Pediatric Annals

Early Identification and Prevention of Unusual Child-Rearing Practices

Ray E Helfer, MD

Abstract

WHERE CAN HIGH-RISK PARENTS OR FUTURE PARENTS BE FOUND?

The term "high risk" refers to parents who are likely to have some type of difficulty with parent-child interaction, resulting in unusual child-rearing practices. There is both direct and indirect evidence that parents who are "at risk" make up a fairly large percentage of the population. A Denver study, not yet completed, screened for possible parenting problems 400 women who came in for delivery of their babies at the University of Colorado Hospital. Approximately 25 per cent of the women were identified as "high risk." When one considers that approximately one in six adolescents wül have some contact with the juvenile court before reaching adulthood, the 25 per cent figure does not seem to be too far removed from reality.

Although parents who are likely to have problems in bringing up their children can be found everywhere, the implementation of an inexpensive, efficient screening program necessitates the identification of at least one place where these potentially high-risk parents or future parents might be found in large numbers. There are three times, in the life of parents or future parents, when they are readily accessible for a mass screening or mass intervention program: first, during the future parent's school years, particularly at the junior and senior high-school years; second, when the pregnant woman comes in for prenatal care or delivery at a hospital; and third, when the parents bring their child to the school system at age five or six to begin the mandatory educational program.

The concept of developing an early recognition and prevention program for unusual rearing practices precludes the use of families whose children have already reached the age of five or six years. By the time the child has reached the age of five and is ready for formal schooling, a good deal of child rearing has already taken place. It would seem likely that utilizing this period to screen out high-risk families is acting too late for truly preventive programs to be helpful. This does not mean that families with rearing problems with their five-year-old children should not be helped; but these would be afterthe-fact services rather than preventive services. While it is important to identify results of unusual rearing practices for "after-the-fact" familydirected services, this segment of the population is not suitable for screening.

Children in elementary and high school present an additional challenge because of their ready accessibility. The use of the school system to introduce parenting skills and childdevelopment material is intriguing. While this idea is not unique, it is clearly one that has not gained the wide support it needs. All children should be taught these skills, not just a select few. The precedents are there, driver education being clearly established in the curriculums of many educational programs.

Those who are most available to be screened are pregnant women coming to offices and clinics for prenatal care and subsequently going to the hospital for delivery. When parents are identified to be in the "high risk" category, they must be offered an intervention program to assist the mother, her baby, and her mate in improving their child-rearing capabilities.

Another important ethical question must be raised. Should we limit a screening program to that group of pregnant women who are most accessible - i.e., those using the public hospitals and clinics? Categorically no! We have no good evidence that women who use private practitioners and hospitals have fewer problems with child rearing than those who are less well off financially and use public facilities. Care must be taken to assess all groups in a screening…

Unusual child -rearing practices are manifested in a variety of ways. While overt physical abuse (i.e., the battered child) and serious neglect of a child generate a good deal of public attention, there are thousands of children with behavioral disorders, learning problems, hyperactivity, withdrawal, and the like who are products of bizarre rearing patterns.

For a variety of reasons, the ability to distinguish a group who will physically abuse or seriously neglect one or more of their children will probably never be possible. The screening methods that are available can only identify parents who may have a potential problem with parent-child interaction. How this problem eventually manifests itself depends on a variety of circumstances, such as availability of a supporting spouse, financial stability, presence of an extended family, educational experiences, friendly neighbors, an easyto-care-for child, etc.

What is possible, however, is the ability to identify "at risk" parents or future parents who themselves had unfortunate childhood experiences that may be manifested by unusual child rearing as they become parents. These rearing practices are likely to produce children who will eventually be brought to helping professionals for a variety of problems, from a behavior disorder or overt physical abuse to learning problems or delinquency.

Early identification programs seek to screen for those parents who are more likely to have problems with parent-child interaction than the general population. The prevention counterpart of the screening program attempts to intervene with educational and training experiences, thereby modifying or eliminating the basic causes of unusual rearing practices that produce children with a variety of difficulties.

