drive the agenda of the group. Ralph reports that parents are asking him different and more focused questions (about temperament and gatekeeping issues, for example) than they were prior to his new approach. He feels he is able to have a deeper relationship with families in his practice and therefore use his individual time with them more productively.

Ideally, all primary care settings could use the resource of parent groups, which can take as many forms as the interdisciplinary collaborative efforts that create and maintain them. Melanie Percy and Sharon Horner, two of the faculty from the School of Nursing at the University of Texas at Austin who attended a Touchpoints training, sent us the following example of how parent groups had been effective for them.

We have been meeting twice a week with teen moms in a support group format. We became involved with the teen support group initially because we were asked to establish a satellite clinic with the children of the teens. It did not take long to realize the mothers were not interested in seeing another stranger and discussing their problems or their children.

This has been a fascinating experience because we initially planned to discuss temperament and development with these mothers. But in the interest of building a relationship with these teens (and taking a Touchpoints approach to the group), we let these mothers take the discussion wherever they wanted. As a result we have discussed: "What was your birth experience, what was your baby like when he/she was born, what is he/she like now, how did your family react to the news that you were pregnant, what did you do then, how has having a baby changed your relationship with your parents, how are you like or different from your mom as a parent, how would you describe your baby, what is he/she like?"

In the three months that we have been running these groups, we have learned quite a lot about these mothers and had quite a few discussions about their babies' behavior. It wasn't exactly what we had planned to do but we needed to spend a lot of time nurturing these mothers, before they were ready to talk to us about their children and in many ways did exactly what the Touchpoints model suggests.

We focused on The teen mother's developmental levels in order to move to the development of their infants and young children. In the process we have been able to identify which mothers need more support in their parenting. We will be initiating a home visiting program with some of these mothers in the fall.

After two months of meeting in a support group format with these teens, I asked them to sign up for well-child exams so we could discuss their child's health and development in depth. I was shocked that all 12 of the slots available were immediately filled. If mothers miss their appointments with me, they ask the next time I see them if we can make it up.

This example describes how joining parents in groups and truly partnering with parents can enhance our effectiveness in primary care. The parents' eagerness to participate in well-child care is one measure of the success of the connection between these providers and parents. The professionals could have expended the same amount of energy in carrying out a non-responsive agenda, but they may never have reached these young mothers.

As individuals and community teams come for Touchpoints training, we, the Touchpoints faculty, are reflecting together on how parents' experience of coming together in groups can best be used both to support the parents themselves and to build a more responsive system of health and child care. The Touchpoints Project is currently developing a parent group manual for health care and allied professionals. This companion to our training manual will be designed to serve as a guide as well as documentation of our application of Touchpoints principles to parent groups.

Practitioner training and community site support

The above examples are gleaned from Touchpoints community sites. The practitioners reporting on their experience received training that included enhanced information about early emotional and behavioral development as well as strategies to establish effective, supportive relationships with families. In turn, we have built a long-term relationship with these sites, who want to bring Touchpoints to their care systems. This commitment extends from identification of the interested community, to the initial training in Boston, to the follow-up reunion at year's end and beyond.

Teams from community sites are made up of three representatives chosen by the local site with consultation from the Touchpoints staff. The teams often include: a coordinator with management experience and a position in the local service delivery system from which she can influence how health and early education services can be delivered, and a pediatric health care provider who is both willing to and capable of training others. The third person on the team may be from another field (e.g., early intervention, mental health, child care) or another health care provider. The make-up of the team reflects the community and sending institutions.

The week-long training in Boston consists of an intellectual and emotional immersion in the Touchpoints approach. It includes:

• didactic presentations of the developmental and relational models;
• demonstrations of the Touchpoints principles with children and families, with extended discussions of implications for the actual work of trainees with the families they serve;
• the use of role play and videotaped interactions to further focus on specific techniques;
• a large amount of reflection on trainees' progress and on the process of the training itself; and
• an orientation to evaluation, consultation resources, and training approaches.

Within the Touchpoints Project, we often talk about the parallels between parents and professionals -- how, for example, both groups have expertise and how both parents and professionals want to be competent in their ability to deliver care. We also discuss the importance of self-reflection and the power that this self-reflection can have over the ability to successfully negotiate relationships. For the parent of a resistant toddler or a public health nurse working with a challenging client (who may be the parent of a resistant toddler), reflection on her own experience of being parented may lead to awareness of how her own history may be influencing current relationships--a critical step in adult development.

