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Folder Title:
Putting Healthy Steps Into Practices - Healthy Steps Training Manual [1]
Stack:
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It A K !( V S
X V C K !•. K M AN.
B
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EN
Boston University
School of Medicine
M n i i a i l Director
Boston Medic.il Center
I'nij'i-ywr m i l l (
'.lituruiiui
Department of Pediatrics
Assncintc D n m /»;• C l i i i i i a l A f j n i r s
Boston University Sdiool of Medicine
November 5, 1996
Melissa Ludtke
30 Buena Vista Park
Cambridge, MA 02140
818 Harrison Avenue
Dowling 3 South. Suite 300
Boston. MA 02118
Tel: 617 534 7424
Dear Melissa:
Fax: 617 534 3833
E mail: ban y.zuckermany'bmc.otg
It was nice speaking to you the other day. I have enclosed a draft copy of our
Healthy Steps project which should transform Pediatric care in a very special and
important way.
I'll speak to you soon.
Barry Zuckerman, M.
! i) S I i > N
I ' N I V 1 K .s I I \
1
M 1• 1 I i ' \ I
(
1. N I I K
Boston Medici I Con lei'
Roslon Univfisily School of Mcdione
Boston University School of Public" Hedlth
Boston UnivL-isity Heniy M. CuUlin.ui Schoul uf DenKil Mi'dicino
�0
eft
HEALTHY STEPS
Putting
into Practices
Healthy Steps
Training Manual
Boston
Uniuersity
^cliooioj?
©BUSM
ItyJeclicL
icine
�Putting Healthy Steps into Practices
Table of Contents
Executive Summary
Introduction
I . Background
Chapter 1
Healthy Steps to An Expanded System of Pediatric Care
•
Bright Futures
•
Themes of Healthy Steps
•
Building a Caring Relationship
•
Components of Healthy Steps
1
Chapter 2
The First Three Years: Overview of the Developing Child
•
Early Brain Development
•
Scenes from the Nursery
•
Child Development Concepts
•
Motor Control
•
Communication Skills
•
Play
41
Chapter 3
Relationships are the Key to Development
•
Parent-Parent Relationship
•
Parent-Child Relationship
•
Attachment
•
Autonomy
•
Father-Child Relationship
•
Siblings
•
Extended Family
•
Discipline
75
I I . Clinical Strategies for Home and Office Visits
Chapter 4
Building Caring Relationships
•
Enhancing Relationships through Well-Child Visits
101
Chapter 5
Creating Teachable Moments
•
Table of Behaviors which Elicit Teachable Moments
109
�Chapter 6
Promoting "Goodness-of-Fit" Between Parent and Child
•
Tempermental Characteristics
•
Maternal Depression
139
III. Implementation
Chapter 7
Putting Healthy Steps into Practices
•
Roles of Pediatrician/PNP
•
Implementation Strategies
146
Chapters
Home Visiting
•
Setting the Tone
•
First Home Visit: NBAS
•
Schedule and Content of Home Visits
•
Quick Check Sheets
160
Chapter 9
Child
•
•
•
•
179
Chapter 10
Reaching Out: Offering Parents Anticipatory Guidance through
Materials and a Telephone Line
•
Child Health and Development Record
•
Link Letters
•
Parent Handouts
•
Child Development Information Line
and Family Assessment: Developmental Check-ups
Developmental Check-ups as Teachable Moments
Components of Developmental Check-ups
Giving Feedback to Parents
Family Check-up - Psychosocial Screening
•
Smoking
•
Parental Depresson
•
Alcoholism and Addiction
•
Domestic Violence
205
Chapter 11
Planning and Leading Parenting Groups
•
Options for Parenting Groups
•
Topics to Address
227
Chapter 12
Linkages with Families and the Community
•
Waiting Room
•
Community Resources
244
IV. Appendix (TAB
•
•
•
13)
Quick Check Sheets
National Healthy Steps Evaluation
Healthy Steps Protocols
�ContriLutingf A u t k o r s
The Healthy Steps Initiative at Boston University School of Medicine
Andrea Bernard, M . A .
Margot Kaplan-Sanoff, E d . D .
Patricia Lawrence, M . S . N . , C . P . N . P .
Tracy Magee, M . S . N . , C . P . N . P .
Jill Nellis, Grants Administrator
Steven Parker, M . D .
Barry Zuckerman, M . D .
The Healthy Steps Initiative at Boston University School of Medicine wishes to express
appreciation to the following Contrihuting Authors:
Ann Adalist-Estrin, M.S.
Parent Resource
Association
Philadelphia , PA
Chapter 3: Relationships
Are the Key to
Development
Emily Fenichel, M.S.W.
Jeree Pawl,Ph.D.
G. Gordon Williamson, Ph.D
Zero to Three/ The
National Center
Washington, D.C.
Chapter 2: The First Three
Years: Overview of the
Developing Child
Phyllis Cokin Sonnenschein,Ed.D.
Center for Parenting
Studies and Families
First
Wheelock College
Boston, MA
Chapter 11: Planning and
Leading Parenting Groups
�EXECUTIVE SUMMARY
INTRODUCTION:
Healthy Steps is a new concept in pediatric care. It expands the traditional clinical
practice by adding specialists whose main focus is on the developmental, behavioral and
psychosocial dimensions of both childhood and parenthood. This manual is intended to
help train a new pediatric clinical team, including the pediatrician or pediatric nurse
practitioner (PNP) and the Healthy Steps Specialist, whose responsibility it is to
develop close relationships with children between birth and three years of age and with
their families. The Healthy Steps Practice provides mothers and father with ongoing
information and support in understanding and responding to their child within the
context of their pediatric care.