A COMPARISON

Drawing an analogy with a "serious disease model" makes the history of child abuse and neglect a bit easier to understand. During the early and middle 1950s, children with cystic fibrosis presented to physicians with the most severe, morbid state of this disease. Growth was slow, lungs were infected, nutrition was poor, and death was imminent. As experience was gained and research progressed, this disease became better understood, and treatment became available to modify the problem and to help these children. Then diagnostic methods were developed that allowed the problem to be recognized earlier, when much of the irreversible pathology could be prevented. Methods are now being studied for intrauterine diagnosis, offering yet another approach for control of this disease: The past 20 years not only have provided a better understanding of the early recognition, treatment, and possible prevention of cystic fibrosis but also have permitted understanding and knowledge in more basic areas - i.e., pulmonary physiology, pharmacology, microbiology, and genetics. Thus, an indepth study of a disease that originally occurred in severe, fatal form some 20 years ago has led to an improvement in the outlook for the disease, as well as to a better understanding of a whole host of related problems.

Similar stories could be told for other diseases - e.g., polio, cholera, diphtheria, and measles. The sequence of events is almost always the same:

Step 1. The most serious form of a given disease is recognized.

Step 2. Nonspecific and supportive treatment programs are developed.

Step 3. Concurrent research into its causes takes place.

Step 4. More specific treatment programs are initiated.

Step 5. Expansion of the concepts of the problem to related areas occurs.

Step 6. Research is conducted on early identification and prevention.

Step 7. Screening and prevention programs are initiated.

This natural history is very similar to what has happened in the area of child abuse and neglect. Step 1 occurred in the late 1950s and early 1960s with the recognition of the "battered chiW»"* Step 2 began with the start of intervention by child protection programs. Concurrently, intensive studies (step 3) developed to explain this problem, which had been with us for many years but for a variety of reasons had gone unrecognized.1 Once a better understanding of the causes became known, step 4 - i.e., more specific treatment programs - could be initiated.2

Progress seems to be somewhat bogged down at step 4. The implementation of what is known to be effective in helping families who are abusive or neglectful requires the cooperation of a variety of professionals and disciplines. These individuals heretofore have had little contact with one another; the result has been poor understanding and communication and a general lack of trust that precludes easy and rapid development of cooperative therapeutic endeavors.3,4

While some communities are struggling with step 4 (and others are still stuck at step 2), steps 5 and 6 are taking place in a few areas of the country. In the minds of some, child abuse and neglect is no longer an entity unto itself but is, rather, a severe manifestation of unusual childrearing practices that appear to be widespread. Expansion of the concepts of child abuse and neglect (step 5) requires a deeper understanding of the effects of these unusual rearing practices on the child and his or her family. When one realizes that many children who should be experiencing normal growth and development are subjected to less than acceptable rearing methods, it becomes apparent that a thorough understanding of the phenomena of early child development is necessary for full comprehension of the effects of bizarre rearing practices on the developing child.5 Once this has been achieved, step 7, the initiation of screening and preventive programs, can begin.

THE CONCEPT OF SCREENING

Frankenburg has clarified the concepts of screening and established basic guidelines for those wishing to move into this field. These guidelines are appropriate whether or not one is screening for lead poisoning, sicklecell disease, or unusual child-rearing practices. He identifies several areas of importance and provides us with some key definitions.6

Frankenburg places strong emphasis on the need to assure that any screening method has both sensitivity and specificity. Sensitivity is the degree of accuracy of a screening test in correctly identifying "high risk" subjects. Specificity is the degree of accuracy of a screening test in correctly identifying "low risk" subjects. The guidelines set forth by Frankenburg must be strictly adhered to if a screening program is to be useful for any group in which a potentially serious problem exists.

There must be certain further considerations. Is it ethical to delve into people's family and personal lives to predict how parents or future parents are going to interact with their children? Do we have this right? Should the rights of some parents to remain uninvolved be paramount over the right of a child to be reared in a positive environment? Few question our "right" and responsibility to screen a pregnant woman for tuberculosis, high blood pressure, or syphiUs, but what about screening her for childrearing potential?

Eisenberg raises a fundamental question: Will the identification of a potential behavioral problem result in the creation of that or a similar problem? In other words, is this a type of self-fulfilling prophecy? "The behavior of man is not independent of the theories of human behavior that men adopt."7

These are difficult, but not unanswerable, problems. If one tries to establish a screening program for unusual child rearing in a local hospital, these issues will be quick to surface, some with almost tidal-wave velocity and emotion.

