Pediatricians have the potential to play a major role in enhancing the involvement of men in children's lives. At the very least, pediatricians have become more aware of the need to obtain clinical data directly from fathers about child health and family adaptation and to include assessments of fathers as data necessary to good clinical decision making.
In this article, we will examine the myths and realities of the current involvement of men with their children, discuss the nature of fathers' involvement with infants and children of different ages, and hypothesize about the unique dimensions of the father-child relationship. We will also emphasize the importance of fathers' involvement on healthy child outcomes. Finally, we will identify the various determinants of fathers' involvement and the opportunities for pediatricians to influence that involvement. Because most of the research on fathers' involvement has been done with infants, this review will emphasize the father-infant relationship but, pending conflicting data, many of the principles can be generalized to older children.
Mass media tout the joys of fatherhood and suggest that the traditional uninvolved father as the breadwinner in the 1950s has been replaced by men sharing child care with working mothers in the 1990s. Historians doubt that the truly uninvolved father ever existed in large numbers, and current survey data suggest that the increase in men's involvement in their children's lives has been modest but real. Moreover, as more women work full-time outside the home and return to work sooner after the birth of the child, the relative proportion of child care done by fathers has certainly increased. Unfortunately, many fathers are not equipped for their expanded role. For many reasons, including disqualification by spouses, inadequate experience, and outdated notions of parenting practices, these men may fall short of their expectations. The pediatrician is in a position to offset many of these shortcomings and enable fathers to be both happier and more effective parents.
Mothers are the predominant caregivers, and fathers' involvement averages approximately 3.2 hours per day spent with the infant to about half that with adolescents,1 and this preponderance of maternal basic infant care has been replicated in other countries, such as Australia, Ireland, and Sweden.2
Recent data suggest that husbands of working mothers are playing a more active role in child care. During the past two decades, father accessibility to their children has tisen about 15%, although it is still only two-thirds that of mothers.1
In addition to the increased involvement of fathers with their children in intact families, there are other sides of fatherhood in less traditional and diverse social settings that have been less well studied: divorced noncustodial fathers, single-parent fathers, gay fathers, fathers of children of teenage mothers, older fathers, and fathers of varying ethnic groups (Hispanic, African- American, Asian, Native American). Although fathers' absence and nonpayment of child support are major social issues, a significant number of nonresidential, unmarried men remain involved with their children.3 This is true even among groups traditionally felt to be uninvolved, such as inner-city teenage fathers, especially during the infancy period. For example, in a recent study, two-thirds of African-American teenage fathers saw their 18month-old infants at least three times per week.4
Fathers' involvement with children can occur on many levels from simply physical presence or absence to a more differentiated presence that may involve direct interaction with the child (play, caregiving, or teaching), the potential availability for interaction, or alternatively assuming the managerial responsibility to arrange for the care of the child (eg, making lunches, washing clothes, organizing child care).2
COMPETENCE OF FATHERS AND INFANTS
Fathers have the capacity to be successfully involved with their child on all of these levels. Using infants as an example because fathers were once termed incompetent to care for them, we will describe the capacities of fathers and infants to interact with each other and to compare the similarities in behavior and psychological experience between competent fathers and mothers.
Studies of these similarities can be grouped into four developmental periods: prenatal, perinatal, early infancy (1 to 6 months), and later infancy (6 to 24 months). A brief discussion of each will illustrate the similarity of maternal and paternal competencies with infants.5 Because most of the studies were conducted in the United States, caution must be exercised in generalizing these findings. During the prenatal period, pregnancy represents a normative psychological crisis for women. During pregnancy, men also rework significant relationships and events from early life and out of this turmoil integrate their new roles as fathers with their previous roles as sons and husbands.
The occurrence of physical complaints during pregnancy is probably one manifestation of this turmoil, and such symptoms are present in men as well as women. Taboos and rituals, such as the couvade, both restrict and enhance the father's role in many cultures. In the traditional form of the couvade ritual, the father takes to bed during the woman's pregnancy, labor, and delivery, as a means of sharing in the experience. The remnant of this ritual in modem cultures is evidenced by the couvade syndrome in which men experience psychosomatic symptoms during their wives' pregnancies.