CHAPTER ONE:
AN OVERVIEW OF HEALTHY STEPS
The Healthy Steps initiative comes at a time when a model of pediatric care half a
century old can no longer keep up with the parenting needs and concerns of modern
families. And it's not just the clinicians who feel unable to address all the needs of
families. Mothers and fathers also can feel overwhelmed by the responsibilities of
being a parent. Yet many feel too intimidated to even raise their most urgent questions,
fearing that the pediatrician/PNP lacks the time, energy or resources to help them.
The Healthy Steps approach to pediatric care is based on three related themes that
are woven though the curriculum and training manual and inform the training plan:
• The first three years are critically important for both the child and the family.
• Relationships are the key to healthy growth and development.
• Healthy Steps represents an enhanced approach to pediatric primary care by
expanding traditional medical boundaries beyond monitoring physical health to
include the promotion of child development and family nurturing.
Healthy Steps provides three levels of care for children and families:
•
Monitoring the child's health and development, with an eye to detecting potential
problems or areas of concern.
•
Promoting positive health and development for children and families.
�•
Problem-solving with families, and working together to determine how to address
developmental issues or medical concerns.
Building a Caring Relationship
The relationship that pediatricians/PNPs and Healthy Steps Specialists develop with
parents and children is a critical ingredient in their ability to promote children's health
and development. There are three key principles to building a caring relationship
between parents and the Healthy Steps team.
•
When a pediatrician/PNP or Healthy Steps Specialist shows interest in the child as a
person, parents take notice. Of course the reverse is also true. Hurried
interactions and vague praise diminish the parents' sense that you know their
child as an individual.
•
Parents need a sympathetic ear as they voice their worries. They also need
encouragement, but only sincere praise is effective.
•
It's inevitable that as parents begin to feel comfortable with a particular stage of
development or child behavior, the child matures and the behavior changes.
Such changes in the child and in the parent-child relationship create a teachable
moment for the clinician, a moment where parents can learn about their child's
and their own adaptive styles and responses to stresses.
Challenges and Opportunities
As we approach the 21st century, the stresses on American families have never
seemed so intense, nor come from so many different quarters. Healthy Steps seeks to
restructure the way pediatric care is delivered in order to help mothers and fathers
optimize health, behavioral, and developmental outcomes for their children—even in
stressful circumstances. These outcomes include raising children who are not only
physically healthy, but who are also curious and eager to learn, who enjoy positive
self-esteem, who are cooperative, prosocial, and use nonviolent means of conflict
resolution, who evidence good self-control when needed, who can form positive
enduring attachments, and who can communicate well with others.
The Components of Healthy Steps
By adding a number of new components to the traditional pediatric practice,
Healthy Steps expands the range of resources available to parents and children.
Healthy Steps adds eight new components to the traditional office practice of primary
pediatric care:
•
•
Enhanced well-child care
Home visits
II
�•
•
•
•
•
•
The Child Health and Development Record
Parent handouts
The Child Development Information Line
Parenting groups
Child and family developmental check-ups
Family and community network
Together with a wide variety of new ways to keep parents informed about their
children's health, growth and development, these components add up to an expanded
system of pediatric care.
CHAPTER TWO:
THE FIRST THREE YEARS: OVERVIEW OF THE DEVELOPING CHILD
Humans are learners from the start. Their day-to-day experiences in the context of
their early relationships are inevitably powerful and enduring lessons for young
children. Through their earliest encounters they come to know who they are. They
also learn what they can expect from the world. Throughout the first three years of life,
the child uses his growing communication and language skills, emotional and
intellectual development, motor control and relationships with others to cope with inner
needs and external demands, to explore the world, and to create meaning from it.
Early Brain Development
Thanks to developments in neuro-imaging, researchers have confirmed what parents
and other caregivers have long suspected: early brain development hinges not only on
an individual's genetic endowment, but also on the impact of experience and
environment, including the quality of relationships with parents and other caregivers.
Children's early experiences—the amount and kinds of stimulation they receive, and the
cognitive challenges they encounter—don't just affect their mood or disposition; they
actually alter the way the brain is "wired." And the kind of nurturing children receive
very early in life does not just affect their disposition; it appears to affect their
emotional resilience later in life. These findings suggest that it is impossible to assess a
young child's health or development without considering the quality of caregiving she is
receiving. Healthy Steps take fully into account the crucial importance of the early
years and place great emphasis on prevention. New insights into brain development
indicate that in order to improve results for children, we have to focus on the full range
of their developmental needs and provide parents and other caregivers with the
information, support and resources they need to meet those needs.
The Developing Infant in a Social Context
Today, practitioners and researchers assume we must understand an infant's
development in the context of his particular social environment. Three concepts are
III
�crucial to understanding child's first three year's of development—the child's biological
endowment; her maturation; and her temperament. Taken together, these concepts
approximate what used to be called a child's "nature":
Each child faces many developmental challenges in the first three years of life:
•
Emotional development: The world of the infant or young child is a world of
feelings. The young child's emotional capacities may be thought of as the
"glue" that holds the child's development together.
•
Motor control: It is in large part through motor acts that the very young child
develops and expresses perception, emotion and cognition. An infant is bom
with all of the basic movements. Through play and social interaction, infants
learn to organize these movements for practical purposes.
•
Communication skills: Children communicate actively from birth. Long before
they begin to talk, infants and toddlers learn to communicate with gestures and
sounds. With increasing motor skills, infants' interactions become more
reciprocal, and communication more complex.
•
Social development: From birth to 12 months of age, the infant needs security
most of all. It is through responsive interactions with parents and a few other
special caregivers that infants develop a sense of a safe, interesting, and orderly
world. Exploration takes center stage as infants become more mobile.The
period from 12 to 36 months is filled with exploration, questioning, discovery,
and determination to find meaning in events, objects, and words. At about 18
months of age, the focus shifts to issues of identity, independence and control.
The social awareness of toddlers is vastly more complex than that of younger
infants.