Considering the epidemic proportions of child abuse and neglect and the devastating effects that unusual rearing practices are having on our children and our society, some type of involvement must occur. Some will say that everyone should learn parenting skills. There is no question about that. Certain parents, however, need skills to a greater degree and sooner than others. This group must be found early and helped with persistent positive pursuit.

Regardless of how we feel about the ethical issue, one critically important fact remains. The great majority of parents, irrespective of how they were reared, want to bring up their children in a manner that will have very positive results. The motivations are there, and ways must be found to tap them.

Our attempts to develop screening programs have been met with cautious concern. The process of getting such a program underway requires slow, deliberate plodding by quiet, tactful, pleasant plodders. Doors to administrative and medical staffs must be open so that these plodders can come in and tread softly, always emphasizing the positive, helpful aspects of the program. Once the plodders are accepted, the program is underway.

Parents who participate in a program of this type must be not only fully informed but also assured of confidentiality. The approach that is taken in our studies does both. Those who are screened receive a signed copy of the "Guarantee of Confidentiality and Informed Consent" form (Table 1), and we in turn keep their signed copy in our locked files. A mutual agreement is thereby developed. While this is not a model for all research in this area, it serves as a sample of the informed-consent protocol that is mandatory in research studies.

Table

TABLE 1GUARANTEE OF CONFIDENTIALITY AND INFORMED CONSENT FOR SURVEY ON BRINGING UP CHILDREN

TABLE 1

GUARANTEE OF CONFIDENTIALITY AND INFORMED CONSENT FOR SURVEY ON BRINGING UP CHILDREN

WHERE CAN HIGH-RISK PARENTS OR FUTURE PARENTS BE FOUND?

The term "high risk" refers to parents who are likely to have some type of difficulty with parent-child interaction, resulting in unusual child-rearing practices. There is both direct and indirect evidence that parents who are "at risk" make up a fairly large percentage of the population. A Denver study, not yet completed, screened for possible parenting problems 400 women who came in for delivery of their babies at the University of Colorado Hospital. Approximately 25 per cent of the women were identified as "high risk." When one considers that approximately one in six adolescents wül have some contact with the juvenile court before reaching adulthood, the 25 per cent figure does not seem to be too far removed from reality.

Although parents who are likely to have problems in bringing up their children can be found everywhere, the implementation of an inexpensive, efficient screening program necessitates the identification of at least one place where these potentially high-risk parents or future parents might be found in large numbers. There are three times, in the life of parents or future parents, when they are readily accessible for a mass screening or mass intervention program: first, during the future parent's school years, particularly at the junior and senior high-school years; second, when the pregnant woman comes in for prenatal care or delivery at a hospital; and third, when the parents bring their child to the school system at age five or six to begin the mandatory educational program.

The concept of developing an early recognition and prevention program for unusual rearing practices precludes the use of families whose children have already reached the age of five or six years. By the time the child has reached the age of five and is ready for formal schooling, a good deal of child rearing has already taken place. It would seem likely that utilizing this period to screen out high-risk families is acting too late for truly preventive programs to be helpful. This does not mean that families with rearing problems with their five-year-old children should not be helped; but these would be afterthe-fact services rather than preventive services. While it is important to identify results of unusual rearing practices for "after-the-fact" familydirected services, this segment of the population is not suitable for screening.

Children in elementary and high school present an additional challenge because of their ready accessibility. The use of the school system to introduce parenting skills and childdevelopment material is intriguing. While this idea is not unique, it is clearly one that has not gained the wide support it needs. All children should be taught these skills, not just a select few. The precedents are there, driver education being clearly established in the curriculums of many educational programs.

Those who are most available to be screened are pregnant women coming to offices and clinics for prenatal care and subsequently going to the hospital for delivery. When parents are identified to be in the "high risk" category, they must be offered an intervention program to assist the mother, her baby, and her mate in improving their child-rearing capabilities.

Another important ethical question must be raised. Should we limit a screening program to that group of pregnant women who are most accessible - i.e., those using the public hospitals and clinics? Categorically no! We have no good evidence that women who use private practitioners and hospitals have fewer problems with child rearing than those who are less well off financially and use public facilities. Care must be taken to assess all groups in a screening program, even those who are hard to reach, before conclusions are drawn as to the likelihood that any given group should or should not be screened.