A well-controlled, epidemiological survey of patients seen by specialists in internal medicine suggests the clinical importance of couvade symptoms.6
Almost one-quarter of all men whose wives were pregnant complained of nausea, vomiting, anorexia, abdominal pain, or bloating even though a diagnostic evaluation uncovered no objective explanation for these symptoms. These men made twice the number of visits to physicians and received twice the number of medications as their controls, in part because the health provider never asked if the men's wives were pregnant. In other studies, as many as 65% of men complained of physical symptoms, which also included backache and weight gain, and described dietary changes and giving up smoking.
During the perinatal period, fathers are now almost routinely present during labor and delivery. In fact, husband support lessens the degree of maternal distress during this time. Fathers' descriptions of their feelings after having witnessed the birth are almost identical to those of the mothers: extreme elation, relief that the baby is healthy, feelings of pride and self-esteem, and feelings of closeness when the baby opens his or her eyes.
Fathers and mothers display similar behaviors when interacting with their newboms. They are equally active and sensitive to newborn cues during the postpartum period.7 Not only do fathers and mothers share the exhilaration of the perinatal period, but they also share the lows or the nonnative postpartum blues of this period as well (eg, more than half in the first few weeks postpartum report feelings of sadness and disappointment).
During the first 6 months of life, infants become increasingly social as they begin to smile and vocalize. One might suspect that these socially responsive infants are good elicitors of social interaction with fathers as well as mothers. Infants by 3 months of age successfully interacted with both mothers and fathers with a similar, mutually regulated reciprocal pattern as evidenced by transitions between affective levels that occurred simultaneously for infant and parent.5 Mothers and fathers are equally able to engage the infants in games (eg, episodes of repeated adult behavior that engaged the infants' attention).5 Infants by 11 weeks of age, and as young as 6 weeks of age, would interact differently with their familiar parents than they would with unfamiliar strangers as evidenced by difference in facial expressions, limb movements, and heart rates.5 In sum, the studies of fathers and young infants supported the hypothesis that fathers are competent and capable of skilled and sensitive social interaction.
Studies of the father-infant relationship with infants aged 6 to H months has focused primarily on the development of attachment as Bowlby and Ainsworth have defined it. These studies have asked questions such as, "Do infants greet, seek proximity with, and protest on separation from fathers as well as mothers?" Such studies provide conclusive evidence that infants are attached to fathers as well as mothers. By 7 to 8 months of age, when the home environment tends to be relatively low in stress, infants are attached to both mothers and fathers and prefer either parent over a stranger. It is helpful for pediatricians to communicate this knowledge to new fathers and encourage their involvement during this formative period. During the second year, most studies also show attachment to both mother and father. However, in part because mother tends to be the primary caregiver, the majority of infants show a preference for mother. Some data suggest that it is mainly boys who prefer their fathers because fathers engage them more actively.
Not only are infants attached to fathers, but the study of qualitative aspects of infant attachment to mothers and fathers using Ainsworth's "Strange Situation" has suggested that infants could develop a secure attachment with the father in spite of an insecure attachment with the mother. In sum, studies of father-infant relationship in each of these developmental epochs (the prenatal, perinatal, early infancy, and later infancy periods) demonstrate both the similarity of the father-infant and mother-infant relationship and the capacities of fathers and infants to interact successfully.
Regardless of the amount of time fathers spend with their infants, they are more likely to be the infant's play partner than the mother, and father's play tends to be more stimulating, vigorous, arousing, and state disruptive for the infant. In our studies of infant games during the first 6 months of life, fathers engaged their infants in tactile and limb movement games in which their behavior attempted to arouse the infant. Mothers more commonly played visual or verbal games in which they displayed distal motor movements that were observed by the infant and appeared to be attempts to maintain visual attention.5'8 For example, fathers play a bicycle game, alternately moving the infants' legs in a bicycling fashion or a tapping game in which they rhythmically tap the infant on the cheek around the mouth. Many mothers of 3-month-olds imitate the infants vocalization, "oohing and aahing" in response to the infants coos (initiating and responding, taking turns and pausing when the infant takes time to rest) or play visual games in which they engage in hand movements and gestures the baby can see without actually touching their infant. Studies of the games parents play with 8month-old infants show similar findings: mothers played more distal games, while fathers engaged in more physical games.7 With older infants, fathers often place the babies high up over their heads or place the babies on their shoulders, rhythmically moving the babies to and fro or up and down, usually eliciting joyful laughter from the infant.