•
Coping: Like their parents, infants and toddlers are constantly coping. Children
cope by drawing on internal resources— their beliefs about how the world
works, their physical and emotional states, their developmental skills, and their
characteristic ways of dealing with threatening situations. They also draw on
external resources such as parents, and other caregivers.
•
Regulation: Babies thrive on routine and structure.
•
Play: Play serves a great variety of needs. Some researchers see play as a window
on the child's inner life and a way for young children to reduce tension, vent
forbidden impulses, and transcend the limitations of their bodies and
environment. Others emphasize the role of play as a safe way for children to try
out roles and relationships they see as part of the grownup world. Still other
psychologists view play as a key way of learning through guided discovery in a
IV
�prepared environment.
CHAPTER THREE:
RELATIONSHIPS ARE THE KEY TO DEVELOPMENT
Clinicians are always lamenting that so many parents are unable or unwilling to
follow their suggestions. The questions parents ask and their responses to suggestions
are often layered with meaning, history, and symbols. Healthy Steps clinicians bring to
the parent-child dyad an awareness of that relationship, skills in acknowledging parents'
feelings and concerns and information that identifies the connections between parents'
relationships (past and present) and the health and development of their children.
Familial relationships fall into three primary patterns:
•
The Parent-Parent Relationship: There are many parent-parent relationship issues
that come to the attention of clinicians as parents play out issues of power,
control and equity within the relationship. The parent-parent relationship lays
the groundwork for future family dynamics. It is the configuration into which
the child attempts to "fit." From this relationship, children also learn to
disagree, argue, make up, cope with conflict and observe what it means to be an
adult.
• Parent-Child Relationships: Parent-child relationships are fundamentally different
from those between adults. The parent's job is providing nurture and care,
balanced with authority and boundaries. Difficulties in the parent-child
relationships often stem from problems with this balance. The kinds of
attachments that mothers and fathers form with their babies, and their enduring
relationships, are affected by many factors, including environmental stressors
and assumptions about childrearing rooted in family history and culture.
•
Child-Child Relationships: The "child system"— an arena of childhood rituals,
games, fighting and competition—gives siblings "legitimate" outlets for power
struggles. Parents often need help in accepting sibling rivalry as necessary and
helpful to the development of relationship skills needed in the adult world.
Practitioners in manyfieldshave developed strategies for explaining aspects of
children's behavior, interpreting developmental stages, and equipping parents with
information and strategies for coping. But the parents' perspective, needs and feelings
must also be equally addressed. Otherwise, parents may silently accept or reject our
information or suggestions and then struggle with resultant feelings of inadequacy,
self-doubt or mistrust of the clinicians when strategies fail.
v
�All parent-child relationships include the shadows of past (and present) others.
These unseen presences ("ghosts") can contribute significantly to personality
development and parent-child relationships. They may include relationships with
parents' own parents, grandparents, aunts, uncles and siblings and may be activated by
life experiences such as parenting a new baby.
Discipline is never simply child training. It always engages the dynamics of family
relationships. Discipline brings together the scripts from one's own childhood, the
confusion over which way to do it, and the awesome sense of responsibility for shaping
the character of this very young child. Discipline involves a complicated series of
choices and decisions that are affected by many emotional, psychological, societal and
cultural factors. It is a mistake to reduce the discipline process to a formula that
ignores such complexity.
The goals of discipline are to teach children to:
•
•
•
•
Understand the effects of their behavior on others
Respect the needs of others
Weigh the needs of self with the needs of others
Make choices and behavioral decisions based on balancing the needs of self and the
needs of others
CHAPTER 4
BUILDING CARING RELATIONSHIPS
The relationship between professional and parent is the foundation of all therapeutic
efforts. If that relationship is collaborative, respectful, and nurturing—in short, a
caring alliance—then much is possible. A caring relationship is the prerequisite for all
successful interventions. Parents need and deserve:
•
Recognition as individuals in their own right, with needs and interests of their own.
•
Opportunities to voice their expectations and goals for the visit.
•
Assurance that their children and their concerns will be met with a non-judgmental
response.
In establishing a relationship, parents generally take their cues from the clinician.
Since the key goal of Healthy Steps is to help to foster strong early parent-child
relationships, clinicians must begin to think about how their style furthers or impedes
that goal. In particular, asking evocative questions creates a non-judgmental
atmosphere in which parents feel free to request specific information about their child
VI
�or family situation.
The timing and frequency of well child-visits, especially in the first year of life,
offers a wonderful opportunity to strengthen the relationships between the Healthy
Steps team and the parents. The following three linked techniques, focusing on the
child's behavior, can be used to enhance this relationship in the context of a well-child
office visit.
•
•
•
Read the baby's behavioral cues together with the parents. For example,
translating the act of fussing into a communicative act helps parents understand
that the baby is an active participant in the relationship and reinforces parental
confidence in their care-giving abilities.
Model constructive interactions with the child: Clinicians must be aware that
how they interact with the child during office or home visits may be more
meaningful to mothers and fathers than what is actually done or said.
Reframe child behavior: Clinicians can interpret child behavior from a different
perspective, explore the parents' responses, and provide information and
support.
There are many strengths to this approach, not the least of which is the shared
responsibility which the pediatrician/PNP and Healthy Steps Specialist have with each
family. The Healthy Steps Specialist provides the time for discussions that the
pediatrician or PNP usually lacks. The Healthy Steps approach provides parents with
an expanded opportunity to develop a caring relationship with a team of pediatric
specialists by having two uniquely qualified professionals with complementary
perspectives on their children's health and development.
CHAPTER 5:
CREATING TEACHABLE MOMENTS
Sometimes a child's particular behavior, like mouthing everything at six months or
throwing blocks at 12 months, creates a wonderful opportunity to promote parental
understanding of child development. The child's action allows the Healthy Steps
clinicians to reframe the behavior for the parents, giving them insights about their
developing child. The child's behavior creates a "teachable moment," when parents
are most open to new information about their child. Using such teachable moments
enhances the relationship between the Healthy Steps clinicians and parents. The
child's behavior also serves as a vehicle for promoting problem-solving and for
working with parents to develop parenting approaches which feel comfortable for them.
