Few would deny the importance of promoting the efforts of parents in raising their children. Parenting is a complex and dynamic process influenced by parental histories, particularly of their childhood relationships and current marriage, personalities, stresses, supports, and characteristics of their children.1 Rapid changes in our social institutions, in how families are constituted and supported, and in the nature of the challenges that parents face make the task of parenting a daunting effort. The promotion of successful parenting as a means of supporting and sustaining families has been a traditional role of many social institutions and public policies. Opportunities exist in the context of pediatrie care to participate in these efforts. To be effective in these efforts requires an appreciation of the determinants and complexity of parenting and a logical approach to its assessment and intervention.
Unfortunately, data are inadequate to outline a definitive approach to the assessment and management of parenting issues. However, given the need and interest in the topic and its potential public health significance, we outline possible strategies for the assessment of parents1 needs and examine some of the resources currently available for help with parenting.
Why should parenting concerns matter to the pediatrician? First of all, parents need and want help with parenting practices, particularly parents of young children. In a recent national survey of parents,2 many expressed a lack of understanding of the connection between their own parenting practices and their children's development, especially social and emotional development (approximately 60% of those surveyed). Fewer than half of parents surveyed felt adequately prepared for parenthood - the others expressing uncertainty about what to do, fear of doing something wrong, and feeling stressed. Ninety percent expressed a willingness to improve, even those who rated themselves as excellent parents.
Also, assessment of parenting has implications for developmental surveillance and anticipatory guidance. Many pediatricians grow to appreciate how the quality of parenting affects a child's development given their unique, longitudinal relationship with a family. However, most pediatricians have approached parenting from a limited "teaching" perspective through anticipatory guidance. Nonetheless, pediatricians are in a position to identify parents who have unmet needs related to parenting and who might benefit from a variety of interventions.
Figure 1. Quality of parenting.
Finally, families today confront a wide variety of challenges and stress - economic pressures, single parenthood, divorce, domestic violence, child abuse and neglect, to name a few. Societal pressures have forced striking changes in families and communities so that traditional supportive systems for parents are less available. Consequently, child rearing education, support, and guidance for parents are increasingly provided by extrafamilial, institutional resources.3 Most parents consider their pediatrie health care provider an important resource for information and support relevant to parenting.4
Parenting resources that address child development are as numerous and varied as the clients and locations they serve. Many resources have developed from grass roots activities in response to local needs. Formal programmatic approaches to parenting are based upon several models with many variations and combinations employed idiosyncratically at the local level. An important question in this era of evidence-based medicine concerns the effectiveness and outcomes from different parenting interventions. Unfortunately, while some approaches and interventions have been studied in university research settings, most have not, and very little outcome and effectiveness data are available from real world sites. Therefore, we will be selective in our discussion of parenting, focusing on issues and programs that we believe are representative and relevant to the pediatrician interested in addressing parenting issues. We will attempt to focus on programs and approaches that seem to work. We also discuss approaches to parenting assessment, strategies for addressing parenting issues in the pediatrie setting, and resources for parents of children who have behavior problems and special health care needs.