Now after two years of training experience, involving dozens of individuals and 12 community "teams" outside Boston, we are also reflecting on our own development. As a Project, as individuals at different points in our careers, and as the liaison amongst all the Touchpoints-trained providers, we have reached a point at which reflection on "lessons learned" is a most worthwhile activity. Above all, we have an appreciation for the ways the Touchpoints Project has gone through a developmental process that is similar to our model of child development. The we think of the Project as our "baby" (and we do), we have seen periods of bursts, regressions and pauses in our development that mirror the process of child development. The regressions themselves often occur immediately before the Project takes a leap forward-for example, as we first extended Touchpoints training to providers outside of the health fields. While these periods of regression can be painful, if we indeed "value disorganization" as Dr. Brazelton always reminds us to, we are strengthened in knowing that its outcome will be further growth and development.

These Touchpoints at the systems level are not limited or unique to our Project, but indeed seem applicable to any organization that is undergoing change. In pediatrics, for example, the introduction of a developmental specialist or the restructuring of a clinic using the Touchpoints approach is bound to cause some initial disorganization. As long as the involved parties are able to articulate their feelings, have mutual respect for one another, and agree on their basic assumptions about parents, they can overcome these transitional periods and function at a higher level afterward.

As several of our sites have demonstrated, often the most opportune times to introduce new elements to an existing practice or to shift paradigms are during periods of ongoing challenges. For example, the transition to managed care has caused disequilibrium in many practices and institutions. A number of sites see this as an opportunity for growth. Establishing a common mission and a shared plan for accomplishing goals has brought together organizations and individuals, previously at odds with one another, with a new sense of motivation. The Touchpoints framework can provide a catalyst for community action in the era of managed care and other system changes in pediatrics (See Brazelton, O'Brien, & Brandt, 1997). Indeed, each training session fuels our energy to continue spreading the work that Dr. Brazelton began four decades ago.

We think of our training process as mirroring the Touchpoints model of development as well. Of note, we have learned to make this fact explicit with providers who come for training--"vulnerability is opportunity." Because we deal with sensitive issues for both trainers and trainees (such as our own contributions to relationships, our "ghosts in the nursery") and we challenge providers to shift their agenda in favor of the parents, we often elicit a great deal of emotional vulnerability during the course of our training. We are not surprised when experienced providers raise personal issues, take risks in role plays, and in other ways expose themselves as they discuss their work. We see this in parallel to and illustrative of the emotional energy that parents put into caregiving. Usually, this provides a perfect opportunity to model for trainees how families who are challenged within a system or are otherwise feeling vulnerable might feel and behave.

Another recurring theme within the Touchpoints approach that has taken on additional meaning in our trainings is the time spent focusing on the relational aspect of our work with families. Two core principles of Touchpoints practice are to "focus on the parent-child relationship" and "focus on your relationship with the family." During the trainings, therefore, we talk about the elements of making a connection with families, identifying markers of healthy relationships as well as recognizing when relationships are not going well. This concept of focusing on the relationship has also been extended to our own work with trainees, in particular the community-level training teams. During their week in Boston we forge a partnership that continues as these teams return to their communities and begin implementing the approach at home.

The elements of effective mentorship--reflection, regularity and collaboration (Fenichel, 1992)-are at the heart of our relationships with these sites. These elements too have a place in our thinking about relationships with families of infants and toddlers. Over the course of the year after trainees return to their communities, we provide ongoing support and nurturance as they address the complicated and challenging task of orienting others in their community to the Touchpoints model. This can take a variety of forms, depending upon the nature of the community and the self-defined needs of the site team. In some instances we have provided consultation on their training model or evaluation. In others we have actually carried out a training session or given a talk to community stakeholders. In all cases we make ourselves available as experts on the Touchpoints approach, as providers of resources with which to address local training needs, and as supportive colleagues who share our trainees' intellectual and ethical commitment to work with young children and their families.

In fact, we have adopted a family-oriented language to discuss our relationship with the site teams. We talk of the individuals trained in Boston as the "first-generation" trainees and the on-site trainees as the "second generation." We have instituted a system of incorporating experienced Touchpoints-trained providers into our site visits; they serve as older, experienced "siblings." A Touchpoints-trained pediatrician from one site, for example, will help link up the support of the pediatric community in another site. Continuing the use of "family" language, we call the return trip to Boston at the end of the year for community site teams the Reunion. And, like a family, practitioners in the growing network of sites are turning to one another for guidance in both structured ways (via internet at www.touchpoints.org and newsletter and in informal ways (chats at conferences).