Each office and home visit can also be a vehicle for creating that constructive
tension—that teachable moment—when the parents are receptive to learning something
VII
�new about their child. Each of the Healthy Steps components offers the opportunity to
create that teachable moment when the parent is most invested in what's going on for
the child at that moment:
During a well-child visit, children often demonstrate a new developmental skill or a
behavior linked to an emotional stage of development. Office visits are busy, and there
is usually a great deal of ground to cover. But it is often possible to take advantage of
the time devoted to clinical examinations as a chance to also help families and children.
Indeed, any interaction with a parent or child can be seen as a potential teachable
moment and intervention:
•
History-Taking: The clinician can give mothers and fathers permission to broaden
the topics for discussion beyond purely medical topics (or to subtly discourage
them by avoiding non-health or emotion-laden topics). Simply acknowledging
how challenging parenting can be allows parents to talk about their feelings and
concerns about caring for their baby.
•
Physical Examination: The examination can serve as a natural springboard to elicit
more information or concerns from the observing parent. Neutral,
non-judgmental comments about the child's behavior may trigger a host of
parental concerns. The physical examination is a wonderful opportunity for the
clinician to reframe the child's behavior in order to enhance the parent-child
interactions. When parents bring their sick child in, they are already anxious
about the child and about what the illness may mean for the family. Helping
parents to master the first ear infection or fever with a sense of confidence and
success can set the stage for how the parents will respond to the next illness.
•
Developmental Check-ups: Developmental check-ups are an excellent vehicle for
creating teachable moments. They offer parents a chance to step back and
observe their child. When the Healthy Steps clinicians conduct the family
psychosocial screening at regular intervals, they create the opportunity for
parents to discuss adult issues.
•
Home Visits: Home visits offer a special opportunity to visit parents on their own
turf, thereby shifting the balance of power from the clinical practice to the
parents. Parents often feel more comfortable talking about their child in their
home. The Healthy Steps Specialist should be attuned to those teachable
moments, to elicit from the parents what their agenda for the visit might be, and
to nurture the parent's role as an expert on their child and in their relationship
with the Healthy Steps team.
•
Child Development Information Line: When parents calls the Child Development
Infonnation Line, they are initiating their own teachable moment. They have a
VIII
�desire to learn and they want information now about their child.
CHAPTER 6:
PROMOTING "GOODNESS-OF-FIT" BETWEEN PARENTS AND CHILDREN
Children are born with a unique combination of temperamental characteristics that
define their particular behavioral style. We might think of temperament as the how of a
child's behavior, as opposed to the what or the why. Temperamental characteristics are
what is sometimes thought as the "innate" foundation on which a personality is built.
Derived from a combination of constitutional, intrauterine, central nervous system, and
postnatal environmental factors, temperamental characteristics are not exactly "fixed,"
but are likely to be persistent and consistent over time.
Researchers have identified nine aspects of temperament which can be used beyond
the newborn period. Using these nine temperamental characteristics, several clinicians
have identified common constellations of behavior which characterize different
children as having easy, difficult, and slow-to-warm-up temperamental styles. Parents
who have insight into their child's temperament will be in a much better position to
create a home environment which complements the child's innate temperament.
When researchers evaluated the outcomes of temperamentally difficult children,
they were surprised to find only a modest relationship between having a difficult
temperament and long-term behavioral problems. They found instead that it was how
the caretakers responded to the child's innate temperamental traits that best predicted
long term outcomes. An explicit goal of Healthy Steps is to identify and enhance the
goodness-of-fit between parent and child. Healthy Steps clinicians can accomplish this
by:
•
•
•
helping parents understand the concept of temperament.
helping parents appreciate their child's unique temperamental characteristics
seeking to integrate the child's temperament and parental caregiving style into a
constructive and nurturing "fit."
It is almost impossible to overestimate the importance of goodness-of-fit to the
well-being of children. The pediatrician/PNP, via regular well-child visits, and the
Healthy Steps Specialist through regular office, home and phone contact, are perhaps in
the best position to notice early mismatches between parent and child, and to provide
timely interventions.
CHAPTER 7
PUTTING HEALTHY STEPS INTO PRACTICES
IX
�The traditional pediatric practice typically comprises a solo pediatrician or pediatric
nurse practitioner who, together with the support staff, tries to address all of the
child's health-related needs. The Healthy Steps approach to pediatrics expands this
team to include a new professional—the Healthy Steps Specialist. Healthy Steps
Specialists, together with pediatricians, nurse practitioners, nurses, receptionists, and
other office staff make up the Healthy Steps "team." Every Healthy Steps practice
will develop an implementation plan which encompasses all of the Healthy Steps
components, but which is tailored to the interests, needs, and constraints of the practice
and the families served.
•
The Pediatrician/Pediatric Nurse Practitioner will, of course, continue to see
children for their well-child and sick visits in the office. Aside from interacting
with the Healthy Steps Specialist they may not significantly change their
practice. If, on the other hand, the pediatrician/PNP wishes, there are expanded
opportunities to interact with children and parents by taking advantage of or
creating teachable moments.
•
The Healthy Steps Specialist provides the glue that holds the program together,
carrying a caseload of families in collaboration with the pediatrician/PNP. The
Healthy Steps Specialist can attend to some non-medical health-supervision tasks
such as assessing and discussing developmental milestones, which the
pediatrician/PNP might not have time to accomplish. In this way, the
pediatrician or nurse practitioner is free to devote more attention to psychosocial
issues of his choice, while retaining the option of allowing the Healthy Steps
Specialist to follow up on the same or other psychosocial issues.