Daniel Stem9 has suggested that the goal of such games is to facilitate an optimal level of arousal in the infant in order to foster attention to social signals. The more proximal games of infants and fathers may help the infant learn to modulate emotional arousal. These findings are surprisingly robust in that they have been replicated with different age infants in different situations. Fathers of newboms, while similar to mothers in most behaviors, tended to hold and rock their newborns more. In describing their reactions to holding their newboms, fathers described the importance of physical contact (eg, the feeling of the babies moving in their arms).
Differences in interaction between mothers and fathers and their older infants all involve play: fathers engage in more play than caregiving activities with 6month-olds and more often pick up their infants (8month-olds) to play physical, idiosyncratic, roughand-tumble games. By comparison, mothers are likely to hold infants, engage in caregiving tasks, and either play with toys or use conventional games such as peeka-boo. By age 2Vi, when parents were asked to engage the child in specific play activities, fathers were better able to engage the child in play. Fathers' play with their children was likely to be proximal (as was described for younger infants), physical, and arousing. Infants at age 8 months tend to respond more positively to play with fathers than mothers, and by age 2½ continue to prefer fathers as play partners. It is perhaps this unique role of father as vigorous play partner that explains some of the beneficial effects of high father involvement. For example, the ability of the father to sensitively challenge his child during play at 24 months of age has been significantly related to multiple indices of children's peer competence and adaptive coping strategies at age 16. m It is often useful for pediatricians to communicate to mothers the importance of fathers' role as play partner.
These differences in play and quality of vigorous stimulation are quite robust and persist even in studies of primary caregiver fathers in the United States5 and in studies of nontraditional fathers taking advantage of paternity leave in Sweden. It is interesting to speculate that these play differences may become less tied to gender as socialization of young children changes. It is important to note that in contrast to these play differences, the performance of caregiving tasks seems easily modifiable and closer in its relationship to role rather than to gender.
PATERNAL INFLUENCE ON INFANTCHILD DEVELOPMENT
Most of the data on the effects of father involvement have focused on the negative effects of father absence. Lack of an involved father is a risk factor for a diverse set of outcomes including behavior problems, poor academic achievement, and poverty with its associated problems.
Father involvement not only directly influences the child but also increases maternal social support and family income. Another role that fathers often play is that of liaison between the child and a wider social network. This expanded universe of contacts often has beneficial effects on the child. For example, the father's participation in school activities (PTA meetings and school conferences) can have a long-lasting effect on academic achievement and life success.
Effects of greater father involvement can be seen as early as the first year. For example, greater father involvement is related to higher scores on tests of cognitive development and better social responsiveness. Some important aspects of this involvement include the father's positive perceptions of the child in play, his provision of verbal stimulation, and his expectations of independence, especially for girls. Boys, on the other hand, may particularly benefit socially when the father is warm and affectionate.
In the preschool period, paternal nurturance is even more clearly related to cognitive competence. Although the data are somewhat thin, the beneficial effects of father involvement with older children have similar positive effects on cognitive and behavioral outcomes.
Other work suggests that pathological father involvement (psychopathology, substance abuse, violence) can lead to adverse outcomes such as cognitive deficits, conduct disorder, or other forms of psychopathology and increased risk for abuse.11 Other work has focused on the impact of the father-infant relationship on gender role identification. Fathers' absence, particularly prior to age 5, has been related to maladaptive masculine sex role adoption among boys and conflicted heterosexual roles among girls. Others have tried to understand the differential relationships of fathers with sons and daughters during infancy. This work shows that not only do fathers vocalize and play more with sons than daughters but that this is especially true for first-born sons.12
Fathers' involvement with high-risk, preterm infants may be even more important for infant outcome. Paternal visits to their preterm infants in the hospital more often involved play (than did maternal visits) and were significantly correlated with better infant weight gain and improved social and adaptive development at 18 months of age.13 In a longitudinal study, fathers of preterm infants reported doing significantly more of the caregiving tasks at 1, 5, and 18 months than the comparison fathers of full-term infants.14 Although father-infant play occurred less often and was less physically arousing with preterm infants than with term infants, there was a significant association between the father's ability to engage his preterm infant in play at 5 months and the infant's developmental outcome at 9 and 18 months postterm on the Bayley scales.14
In a national longitudinal study of 985 low birthweight preteral infants followed from birth to age 3, within the black ethnic subsample, high father involvement was significantly associated with improved cognitive outcome at age 3, even after adjusting for family income, neonatal health, and paternal age.3 These data suggest the importance of the father's role in influencing developmental outcome for preteriti infants.