HOW CAN THESE PARENTS OR FUTURE PARENTS BE IDENTIFIED?

While the understanding of the underlying causes of unusual rearing practices is being clarified,1,2,8-10 the development of reliable and valid screening methods is still in an early stage. Research is progressing, and the preliminary results are encouraging. Eight years ago, attempts were begun to develop a child-rearing questionnaire to assist in the screening and early identification of parents who might have problems interacting with their children. This questionnaire has now been revised. A 50item technique is currently being tested for reliability and validity as a method of screening.*

Other screening assessment methods are also being studied. Detailed observations of mothers and babies in the delivery room are demonstrating types of behavior that appear to correlate with potential problems in mother-child interaction. Experience has been gained both in Denver and in Lansing, Michigan, in identifying specific verbal and nonverbal cues that mothers provide at the time of delivery as a means of foreseeing possible problems with future mother-child interaction. These studies are continuing and are most promising.** Observations of the mother and baby during early feeding experiences, and of the interaction of the father and the newborn baby during the first few days of life, provide key information that appears to be related to high- and low-risk parenting skills. Studies by Klaus and Kenneil at Case Western Reserve University have demonstrated that observing the feeding of an infant by a mother can be very helpful in assessing potential problems with mother-child interaction.11 Parke's work at FeIs Research Institute would indicate that fathers react to newborns much like mothers, and that they have been underestimated in their capability of providing positive experiences for newborn infants.12

Other methods of identifying parents with potential child-rearing problems have been adopted throughout the years even though they are less well documented. For example, teenage, addicted, and incarcerated parents are seen as being high-risk by many groups (and some state laws). Subjective reactions of nurses, doctors, and others in delivery rooms, hospitals, and clinics may tend to indicate potential parenting problems.

WHAT CAN BE DONE TO HELP?

Any discussion of preventive services will, by necessity, have to be speculative, since only minimal experience is available. The goal must be to improve family life and childrearing practices before the development of serious and often irreversible problems for both child and family. It is encouraging to note not only that this preventive approach has been effective in other fields and disciplines but also that the experience with after-the-fact services in helping abusive and neglectful parents is now extensive, and the results have been very encouraging.

From the theoretical point of view, what programs should be expected to work? The basic therapeutic approaches that are effective in the after-the-fact treatment of child abuse and neglect are at least a place to start.8-10 Only experience and evaluation will determine what modifications will be required and the expansions that will be necessary. The basic approaches include:

1. Skills and content learning in parenting and early child development

2. A vigorous approach to the teaching of trust in others, enhancement of self-esteem, and imparting the skills of developing friendships 3. A joint therapeutic approach to help the parents better understand, accept, and support one another 4. An extensive program to provide the children with age-related early childhood experiences both in the home and in the community 5. The teaching of methods of problem solving, crisis prevention, and resolution.

WHO IS TO DO IT? Departments of social services around the country cannot be expected to provide this preventive approach. They are charged with the responsibility for after-the-fact services for child abuse and neglect, but they have little precedent for early intervention. Unlike fire prevention, driver education, and public health, social agencies must usually wait for something to happen before they can offer services. Moreover, their tradition is to serve only poor people.

They do not have the staff, the experience, or the funding to proceed in this area. Where can we turn? The tasks must be assumed by others.

Several options exist; some or all should be available in every community.

1. The school system must be convinced or coerced to initiate parenting and early child development courses and skill-learning experiences for every elementary and junior and senior high-school student. If preschool programs (nursery school and day care) were associated in some way with the public school system, a natural "laboratory" experience would be readily available for these students. This as well as classroom work should make a significant advance in alleviating the present dearth of educational experience in parenting in the public school system.

2. The same public school system must add parenting and early child development programs to its adult education program. If we can justify basket weaving, speed reading, and cabinetmaking in adult education, we can surely justify child-rearing courses and experiences.

3. Hospitals must expand their prenatal education programs beyond the handicraft skills that are now being taught to include parenting skills. These courses must also extend beyond delivery for several months to provide a continuing experience for the new parents.