•
The Nursing Staff: If the pediatric practice employs nurses then each member of
the health care team—pediatrician/PNP, Healthy Steps Specialist and
nurse—will need to develop guidelines about regular office routines, such as
who sees the family first.
•
The Office Staff: The office staff plays a critical role in implementing Healthy
Steps. The look and feel of the office when families arrive for their visit, the
tone and information communicated over the phone when families call to make
an appointment or ask about an ill child, all of these intangibles create an
environment which should convey messages of nurturing and knowledge about,
children and families.
Changing office practice to incorporate the themes and components of Healthy
Steps requires some initial rethinking of how a practice "does business as usual." All
practices should anticipate a period of transition as they implement new office
approaches and incorporate new staff into the practice. Frequent communication
�among team members will help alleviate the misconceptions, confusion and the
disequilibrium that always accompany change.
CHAPTER 8:
HOME VISITING
Home visits provide another avenue for ensuring that children experience an
optimal relationship with their parents and for helping parents understand and focus on
their particular child's behaviors and development. Home visits are timed to reach
parents and children at critical junctures in their developing relationships. Home visits
encourage parents to explore with a knowledgeable and compassionate professional
crucial developmental issues such as attachment and separation. Parents are also helped
to identify their child's areas of strength.
Each home visit takes place in conjunction with the well-child care provided by the
Healthy Steps practice. Issues raised by the family during well-child visits can be
expanded upon during the home visit. In addition, home visits provide better
understanding of the family's connection to the larger community and additional
resources can be sought if necessary.
Home visiting is often appealing to parents for several reasons. As one parent said,
"convenience is not a luxury; it's a necessity." Home visiting suggests to parents that a
service is being provided that truly fits their needs. For the Healthy Steps Specialist, the
home visit provides a special opportunity to observe the family in their normal setting,
and to gain insight into the family's culture.
The first home visit, which generally takes place when the baby is three tofivedays
old, occurs during a critical adjustment period for mothers, fathers, and their newborn.
At this point parents are generally eager to have a realistic understanding of their
infant's behavior. The visit may include:
•
The Brazelton Neonatal Behavioral Assessment Scale (NBAS): At this point
parents are often anxious to shift from the fears and fantasies they created about
the baby during the pregnancy to a realistic understanding of their infant's
behavior. Many of these questions can be addressed by helping parents
understand the meaning of their newborn's responses in relation to the NBAS.
Doing the NBAS creates a powerful teachable moment at a time when mothers
and fathers are intensely interested in learning about their newborn.
•
A discussion of breast/bottle feeding: Many parents, particularly mothers who are
breast feeding, are concerned about the potential for their newborn to lose
weight. They worry about whether their newborn is drinking enough at each
XI
�feeding. A general discussion about these concerns, and support for the
breast-feeding mother, is an important part of this visit.
•
Concern for parents' feelings and mood: Many new mothers experience a wide
range of feelings and mood changes caused by hormonal changes as their bodies
adjust to the post pregnancy or lactating state. Fathers and adoptive mothers
can also experience mood swings during their first weeks as new parents. It can
be very helpful to talk about these feelings.
•
Scheduling visits: Setting up an ongoing schedule of home and office visits with
the Healthy Steps Specialist is an important next step. Some parents may request
additional visits as needed.
•
Documenting visits: Healthy Steps Specialists are expected to keep careful records
of each home visit.
CHAPTER 9
CHILD AND FAMILY DEVELOPMENTAL CHECK-UPS
Developmental check-ups aim to enhance the parent-child relationship to promote
better relationships, behavior, and development for children. The developmental
check-up comprises four components:
• History-taking
• Informal observations of mother, father and child
• Formal Testing
• Feedback, discussion and referral
All clinicians must keep a sharp eye out for pathology. We are, after all, in the
business of rooting out disease or developmental delays and promptly treating them.
We focus on negative aspects of the child, on the areas where trouble may be brewing,
on risks (such as unintentional injury) to the child's well-being, on problems in
development or worrisome behaviors.
This model needs to be tempered with a more constructive assessment of the child's
strengths. This listing of strengths is vital if the clinician is not to unwittingly support a
one-sided, pathological view of the child or, at the least, underestimate his strengths.
Especially if the child has a significant medical, developmental, or behavioral problem,
parents need help in seeing a positive side that offers hope and responds to
XII
�nurturing—even if the problems require inordinate care and attention.
Children's health is determined by familial, social, psychological and biological
factors. In young children, parental psychological factors are especially important.
Failure to recognize these problems and their impact on children is a missed
opportunity for the pediatric practice to provide a real service to children and families.
Five specific psychosocial issues have a demonstrated impact on childhood
well-being:
• Cigarette smoking: Smoking has numerous adverse effects on children. The
clinician needs to support parents' efforts to quit smoking and minimize the child's
exposure to smoke, recognizing that relapses are common. Typically, it takes four to
five attempts to quit smoking for good.
• Parental depression: Many parents suffer from post-partum blues in the weeks
following the arrival of a new baby. Post-partum depression is more intense and
severe, and needs attention both to relieve the parent and improve the chances of a
strong parent-child relationship.
•
Alcoholism or drug addiction: 1 in 6 children in the U.S. has an alcoholic parent.
Approximately 5 percent of children born to alcoholic mothers will have Fetal
Alcohol Syndrome, while many children raised by an alcoholic parent will
have some behavioral or developmental problem, especially without support and
intervention.
Parents' own early childhood experiences: Mothers' and fathers' own early
childhood experiences echo, sometimes loudly, in their own caregiving style.
Helping parents to recognize these "ghosts in the nursery" and to seek treatment for
their issues can help to put the ghosts to rest rather than transmitting them to yet
another generation. Within the context of a supportive relationship, parents should
be made to feel comfortable talking about their childhood experiences and their
effect on their own feelings and ability to nurture and support their own children.