DETERMINANTS OF FATHERS' INVOLVEMENT
Fathers' involvement can be influenced by numerous individual, familial, and societal of community factors. Individual factors include the father's relationship with his own mother and father and his efforts to compensate or alternatively model the involvement he had with his own father. The father's attitudes about caregiving and gender roles may influence his motivation, because men with less-stereotypic notions of male and female gender roles tend to be more involved with their children. The timing of entry to fatherhood may interact with financial or career stresses to influence father involvement, and pediatricians may be especially able to influence skill level by modeling or making available simple interventions.
Familial factors, most notably the marital relationship, is a major influence on rather involvement. High marital satisfaction has been associated with the quality of both parents' relationship with the baby. Heightened paternal feelings of competition with his spouse have been shown to occur after the birth of the infant, particularly if the father has a close relationship with the baby and the mother is nursing. Husbands of nursing mothers described feelings of inadequacy, envy, and exclusion, and the competition may actually undermine the mother's attempts at breastfeeding unless these feelings are addressed. Nonresidential fathers who are allowed to participate in decision making about child rearing tend to be more involved.
The importance of the family context for understanding the father's role has been illustrated by the fact that the mother-infant relationship is typically dyadic, while the father-infant relationship typically is triadic and involves the mother. In families in which the mother is at work all day, she actually spends more time with the infant in the evening, and this is associated with lower levels of father-infant interaction. Infants and young children frequently elicit competitive feelings from adult caregivers. Mothers may feel so in love with their young infant that they become reluctant to allow the father to share that relationship. Numerous factors may heighten their normal feelings, such as a mother's stereotypes about the maternal role, low self-esteem, or feelings about her relationship with her own father. Mothers who perceive their own fathers as having had a minimal role tend to be married to men who are highly involved in child care. Pediatricians can assist families to acknowledge their normal competitive feelings and help them explicitly negotiate a role for fathers that works for the whole family. The mother continues to influence a father's relationship with his infant even when he is not home, because the mother conveys a representation of the father in his absence that influences the fatherinfant relationship after the father's return.
Community institutions, such as schools and hospitals, cultural practices, economic constraints, and employment policies, such as paternity leave and flexible work schedules, all have major influences on paternal involvement. Stresses such as job loss may be associated with paternal depression, and, although this may result in additional free time for these men, they have adverse influences on both behavioral disorders in children and on the incidence of minor infectious illnesses.15
Changes in hospital policies and simple interventions may have dramatic influences on paternal involvement in childbirth. The changes in obstetric and neonatal services that encourage the father's presence during labor and delivery and in the nurseries have gone far toward reversing the separation and exclusion of fathers from their infants. Postpartum support groups for fathers document fathers' unmet needs for discussing their concerns and fears without being labeled aberrant. Several educational programs have shown that brief interventions with fathers in the perinatal period could influence their attitudes, caregiving skills, and knowledge of infant capabilities for as long as 3 months.12 Even simple instructions given to new fathers on bathing, changing, and feeding in the perinatal period can increase the amount of father-infant caretaking activity after discharge.
Demonstrations of neonatal behavior to fathers in the newborn period has been shown to influence paternal involvement for as long as 6 months. Eliciting visual and auditory tracking and social responses in newborns and explaining infant state differences and self-consoling abilities gives fathers an enhanced view of infants' competence and increase the fathers' confidence to remain involved. Such demonstrations can be done live or using videotape. Simple interventions with fathers of older children (instructing them to play with their 12-month-old sons 1 hour a day) are also effective. More prolonged interventions have been shown to improve the infant's competence as well. Changing our stereotypes about the relationship of fathers and infants probably requires educating children and adolescents about infants as part of a school curriculum in parenting education, and several boys' schools have initiated a fifth grade class in child care.