4. Likewise, hospitals must not only allow but encourage fathers to be in the delivery room and permit both parents to have physical contact with their baby within a few minutes after delivery. This contact should continue throughout the hospitalization, with frequent mother-fatherbaby interactions in the hospital room. If the baby cannot leave the nursery for some reason, the parents must be allowed to participate in the child's care in the nursery or intensive-care unit.

5. Hospitals must make available mother-baby aides to work with every mother and newborn to help them establish a positive bonding or attachment while they are hospitalized. These helpers could be either volunteers or staff members. Regardless of how it is resolved, a program to augment mother-baby bonding cannot be left entirely up to busy nursing personnel, who may not have time to spend with the mother and her baby. This task must be delegated to a specific person for each family.

6. Home visits should occur at frequent intervals after the discharge of the mother and baby. This could be done by specially trained volunteers.

7. We must expand health services, group practices in pediatrics or family practice, private social-service agencies, and schools to provide courses in child rearing. A number of parenting books and a few programs are currently available. Books by Haim Ginott, Lee SaIk, and Thomas Gordon are certainly high-priority reading. Unfortunately, each of these authors makes certain assumptions about background experiences that may not be true for many "high risk" parents, who may have difficulty in relating with their young children. Certain books and courses on parenting are like taking an advanced algebra course without having had elementary mathematics. There should be a "preliminary" course or primer for those who have had disastrous rearing experiences in their own childhoods in order to prepare them for the writings of these and other authors.

8. A network of home extension services (the old Ag Extension Program) has moved into nutrition programs. There is no reason why child-rearing and parenting skills cannot be added to the tasks of these capable existing workers.

The reader will be able to add many other options within his or her community. The cost of implementing any of these programs woulc Lv minimal compared with the ykKi particularly if those who are proviuc L these services have been identified through the screening programs as being most in need.

An ethical question is raised when one considers whether these instructional programs should be voluntary or mandatory. Little can be gained by forcing someone to learn something. If the screening assessment clearly indicates that a high-risk situation is present, a variety of efforts must be made to work with the parents to help them better understand the need to improve their parenting skills.

Finally, who might be helped by these programs? Clearly all parents and their children. Some wÜl need more help than others - i.e., those who fall into the "high risk" group of parents identified in the screening programs. These may be the most resistant, reluctant, and frightened group. Reaching them will be difficult, but it is possible with persistent, positive pursuit.

BIBLIOGRAPHY

1. Heifer. R. E.. and Kempe. C. H. (eds.). The Battered Child. Chicago: University of Chicago Press, first edition 1968. second edition 1974.

2. Kempe. C. H., and Heifer R. E. (eds.). Helping ffte Battered Child and His Family. Philadelphia: J. B. Lippincott Company, 1972.

3. Heifer. R. E., and Schmidt, R. Monograph on developing community programs for child abuse and neglect. In a forthcoming book to be edited by Drs. Heifer and Kempe and published by Ballinger Press in the spring of 1976.

4. Heifer. R. E. Unit V, "Self-Instructional Program on Child Abuse and Neglect." American Academy of Pediatrics. 1974.

5. Martin. H. The development of abused children. Adv. Pediatr. 21 (1974), 25-71.

6. Frankenburg. W. Pediatric screening. Adv. Pediatr. 20 (1973). 149-175.

7. Eisenberg, L. On humanizing of human nature. Impact of Science on Society 23 (1973). 213-223.

8. Making the diagnosis of child abuse and neglect. Pediatric Basics (Gerber Company publication). January. 1974.

9. Therapeutic approaches. Pediatric Basics, November, 1974.

10. Office of Child Development. "Diagnostic Process and Treatment Programs." Washington, D.C.: Department of Health, Education, and Welfare. 1975.

11. Klaus. M., and Kennell, J. Mothers separated from newborn infants. Pediatr. Clin. North Am. 17 (1970). 105.

12. Riegel, K.. and Meacham, J. (eds.). The Developing Individual in the Changing World. Volume II. The Hague: Mouton, 1975.

TABLE 1

GUARANTEE OF CONFIDENTIALITY AND INFORMED CONSENT FOR SURVEY ON BRINGING UP CHILDREN

10.3928/0090-4481-19760301-10

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