Domestic violence: All too often, children are the silent witnesses of violence at
home. Few clinicians identify domestic violence, although they may be the only
professionals seeing the affected families. One way to identify domestic violence is
to ask parents how they resolve conflict. Begin by saying that most parents have
conflicts and that people resolve these differently, some ignoring each other, others
have yelling matches, still others use hitting. Since children observe many of these
conflicts, stress that nonviolent conflict resolution offers children healthier models.
Only universal screening can markedly improve detection of these problems, which
XIII
�are not confined to any one economic or social group or geographic area. Limiting the
psychosocial questions to settings typically considered high-risk actually misses the
majority of families with these problems. Furthermore, studies confirm that clinical
judgment is a poor predictor of which families and children are having problems.
One of the most important clinical skills is how to make a successful referral for a
family problem. If an developmental check-up seems to indicate the presence of a
psychosocial problem, the team should present their concerns to the mother or father
and ask whether they would like help. An open discussion in any one of these areas
should lead to a referral for further assessment and treatment.
Making a referral to a community program can be seen as a welcome source of
information and help for the family, but it can also be perceived as an invasion of the
family's privacy and a lack of trust in their parenting skills. Cultural, ethnic and family
beliefs about child care, parenting and other therapeutic services must be understood
before a successful referral can be made.
CHAPTER 10
REACHING OUT: OFFERING PARENTS ANTICIPATORY GUIDANCE
THROUGH MATERIALS AND A TELEPHONE LINE
Though the Healthy Steps team can provide a great deal of information about child
development and behavior during scheduled office and home visits, parents' concerns
don't arise conveniently around these appointments. For this reason. Healthy Steps is
committed to anticipating and addressing the broad range of concerns that most new
parents have, helping them keep track of their child's growth and development, and
providing timely responses to individual concerns and questions.
Healthy Steps uses a number of interlocking strategies to provide families with
information, suggestions, and reassurance. The principle underlying all of these
strategies is anticipatory guidance—offering parents information about what to expect
from their young children as they develop and ideas about how they can meet the
parenting challenges that arise in the process. When parents know what to expect, when
they feel ready for the next developmental or behavioral milestone, then the changes in
their child's behavior feel exciting and interesting rather than overwhelming and
confusing.
XIV
�•
The Health and Development Record was designed to give parents a single place
to write down a wide range of information about their child's health and
development. It helps parents organize information, creating a historical record
that catalogs the health and development of the growing child. The Health and
Development Record encourages and facilitates communication between families
and the Healthy Steps team. By raising questions and concerns, it empowers
parents to take control of their child's growth and development in partnership
with the Healthy Steps team.
•
Link Letters are sent to parents before each well child visit. The letters are keyed
to the age of the child with important questions that the family might want to
think about before coming for their appointment. These "link letters"
encourage parents to add their own questions and concerns to the agenda,
making for a more collaborative and satisfying visit for families and the Healthy
Steps team.
•
Parent Handouts are concise written explanations covering a wide variety of topics
related to common parenting concerns and important child health and
development issues. Each handout includes practical information, written in an
accessible style, as well as suggestions for additional reading.
The Child Development Information Line is one element of Healthy Steps' overall
commitment to promoting parenting competency. Intended as a non-crisis
service, the line does not substitute for a medical information line. Rather, it is
a resource that parents can reach out to during times of stress, isolation and
insecurity, when they need timely suggestions about a particular topic, or when
they want specific instructions about how to deal effectively with their child's
behavior.
CHAPTER 11
PLANNING AND LEADING PARENTING GROUPS
Parents are busy. They often feel isolated. They may be dissatisfied with the way
they are relating to their children or may just be in need of reliable information, ideas,
and/or validation. High quality parenting groups have the potential to offer a
remarkable mixture of benefits for a wide range of parents. In part, they provide
parents with:
•
•
New information and ideas
A source of new friendships and social support
XV
�•
•
•
•
Practical help with problems that ease tensions at home
Improved relationships with children
Increased self-confidence
Pleasure in the parenting role
Parenting groups may be organized as single-session workshops or a series of
meetings. They may address generic questions or they may be designed for parents
who share particular characteristics or challenges. But no matter what the format,
parenting groups must respect the strengths parents bring and the questions they have.
Information and support should be woven together, leading to engaging, informative
and highly interactive and enjoyable sessions. The mix of information and support is
key. One without the other is inadequate as adult learning involves not only cognitive
material, but feelings about concepts and readiness to do something as a result.
There is no need to duplicate services provided elsewhere in the community.
Parenting groups have become quite popular and many professionals have been trained
to lead them. Various types of parenting groups are being offered in town libraries,
children's museums, toddler indoor playgrounds, child care centers, and social service
agencies. Even supermarkets and health clubs are beginning to offer workshops on
topics of interest to parents.
But the quality is extremely variable. To check out potential referrals, ask for
evaluations of previous programs or observe a session or two to make a judgment
before recommending these options to parents. If it turns out that there are few high
quality programs available for parents in Healthy Steps communities or if those offered
do not deal with the issues that Healthy Steps sites have identified as important, all the
more reason to offer them at the practice.
Leadership of parenting groups has become extremely interdisciplinary.
Psychologists, educators, social workers, pediatricians, nurses, school administrators
all have the capacity to become skilled leaders. Many professionals are currently
receiving education and specialized training as parent group leaders. What is required
is a non-judgmental, respectful, empathetic attitude towards parents, knowledge of
content, group facilitation and teaching skills, and an appreciation of the fact that being
a parent is the most challenging responsibility an adult can have.
CHAPTER 12
LINKAGES WITH FAMILIES AND THE COMMUNITY
The Healthy Steps Specialist plays a ciitical role in linking families with each other
XVI
�and with their community. Various strategies can be used to link a Healthy Steps practice
to the community:
•
Parent-to-parent bulletin board: If possible, hang a bulletin board which parents
can use to communicate with each other. Parents may want to use this space to
notify other families about child care information or baby-sitting opportunities, to
form play groups, or to advertise used child-care equipment.
