As pediatricians, almost everything we do to foster health and well-being of children depends on each child's caregivers, the parents. This is true for all the physical health problems and solutions before adolescence, because we rely on parents to become concerned, call, bring the child in, communicate symptoms, consent to our suggestions for evaluation, and to administer treatments. Parents go far beyond being the mediators of treatment. They are the central force promoting the child's development and psychosocial well-being, and this is especially true in the first 5 years, before formal schooling begins its impact. Psychosocial problems, once called the "new morbidity," are by far the most common sources of morbidity and mortality for children in the United States. Diagnosable mental health problems have been estimated to affect from 17% to 22% of children. Homicide and suicide, the two leading causes of death for school-aged children, do not occur randomly among children; the parenting these children received from early on can play a major role in establishing patterns of aggression or depression, and these can predispose such tragic outcomes. Thus, much of what pediatricians can do to alter the course of psychosocial risk factors is through impact on the parenting the children receive.
It is clear that a large range of parenting styles can result in positive child outcomes. However, some general parenting behaviors are known to promote development and others to be detrimental. Our pediatrie training may or may not have included information about the parenting factors that affect development but our concern for children stimulates us to intervene in many cases anyway. Unlike treating infectious or other diseases, we may find ourselves giving advice regarding parenting based on how we were patented rather than from factual knowledge. This edition of Pediatrie Armais is designed to help fill that information gap and provide references for further study. It includes articles discussing the impact of parenting on child development and the different types of parenting interventions (Regalado and Halfon, pp 31-37), the importance of fathers and how to promote their role (Yogman and Kindlon, pp 16-22), a schema for anticipatory guidance of parenting during health supervision visits (Stumer, pp 44-50), the diversity of family types and suggestions for adapting to them (pp 38-43), and the role of the pediatrician in dealing with troubled parents (Krugman and Wissow, pp 23-29). We must not forget how subjective we may become in dealing with parenting issues, however. The remainder of this introduction concerns the mutual impact of our own patenting experiences and our work as pediatricians.
THE EFFECT OF NOT BEING A PARENT ON BEING A PEDIATRICIAN DEALING WITH PARENTING
Pediatricians who are not parents miss a potentially important source of information. They know less about the normal range of behavior based on mundane daily experience. It is difficult to teach a pediatrician how hard it is to brush the teeth of an unwilling child and how much frustration this situation can elicit. As a result, pediatricians without children may have unrealistic expectations for families and find it harder to institute changes and express appropriate empathy to the difficulties of parenting. The chilling question so many young pediatricians face - "Do you have children?" - is sometimes a clue that their suggestions or degree of empathy were not hitting the mark with the parent. The pediatrician who is not a parent has a special need to acquire a fund of knowledge of child behavior and development. This includes a progressive accumulation of experience from other families and an approach that includes good listening skills and a family-oriented problem-solving strategy. On the other hand, pediatricians without children may be more objective in their evaluations and treatment and are likely to have more time and energy to devote to their profession.
THE EFFECTS OF BEING A PARENT ON BEING A PEDIATRICIAN DEALING WITH PARENTING
There are hazards, too, in being a parent and a pediatrician. We have an obligation to ensure that our management of the families in our care comes from professional objectivity and not as a reaction to similar issues in our own lives. We should individualize our advice to our patients and base it on scientifically sound information rather than what we "learned" from how our mother handled things or what worked for our children. If we over- identify with characteristics of our patients' parents, we will be less objective and can ignore signs of real problems. We may take sides when neutrality is needed, as for example in a divorce situation. If we over-identify a child in our care with one our own children, we may become too emotional to be objective. To ward off our own anxiety, we may downplay the seriousness of a condition.
Pediatricians' careers also affect their parenting roles. Many become parents at older ages as a result of years of training. Those who have children during training are constrained in the amount of time and energy available for their families. A survey of spouses revealed that time and energy is actually even less available once the physician attains a staff position.2 Some children of pediatricians express jealousy that their parents are away to care for children other than themselves and may focus on physical complaints to gain attention. Spouses may expect above average involvement and skill for parenting because of the pediatrician's chosen field and be resentful when this is not the actuality. The pediatrician my feel demoralized professionally when he or she handles problems at home in a less than ideal way. Spouses are generally unaware that pediatrie training includes very little or no instruction in dealing with normal chilien. The pediatrician's reactions when his or her own children become ill is also likely to be affected by their training. Many treat their own children's illnesses, although this is not recommended because of its effect on the parentchild relationship and the potential for lack of objectivity about possible diagnoses or need for tests or treatment. When the problems are behavioral or emotional, shame and a sense of failure can interfere with having another physician assrss the problem or provide treatment.3 Embarrassment can also occur if children display problem behavior in public. There is pressure for the pediatrician to be a good model of parenting behavior as well as for his or her children to behave well.
One benefit of working as a pediatrician is rarely discussed. It is the profound way this enriches us as human beings and as parents. We are forced to reflect on how we are raising our children as we see the wonderful richness of others' ways of doing it. We often get ideas for management, equipment, or just toys. We can use these ourselves and pass them on to other families. Sometimes, we even recognize our own practices as maladaptive strategies when we see them performed by others. Our advice to them may become advice to ourselves. Our empathy with their pain may become self-comforting. By our special privilege of learning the intimate details of the lives of the families in our care, we have the opportunity to reflect on our own past and relive the development of our own children. By observing hundreds of children, sick and well, we are reminded daily about how precious our own children are, how fragile and how strong, how quickly they grow up, how much they need us, how much of their behavioral struggles are part of each stage of development, and how each has a special uniqueness.
1. Costello EJ, JaniaewsUi S. Who gets treated? Factors associated with referral in children with psvchiatric disorders. Ana Psychiarr Scand. 1990$ 1:523-529.
2. Olsen R, Sande JR, Oisen G. Maternal parenting stress in physicians' families. CIm Peiotr. 1991 ;30:586-590.
3. Vaillant GE, Sobowale NC, McArthur C. Some psychological vulnerabilities of physicians. N EngU Mei 1972;267:372-375.