Opportunities for Pediatric Intervention
OPPORTUNITIES FOR PEDIATRICIANS
Pediatricians, because of frequent family contact at critical teachable moments, are in a unique position to facilitate father involvement. Examples of these ideas are summarized in the Table. During prenatal visits, asking the father questions about his own family, his opportunities for a flexible work schedule after birth, and his plans about circumcision conveys an important expectancy that he is an active participant in the baby's care and in pediatrie visit. At hospital visits, demonstration of the baby's visual and auditory alertness may convey to the father the reality of newborn competence and the availability for direct interaction with the father. Encouraging hospitals to offer newborn care classes (bathing, diaper changing) directly to fathers can enhance skill levels and promote confidence and competence that enhance involvement.
Fathers can be advised to participate in feeding the baby. Even if mothers are breastfeeding, most families want some flexibility in feeding, and after a month of nursing, fathers can feed one bottle a day without disrupting nursing.
Fathers are more often coming to office visits, and pediatricians need to use any opportunity to engage the father and reinforce his participation. Invitations to fathers to attend office visits where the pediatrician meets them either prenatally or in the hospital can be an effective outreach. Appropriate magazines and waiting room materials for fathers may make them feel more welcome, and evening and Saturday office hours may minimize conflicts with work schedules. It is often helpful to discuss and acknowledge that fathers can develop their own unique relationship with the child that may be somewhat different from the mother-child relationship. Differences in play styles and games with young infants between mothers and fathers are one example. In divorcing families, pediatricians can play an especially important role in advocating for the child's need to maintain a loving relationship with both parents in spite of conflict between ex -spouses. In families with children of unmarried teenage mothers, the pediatrician should not automatically assume that the nonresidential father and his extended family are uninvolved but can sensitively explore the nature of father's relationship with his child and facilitate it.
Fathers of handicapped or special needs children require special pediatrie outreach. These fathers are often expected by extended family members to be strong and invincible and moreover to rectify the situation and make the child well again regardless of how unrealistic that may be. The communication of complex information by medical professionals to these families makes it imperative that fathers be present, because otherwise the mother is put in the awkward position of translating information from physician to father.
Addressing behavioral concerns with children almost always requires meeting with both mother and father to understand the genesis of the problem and to devise any solution that the parents can implement in a unified way.
In summary, these are just a few examples of the importance of understanding the father-child relationship for more effective management of child health problems. The studies of the father-child relationship are beginning to fonti a basis for theorizing about the influence of paternal involvement on child personality development, health, and developmental outcome. Fathers can have a meaningful and direct relationship with their infants right from birth, and the pregnancy/parenting experience is a time of developmental transition for fathers as well as mothers.
Because father involvement is an important influence on healthy child outcome, it is important that the pediatrician facilitate father involvement. In part, this can be accomplished by validating the unique roles that fathers occupy.
First among these is the important role of the father as a vigorous play partner for the child, complementary to that of the mother, neither redundant nor competitive with the mother's role. Second, the father plays an important role as liaison between the child and the wider social community. Lastly, nonresident and nontraditional fathers play an important role in the child's life and especially need pediatricians' encouragement to remain involved.
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2. Umb M. The Role of the Father m Child Development. New York, NYi John Wiley; 1997.
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5. Yogman MW. Competence and performance of fathers and infants. In: Macfarlane A, ed. Prop-ess m Child Health. London; Churchill Livingston; 1984:130-145.
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9. Stem D. The ijtifrpfrsonal World o/ die infant. New York. NY: Basis Boob; 1985:189-190.
10. Kindler H, Grossman K. Longitudinal sequelae of father's sensitivity while challenging the child during joint play. Postet presented at the Society for Research in Child Development Biennial Meeting; Washington. DC; 1997.
11. Phares V. Fathers and Developmental Pijchojxuhology. New York. NY: Wiley; 1996.
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15. Margoles L. Help wanted. Pediatrics. 19S2;69:816.
Opportunities for Pediatric Intervention