•
Newsletter: Together with other members of the practice you can design a pediatric
practice newsletter. Encourage all staff members to generate ideas for the
newsletter. The Boston University team can provide you with a newsletter
template on computer disk if you are interested.
•
Using the Internet: The Healthy Steps Initiative plans to have a home page on the
Internet for those Healthy Steps Specialists and parents who have computer access
to the World Wide Web.
•
An inviting waiting room: A waiting room that is comfortable and welcoming can
have a tremendous impact on how a pediatric practice is viewed. Numerous
pleasant and distracting activities can be provided for children and parents. You
may want to ask volunteers to assist in supervising such activities.
•
Access to community resources: Information on local resources can be collected in
binders and kept in the Healthy Specialist's office or in a central location, such as
the waiting room. Parents should have an opportunity to access information on
their own, allowing them to look up sensitive topics in private.
XVII
�Introduction
Healthy Steps is a new concept in pediatric care. It expands the traditional clinical
practice by adding one or more specialists whose main focus is on the developmental and
psycho-social dimensions of both childhood and parenthood. This manual is intended to help
train a new pediatric clinical team, including the pediatrician or PNP and the Healthy Steps
Specialist, whose responsibility it is to develop close relationships with children between birth
and three years of age and with their families. Through a carefully designed series of office
visits, home visits and a telephone advice line for parents, the Healthy Steps Practice provides
mothers and father with ongoing support in understanding and responding to their child in the
context of a developing body, mind and social world.
The term clinician is used throughout the manual to refer to any one of the expanded
pediatric team: the pediatrician, the pediatric nurse practitioner (PNP) or the Healthy Steps
Specialist. This manual provides an overview of the organization and operation of an expanded
Healthy Steps pediatric practice comprising such a team.
The Background provides an overview of Healthy Steps, a review of physical,
psychological and social development of the child in the first three years, and a review of the role
of relationships as the basis for normal development..
Clinical Strategies for Home and Office Visits provides both background material and
practical suggestions for the Healthy Steps Practice on how to work with families in
understanding the complex relationships among a child's physical growth, mental development
and the complex web of specific social relationships which affect both. The Healthy Steps
Specialist is given detailed instruction in conducting home visits and various kinds of assessment
�of both the child and his family. The general framework for these assessments is laid out in an
extensive set of Quick Check Sheets which are found in Appendix A at the end of the manual.
These Quick Check Sheets are based on the concept that one of the clinician's primary jobs is to
create "teachable moments" for parents, when their child's examination or assessment becomes
an opportunity for them to learn about their child's needs and how to best meet them. By helping
parents to reframe their understanding of their children and of themselves in relation to the
children, Healthy Steps acknowledges the close relationship between child development and
family development.
Implementation chapters outline a wide range of practical issues dealing with the actual
running of an expanded Healthy Steps practice. Issues include:
•
reconfiguring traditional practices along the line of Healthy Steps
•
organizing and conducting home visits
•
setting up telephone advice lines for parents; and
•
running various kinds of parent groups
In the interest of clarity and accessibility, information is presented wherever possible in
the form of bullet-charts, lists and concrete case studies. The manual is addressed to individuals
wishing to become part of a Healthy Steps team, including pediatricians, nurse practitioners,
Healthy Steps Specialists, nurses and office staff.
�I , Background
�CHAPTER 1
HEALTHY STEPS TO AN EXPANDED SYSTEM
OF PEDIATRIC CARE
It's time for Timothy's two-year checkup and the factions could not be •
clearer. Timothy's parents are concerned that he seems quite active and
somewhat aggressive. They remember with mortification the callfromthe
child care center saying that he had bitten another little boy and drawn
blood. With the latest Newsweek report fresh in their minds, they wonder if
his aggression is innate and will always be a problem. To make matters
worse; Timothy isn 't speaking nearly as much as his age-mates. His parents
are worried. But they're unclear if they should raise their concerns to their
pediatrician who, after all, is sa busy and maybe not all that interested in
such "non-medical" issues.
For her part, the pediatrician has her own very full agenda for Timothy.
After all, she may not see him for another full year. Her schedule calls for a
discussion of injury prevention, nutritional counseling, inquiring about
sleep arid toileting issues, a general developmental assessment, a discussion
of discipline and anticipatory guidance around the "terrible twos. "All this
must be covered, in addition to a complete physical examination of the boy.
The clinician figures she has about 20 minutes to complete her agenda and
is anxious to get the show on the road.
Finally, there's Timothy himself, who has an entirely different agenda of his
own. Angry to be in this office of pain, he wants out. He's intent on waging
yvar until he is extricated from this unpleasant situation. Clinging to his
mother for dear life, Timothy vigorously protests what he feels as invasions
of his personal space, which he generously defines as anywhere within two
feet of him. He's determined that any examiner victories will be hard won
indeed.
No one wins this kind of war. Conflicting agendas like these often leave all parties
dissatisfied. The parents feel they never have their real concerns addressed. The
1
�pediatrician/PNP, as usual, can't get through her own agenda. As for Timothy, he ends up
feeling helpless and out of control. The Healthy Steps initiative comes at a time when a model
of pediatric care half-a-century old can no longer keep up with the parenting needs and concerns
of modem families. And it's not just the clinicians who feel unable to address all the needs of
families. Mothers and fathers also can feel overwhelmed by the responsibilities of being a
parent. Yet many feel too intimidated to even raise their most urgent questions, fearing that the
pediatrician/PNP lacks time, the energy or the resources to help them out.
Families
Pediatric visits don't occur in a vacuum. Healthy Steps recognizes that "child
development" is also a process of "family development." Parents and children bring to the visit
their own hopes, fears, and desires. Some parents are anxious and need reassurance. Others feel
ashamed about negative feelings they may have about their child and about parenthood itself.