ASSESSMENT OF PARENTING
Quality of Parenting
Before addressing approaches to the assessment of parenting, it is important to discuss those aspects of parenting important to child development. Parents need to nurture and protect their children,5 they must provide a stimulating environment for them to not only grow but thrive,6 and they must prepare them for life in a social world.7 The quality of parenting has a significant impact on all aspects of development, particularly socioemotional development.7'9 Two aspects of parenting that affect social competence are parental sensitivity and the character of their guidance (Figure 1). Parents who show warmth and sensitivity toward their children and guidance that is authoritative, ie, providing reasonable structure with developmentally appropriate expectations, foster social competence. In contrast, parents who show hostility and rejection toward their children and who use guidance that is authorl· tarian, ie, rigid, arbitrary, and excessively harsh, foster the reverse.9'13 Children whose parents are warm, sensitive, emotionally available, and authoritative in their guidance have high self-esteem and motivation, show greater compliance to everyday rules and routines, internalize moral standards effectively, have better social skills, and have better peer relationships.14'17
It is also helpful to consider dynamic aspects of parenting. Sameroff's transactional model of regulation18 provides a useful framework for conceptualizing parenting problems and types of interventions. In this model, the parent-child relationship is viewed as a dynamic microsystem within a larger ecological social system. It is an interactive system regulated directly by affective exchanges between parent and child and indirectly by other social relationships, family rituals, daily routines, community factors, and cultural expectations. The parent-child system changes over time as a function of the child's biological development, transactions between parent and child, and changes in the environment,
It is helpful to consider a brief clinical vignette to understand how the model works (Figure 2). A 15month-old child who was previously healthy presents to the pediatrician with wheezing. He requires a short admission to the hospital, but suffers no serious complications. During the illness, and for a week after the hospitalization, the child's sleep and feeding patterns are disrupted. For several nights, the child awakens frequently and requires the parent's presence to return to sleep. For several days, the child's appetite is affected, and the mother does more of the feeding for the child. Before the illness, the child was participating by selffeeding of finger foods- Although her child recuperates uneventfully, the mother continues to feel unsure of herself and her child's health and, perhaps, guilty about his illness. This uncertainty forces her to "over-regulate" feeding interactions by controlling most of the child's intake. This prevents a return to the social dynamics characteristic of meals together before the illness and leads to food refusal.
Figure 2. Transactional model of regulation. Both parent and child change over time as a result of their dynamic influences on each other. In this case, an acute illness changes the dynamics of social interaction during feeding, resulting in food refusal.
Approaches to Parenting Assessment
This scenario could resolve on its own or it could proceed in several different directions (eg, to growth deficiency or failure to thrive).19 Regardless, it exemplifies the concept of illness as a social construct in terms of transactional regulations20 and its importance to pediatricians. Illnesses disrupt social interactive processes, forcing adjustments in social relationships. Those with caring roles temporarily regulate more of the behavior of the person in the sick role. With the return to the usual state of health, there should be a readjustment of the social regulatory processes back to the original circumstances. When the readjustment does not occur in the parent -child relationship, it may present as a behavioral problem, in this case food refusal. The pediatrician is very familiar with these parenting issues that develop in the context of childhood illnesses. It is important to realize that these experiences generate a significant amount of prosocial behavior in which the child learns about self, others, and social relationships.20 Therefore, they are opportunities for the pediatrician to influence the child's social and emotional development in a positive way by addressing parenting issues. Even in the absence of illness, developmental change in the child's behavior requires adjustments in social interactive regulatory behavior, which can also be monitored in the pediatrie setting. This regulatory function of parenting is important to the development of self-regulation in the child.21
As a regulatory system, the parent-child relationship presents three opportunities for intervention (Table 1). "Remediation" refers to those interventions directed toward changing the child to enable a better regulatory fit between parent and child (eg, speech and language therapy to facilitate communication). "Redefinition" refers to those interventions toward changing maladaptive parenting perceptions of the child (eg, when parents do not view the child as normal). Finally, "re-education" refers to those interventions for enhancing the parents' skills (eg, those of patents with premature infants). In general, one or more interventions may be required at different levels or at different times in the child's life.
Clinical Approaches to Assessment
How does one assess parenting, particularly its qualitative aspects? How does one know if parents need or want help with parenting? Unfortunately, there is no single clinical assessment tool that is suited to the needs of the pediatrician.
Dimensions of Parenting
Parenting concerns are usually addressed in the context of developmental surveillance and anticipatory guidance (Table 2). As noted above, illnesses frequently disrupt the process of parenting and are opportunities to explore how the parent is managing under those stresses. The clinician may also elicit concerns from the parent by asking open-ended questions (eg, "What is most difficult about caring for your child?")· Other ways to address parenting concerns include the use of questionnaires or checklists (eg, Pediatrie Symptom Checklist)22 to facilitate discussion of child behavior problems and assessing the psychosocial context for risk and protective factors.23 Different psychosocial contexts raise varying degrees of concern. For example, financially secure, professional parents with a toddler in day care who have a concern about biting and aggressive behavior warrant a different approach than a single, adolescent mother with limited resources and support whose toddler is aggressive in the same way. Kemper and Kelleher have made an important argument for screening in high-risk psychosocial contexts where maladaptive parenting is likely to be part of the service need.23 These include parental depression, substance abuse, domestic violence, parental history of abuse as a child, housing instability, and inadequate social support. This is important because several programmatic approaches have been shown to be effective in improving parenting in high-risk settings (eg, home visitation programs for families with low birth weight babies and families at risk for maltreatment.24' Children with special health care needs form another group that presents parenting challenges. Their families may benefit from services that might include parenting education, support groups, skills training, and counseling as the need arises.