We are discussing extending this relationship to include an annual gathering with all Touchpoints trained providers, so that they can continue to grow from the shared experiences of the growing Touchpoints family. This expanding Touchpoints network is a natural support system that fuels us all. Again, these elements of being there for the long run, being available through difficult periods in development, and learning from one another's experience parallel successful parent-provider relationships.

Lessons learned from training

Touchpoints is devoted to reinforcing the notion that providers need to take each family where they are and give priority to the family's agenda rather than their own. In order to model this assumption, we incorporate into our efforts to deliver the Touchpoints model as much flexibility as possible. Thus, no two trainings, like no two children, are exactly alike. Teams vary in their composition, individual participants' level of experience, and their level of working together prior to Touchpoints. As one would expect, these variables affect the training week. With such variability as a given, and with our recognition that there needs to be some organization to offset the disorganization, we have learned several lessons about our training.

1. Advance preparation is critical. Whenever possible, we advise upcoming community-level training team members to meet together prior to coming to Boston for training. We encourage them to agree on their goals and begin developing a timeline and a plan for their return to their sites. With the materials sent out in advance of the training, we include "homework" exercises, designed to help trainees begin to hone their observational skills around the newborn touchpoint. Our goal is to encourage the provider to understand the uniqueness of every infant, much as we would guide the parent of a newborn to understand her child's unique abilities.

2. Constant monitoring of our effect on and relationship with trainees is essential. During the training week itself, we include "check-in" periods at the beginning and end of each day to constantly monitor the pulse of the trainees. We examine the feedback we receive during the week very seriously and at the week's end and tailor the training accordingly. During the year after training, we use our site liaison role and site visits to deepen our relationship with the trainees as Touchpoints unfolds in the community. This model of mutual learning has allowed the Touchpoints training experience to flourish and has, in our minds, been the stimulus for great growth and development in our ability to deliver the Touchpoints philosophy. In terms of what this means to these individuals' practice with families, we have modeled the principle that sometimes our agenda is not the most important thing. Rather, understanding and being with the trainees' own feelings of crisis or challenge is an enormous source of support for them. By "holding" these providers and valuing their expertise, we are in fact modeling what we ask them to do with the families they serve.

3. We never underestimate the power of discovery in our understanding of children and families. We are continually amazed at the competence and energy that trainees bring to the trainings in Boston. Together, we are continually discovering new ways to observe, make sense of, and communicate aspects of child and family development. As a team we aim to model and engage trainees in this dynamic process.

Evaluation

Just as we, as providers, track families' growth and development, the Touchpoints Project tracks the development of practitioners and the community level sites. Our evaluation is based upon both qualitative and quantitative evaluation methods, and we are collecting both types of data. To date we have focused more on qualitative methods of information gathering-interviews with trainees, site visits, and observations of onsite trainings. We have gained insight into the various ways that practitioners have changed and how sites have incorporated Touchpoints into their systems of care. In addition to how application of the Touchpoints approach affects children and families, we are interested in how trainees from a variety of disciplines progress from novice to expert (Benner 1982) in Touchpoints practice and how community level teams meet their own personal, professional, and system-level expectations.

Each trainee enters Touchpoints training at a different point on the novice-expert continuum, which is based upon the developmental and relational knowledge and skills that we have outlined. As practitioners move through the training and begin to integrate its elements into their practice, we are using site visits and written vignettes to observe and assess trainees' depth of understanding of the Touchpoints relational model, as well as the explicit application of Touchpoints principles in their practice. We a re continually reminded of the need to understand development in dynamic relationship to the family context as well as of the profound importance of self-reflection in the change process.

At this early stage of evaluation, we have discovered that how the Touchpoints model is delivered in the communities varies according to three key ingredients: passion, scale, and clarity of vision. Passion refers not just to the individual providers' commitment to enhanced care to families, but also to the mission of making systems changes in their community. Scale is a critical variable to explore. Sites that have come for training thus far range from ones where the initial focus was on changing one agency's focus to communities where the goal is to incorporate Touchpoints into county-wide initiatives. While the larger the initiative, the greater the logistical challenges to implementing Touchpoints, the more important variable is the clarity of vision each team has for their community. While this vision is, ideally, sketched out prior to training, for some communities developing the vision, mission and goals is the first task the team tackles upon return to their site. Our site visits have demonstrated that less important than the timing of this goal-setting is the pace at which the team proceeds in order to maintain maximal integrity of the model.