It is also helpful to consider approaches taken by researchers to evaluate parenting. For example, Mrazek and colleagues25 identified five dimensions to characterize parenting (Table 3). Emotional availability and warmth expressed to the child, the degree of parental control, the presence of parental psychiatric illness, the parents' understanding of child development, and the degree of commitment of parental time and energy toward enhancing the child's development are considered important aspects of parenting. Evaluation of these dimensions enables parenting risk to be categorized as either a serious risk requiring intervention, an intermediate level of concern that does not require intervention, and a low-risk category where parenting is anywhere from adequate to exceptional.25 A clinical approach to the assessment of parenting that incorporates appraisals along these dimensions can be helpful to pediatrie decision making.
To summarize, conceptualizing a feasible approach to the pediatrie assessment of parenting is clearly important. The approach should include strategies for screening the general population for concerns, particularly under stressful circumstances where one might expect parenting difficulty. There should be strategies for targeting specific groups where parenting challenges beyond the norm are likely. We have suggested that the pediatrician interested in addressing parenting issues explore concerns as part of the health visit, especially around times of illness and developmental change. The use of behavioral questionnaires and psychosocial screening tools may be helpful.
APPROACHES TO PARENTING IN THE PEDIATRIC SETTING
Considerations for Sick and Well Child Care
In most cases, pediatricians will find that parents approach caregiving and discipline in a manner that is nurturing. For these parents, acknowledgment, empathy, and supportive reassurance are validating and bolster their confidence and understanding of their child. The practitioner's knowledge of child development and behavior is basic in being able to help parents know what to expect and to redefine misperceptions of their child's behavior. When a child's behavior is of concern, appraisals must be made of its clinical significance. Is the behavior an expected and normal variation of development? Is the behavior due to a more serious problem? The chronicity and pervasiveness of the problem, the severity of" the symptoms, psychosocial risk and protective factors, and the degree of impairment of child and family function are considerations in the appraisal.26 Some parents may do well with a limited intervention (eg, specific advice and reassurance), while others might require a more global supportive effort (eg, an organized program for teenage mothers or referral to a mental health specialist).
Consider again the 15-month-o)d child with food refusal after a serious illness. That child and parent might have a different course if parenting concerns are discussed after the hospitalization. During recovery, the mother can be helped by reassurance about her child's physical integrity and by focusing her attention back on normal relationship interactions. Perceptions of the child as biologically vulnerable can be examined and redefined. It is important to make an accurate appraisal of the child's behavior and, in the context of illness, to pay proper attention to the parent-child social relationship. A common pitfall is to take a strict medical approach to social relationship disturbances associated with illnesses.
There are other problems that surface when evaluating parenting practices. Suggesting that a parent may need help with parenting is a very sensitive issue. It is a threatening prospect to consider that one's caregiving abilities are being scrutinized. Furthermore, one must be careful not to assume that there is a universal approach to parenting. In particular, there is always the risk of entrapment by the social deficit model with families of low socioeconomic status and/or from ethnic minority backgrounds.27 When a concern about parenting must be raised, specific recommendations should be carefully considered. If a referral is made to other resources for help with parenting, there should be timely follow-up with the referring physician. It is important that the parents feel continued support from their primary doctor and not feel as though they are being "punted" to someone else.
Even when issues are raised in a sensitive manner, helping the parents is not always straightforward. Simply making a recommendation or referral to resources is unlikely to be effective if the parent's motivation to change is lacking. Exploring the parents' "explanatory model" is a useful exercise to examine whether the pediatrician's and parents' understanding of the issues are consonant. Other novel approaches, such as motivational interviewing,28 should be considered in conceptualizing the pediatrie role in counseling on parenting issues. It seems logical to consider parents' motivation to change their own behavior before making recommendations. If there is little motivation to change, recommendations are not likely to be effective. Instead, efforts should be directed at working with the parents' motivation28 if the parenting issue is considered important enough.
Nontraditional Approaches to Well Child Care
There are several recent projects in varying stages of implementation that incorporate novel approaches to the delivery of primary pediatrie care with nonmedical child development specialists, home visits, parent support groups, telephone information lines, and service coordination. Examples include the Commonwealth Fund's National Demonstration Program: "Healthy Steps"29 and the Zero to Three's Developmental Specialist in Pediatrie Practice.30 These programs are prospective and preventive, working to educate and support parents with services based on a developmental perspective in contrast to the "find it - fix it" medical perspective. A team approach incorporating a child development specialist who can work with families alongside the pediatrician may be a way to address parenting issues in a busy office practice.
Resources for Parenting Skills Improvement
PARENTING RESOURCES OUTSIDE THE PEDIATRIC SETTING
Parent versus Family Approaches
Occasions will arise when referrals to individuals or programs outside the pediatrie practice for help with parenting is necessary. In general, a distinction can be made between parenting approaches and family approaches to intervention.31 Parenting programs target the parents or caregivers only. Family approaches work with the parents and child together. Family support programs have evolved from several different perspectives, emphasizing the importance of an ecological framework in addressing the needs of families.32,31
The type and intensity of services offered for parents varies with the age of the child and the degree of family risk. Parent education programs and parent support groups are common resources for the general population at low risk for parenting dysfunction. For high-risk families with young children, parent skills training and other supportive services are available. For example, high-risk families with older children and adolescents may benefit from family skills training and specific education programs for gang, alcohol and drug abuse, and school dropout prevention as needed. Families in crisis or with chronic social problems that place them at risk for child abuse and neglect may receive help from programs through Child Protective Services. For example, family preservation programs target families at high risk for child abuse and neglect with a wide range of services administered through a collaborative community network. The services may include social support services, skills training, drug and alcohol treatment, and family and individual counseling depending upon the individual case. Many of these services are homebased, and some are court-mandated. The following discussion addresses only parent education, support groups, skills training, and considerations for children with special health care needs (Table 4).
In actuality, parent education is a universal component in all parenting interventions, including anticipatory guidance. Parent education refers to all resources that provide knowledge to the end of improving parenting practices or family relationships. It also provides information about community resources for children and their families. Parent education topics vary in format with the age of the child and with the interest of the authence. For parents of toddlers and young children, popular topics addressed include management of temper tantrums and effective limit setting. For parents of older children and adolescents, parent education may address the risks of alcohol and drug use (eg, how to recognize the early warning signs of drug use and ways to talk with children about alcohol and drug abuse). Because parents view pediatricians as an important resource for parenting education, the pediatrician may take steps to enhance resources within the office. Establishing a "resource center" at the pediatrie office with a lending library of books and videos addressing parenting is one suggestion.
Parent Support Groups
Parent support groups are diverse, grass roots organizations that provide support and education for members. National organizations (eg, The Autism Society of America, CHADD for parents of children with ADD, and Parents Anonymous for parents who feel that they may lose control with their children) have local chapters that offer parent support groups. Support groups provide education, respite, transportation, and opportunities for networking and for sharing experiences with others. Some parents are more open to the support of groups than others depending on personality and the ages and cultural backgrounds of the specific group members. Familiarity with the details of specific groups can help pediatricians describe them to parents so as to encourage enrollment. To be effective, parent support group activities should be based on the perceived needs of the parents and should consider the context of family and community life. Support group meetings may employ a group facilitator or a resource person who has background knowledge to help families sort out their concerns.