In our model, we try to take each site where it is and value team members' unique strengths rather than compare sites directly to one another. Each site's developmental progression is different. Regardless of when it happens, though, we think that identifying and tracking the personal, professional and system-level expectations of providers involved in the Touchpoints training is an absolutely vital step in determining success at the community site.

Future directions and challenges

Touchpoints is a living, dynamic project, constantly growing in new directions. Both here in Boston and at our community sites, new applications of Touchpoints and refinements and extensions of the model are being developed. Three future directions that are particularly noteworthy at this point in our evolution are collaboration with other forces of change in primary care, developing improved methods of documentation, and integration with preservice training.

Collaboration with forces of change takes place at two levels. At the larger socio-political level we see the Touchpoints framework as complementary to many of the current initiatives, such as Building Bright Futures, Healthy Steps, and ZERO TO THREE's Developmental Specialist in Pediatrics Project, that aim to change the face of primary health care for young children and their families. As each of these programs matures, we plan to examine the common lessons that have been learned and where each approach is unique or strengthened by integration with another.

At the practice level, we are increasingly extending the Touchpoints approach to child care, allied health, and early education processionals. Most of our training content and materials emanate from a primary health care model, but practitioners from these fields are finding the framework highly compatible with their own innovations. Indeed the of Touchpoints is largely a language that has a common base in child development and relational approaches. Touchpoint principles apply to anyone working with families of young children. We will be attending more to training and materials that apply more directly to other disciplines as we continue to emphasize the importance of interdisciplinary collaboration in a seamless system of care for families.

Relationship-building strategies and the value of relationship in the care of families need to be reclaimed as an integral component of primary care. Increased communication among providers is one approach to enhancing seamless service delivery. Documenting relationship-based information alongside traditional "chart notes" (i.e., height and weight, physical condition) is a particular area in which Touchpoints is making a difference. Touchpoints-trained providers have reported that their notes were not taken seriously initially, but now they are being read carefully and used by their colleagues. Other providers describe how documentation of the newborn assessment is increasingly finding its way into the pediatric record, providing an important link, for families and the professionals caring for them, between the birth experience and the first pediatric visit . As we document the relationship clearly, we benefit all the members of the health care team. As a Project, we plan to increase our focus on documentation as a means of fostering a seamless and supportive system of care.

We also see Touchpoints as a model that can be useful in medical, nursing, and early education training. Often our practicing trainees lament that elements of the Touchpoints model were not included or emphasized sufficiently in their preservice training. Most recently, faculty from the School of Nursing at the University of Texas in Austin attended a community-level training with the plan of incorporating Touchpoints into their curriculum for the education of advanced practice nurses. The model will also be integrated into their wellness clinic and their community This school of nursing has an opportunity to make a significant impact on the education of nurses and their practice, as well as on the health care of a community. We will work with them over the next year to support them in their efforts.

Our ongoing challenge as a training initiative is to balance two equally important goals) making explicit the developmental and relational aspects of Touchpoints, and 2) ensuring that our model remains adaptable and flexibly incorporated into a variety of settings. Our experience with sites to date shows that Touchpoints principles are successfully being applied with Latino migrant families, middle-class families, single and two-parent families, and families of children with developmental delays. The model is also being imparted through the second-generation trainings to an array of practitioners, including WIC workers, child protective service workers, and child care providers. We are closely monitoring Touchpoints' applicability and modifications within these settings. Across the board, our sites are telling us that interagency collaborations have increased, a "shared mission" has united their communities, relationship-centered care has often replaced their previous information-driven style with families, and practitioners are bringing a more sophisticated understanding of development to their work with families. Such feedback is rewarding evidence that, across the country, Touchpoints is taking hold and enhancing the care families are receiving.

References

Benner, P. (1982). From novice to expert. American Journal of Nursing (March).

Brazelton, T.B., O'Brien, M., and Brandt, K (1997). Combining relationships and development: Applying Touchpoints to individual and community practices. Infants and Young Children, (10)l.

Fenichel, E. (Ed.) (1992) Learning through supervision and mentorship to support the development of infants, toddlers, and their families: A source-book. Arlington, VA: ZERO TO THREE.

Stadtler A., O'Brien, M., and Hornstein, J. (1995). The Touchpoints model: Building supportive alliances between parents and professionals. Zero to Three (15)1.

* The authors would like to acknowledge the support of the General Mills Foundation, the Mailman foundation and an anonymous foundation in Boston for their generous support to the development of the Touchpoints Project.

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