Behavioral Parent Training Programs
Programmatic approaches to parenting skills training exist for parents of two groups of children: those with behavioral problems and those with special health care needs. For healthy children, noncompliance with parental rules and requests is one of the most frequent concerns of parents referred for behavioral treatment.34 Noncompliance, coercive parenting strategies, and poor monitoring often lead to antisocial behavior, depression, and school failure.35 Behavioral parent training programs are common therapeutic approaches employed by mental health specialists in the management of behavior problems. Other therapeutic modalities (eg, parent counseling or family therapy) may be included depending upon individual need.
Behavioral parent training programs, which focus on behavior modification, represent a trend away from the traditional child guidance model, which places parental motivations and past histories at a higher priority. The reasons for this are unclear, but may be related in part to limitations imposed by mental health insurance coverage. Regardless, an important concern is that parenting skills training programs might treat the symptoms without addressing the disorder. Ideally, behavioral parent training programs should be part of a comprehensive approach to the child and family, which considers the larger psychosocial context. Social and emotional factors are so important in the development of behavioral disturbances that pure cognitive approaches to their management are likely to be insufficient.
Most behavioral parent training programs are variants of the model developed by Patterson and his associates.35'36 Parent training programs place parents in the role of treatment providers by teaching them skills necessary to change their children's behavior. They are highly structured with programmed materials and assignments. Programs frequently include strategies toward improving the parents' understanding of the problem and their own attitudes toward parenting. Parents are taught how to monitor their child's behavior, how to use positive reinforcement (ie, "catching your child being good"), and how to decrease unwanted behavior (eg, ignoring bad behaviors or using mild punishments). Behavioral parent training programs are most effective with oppositional defiant and conduct disordered children.37 They are helpful for children with attention deficit hyperactivity disorder only when oppositional defiant disorder and conduct disorder are comorbid conditions.38 Another model for parent training programs that is commonly employed is the Adlerian model with an approach that focuses on the child's self-concept and stresses communication and understanding in the parent's use of discipline. Examples include Systematic Training for Effective Parenting (STEP)39 and Parent Effectiveness Training (PET).40
For parents of children with special health care needs, their role in the service system changed dramatically with the passage of Public Law 94-142, the Education for All Handicapped Children Act of 1975, Public Law 99-457, and the Education of the Handicapped Act Amendments, which guaranteed free and appropriate public education to children with handicaps, birth through age 21 years.41 Every program of services for children with special needs now must include plans to help and involve parents. Parent training is often a component of family-oriented services, which also includes education and information resources, support groups, respite care, therapy, and service coordination. Teaching parents how to advocate for their child in the educational sys' tern and for entitlement services is frequently part of the skills building program.
Parent skills training programs for children with special health care needs address different issues than those targeting healthy children with behavior problems. Behavior management is a component of the programs, but the major focus is upon teaching skills to the children (eg, communication skills and activities of daily living)."11 Parents with special needs children confront additional problems (eg, mental retardation, neuromuscular disorders, orthopedic handicaps, and sensory impairments), so that the behavior problems they face are qualitatively different and require a different approach to management. The response of special needs children to behavior modification is less predictable and less generalizable to other contexts compared to healthy children.42
Parenting poses enormous challenges to all families. Most parents feel unprepared for parenting, particularly with their first child, express a desire for more information, and consider their pediatrician an important resource for help. An assessment of parenting needs and parenting effectiveness is implicit in developmental surveillance and anticipatory guidance, although it is often done in a casual manner. Guidelines for determining who may need help with parenting difficulties and how to provide it are not spelled out well. Still, the pediatrician can provide an important service to parents by showing an interest in the importance of parenting during well child visits, screening for child behavior problems and psychosocial risk factors, focusing upon parenting difficulties in high-risk families, and by providing resources directly. Innovative approaches that address the needs of parents are emerging in attempts to make services for families more effective and may provide models for the future.
Finally, parent education, support groups, skills training, and counseling are resources available outside the office setting. Although we have presented these resources individually, they are generally employed together in many settings. Furthermore, they should be considered components of a comprehensive approach to parenting that considers the larger psychosocial context.
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Approaches to Parenting Assessment
Dimensions of Parenting
Resources for Parenting Skills Improvement