Dare they risk disclosing these private feelings to the clinician? Still others are on more solid
ground. Confident in their parenting, they simply seek confirmation of their skills. And there
are those parents harboring unspoken fears about their child's health, fearful that the visit will
uncover some catastrophic illness. Even parents with a perfectly healthy child may be coping
with unspoken grief. Perhaps they mourn the loss of a fantasized child. Or maybe they long for
their lost marital relationship before parenthood disturbed it. Some may be dealing with a
profound disillusionment with the experience of parenthood. Other parents may have no such
conflicts. Sure that their child is healthy, and confident as caregivers, they are simply looking for
�practical information. Those with significant problems and unresolved family issues may or may
not be ready to voice their concerns, to hear the clinician's concerns, or to accept their
therapeutic suggestions.
These often unrecognized goals, feelings, hopes, and fears on the part of the mother and
father define the social context of the pediatric visit. Intervention efforts will likely be futile if a
clinician fails to pay attention to this often invisible social context of the visit. Even under the
best circumstances the pediatric visit is usually a time of heightened sensitivity for parents. And
so it is an opportune time for powerful teachable moments. It is also a time when mothers and
fathers can feel vulnerable and exposed to our expertise and skills. What is said, and often, more
importantly, how it is said, can easily wound or uplift them. So if a clinical encounter is to
produce maximal therapeutic benefits, clinicians need to be sensitized to the importance of the
mother's and father's emotional states. Clinicians have a complex set of goals. They want to
help families raise children who are physically healthy, are curious about their world, are eager
to learn, communicate easily and willingly, are cooperative, friendly, have positive self-esteem,
can exercise self-control, and form strong attachments. Healthy Steps offers strategies which
allow both families and clinicians a new and expanded system of care designed expressly to meet
these goals.
Bright Futures: A Vision for Healthy Steps and Pediatric Care
Five years ago, the Bright Futures initiative developed health supervision guidelines
responsive to the changing needs of children and families. Bright Futures takes a comprehensive
view of the child's health, including social relationships, emotional well-being, and intellectual
3
�development. The child is viewed in the context not only of his or her body but in relation to the
family and the community as well. Health supervision is understood both as highly
individualized and framed by the family's culture. Rather than assessing a child's needs solely in
relation to some general baselines, Bright Futures stressed the complex and changing social
context of health needs, recognizing for instance the special requirements of children at stressful
periods of the lives, such as moving, divorce, remarriage or illness.
The goals of Bright Futures were never meant to be the exclusive responsibility of the
pediatric clinician. Doctors or nurses alone may not have the time or resources to fill all these
needs. Bright Futures broadened the concept of health supervision to include a team effort by
various professionals with different roles and responsibilities. By expanding pediatric services in
the interest of both child development and parent development. Healthy Steps represents an
extension of the vision outlined in Bright Futures.
Table 1, at the end of this chapter, summarizes the goals proposed in Bright Futures,
organized by age of well-child visit. It suggests graphically the great variety of ways in which
health care can be effectively delivered. These include home visits, visits with the Healthy Steps
Specialist, parent handouts, resource and referral through the telephone advice line. Healthy
Steps practitioners all share the basic objectives set out in Bright Futures. But no two children
are the same. And no two families are the same. So each Healthy Steps practice is assured the
flexibility to choose the components of Healthy Steps are best suited to meet each objective (see
III Introduction for details). For example, a practice may decide that injury prevention issues
arising when infants become mobile might best be addressed by a home visit at 9 months. The
focus of the home visit by the Healthy Steps Specialist would then be on helping families "child4
�proof their home. Another practice might view safety handouts as sufficient. In this case, the 9
month home visit might be used to discuss issues of separation and autonomy.
Themes of Healthy Steps
Three Basic Themes of Healthy Steps
1. The first three years are critically important.
2. Relationships are the key to healthy growth and development.
3. An expanded approach to primary care.
The Healthy Steps approach to pediatric care is based on three related themes.
Woven throughout the Healthy Steps materials and strategies, these themes create a consistent,
focused system of care for young children and their families.
THEME ONE: The first three years are critically important for both the child and the
family. The infant brain grows fast even before birth, and much of the crucial cortical
development for the infant takes place in the first years after birth. This means that the infant's
nervous system develops in an intimate relationship with its social and physical environment.
Perhaps more surprisingly, it has been demonstrated that not only do biological factors (such as
good health and nutrition) alter the architecture of the brain during the first years of life, but so
too do the child's everyday social environment and experiences.
With little exaggeration it can be said that the child possesses a truly eco-logical brain.
�Researchers have begun to delineate those aspects of the child's everyday world that can affect
brain structure, as well as cognitive, emotional, and behavioral development. During the first
three years of life, infants develop basic motor coordination, basic cognitive and communicative
skills and a basic social orientation to the world.
Theme Two: relationships are the key to healthy growth and development. Since all
aspects of development occur in a profoundly important social context. Healthy Steps views
child development as intimately linked to family development. Healthy Steps practices support
the relationship between mothers andfathers and infants by helping parents understand their
infant's unique temperament and ways of signaling wants and needs. Healthy Steps practices
also support the relationship between parents and their pediatrician/PNP. Parents who feel
confident in their ability to parent their baby translate that confidence to the baby. They also
bring a different kind of interaction to their relationship with their pediatrician/PNP. They feel
empowered and more like an equal partner in the relationship with the medical system. Finally,
Healthy Steps practices offer parents linkages to other parents in the practice and to community
resources which further increase their sense of confidence and competence.
THEME 3: Healthy Steps represents an enhanced approach to pediatric primary care
by expanding traditional medical boundaries beyond monitoring physical health to include the
promotion of child development and family nurturing. Healthy Steps allows
pediatricians/PNP's to provide more than just standard medical care. Families often feel isolated
while raising their children. The pediatrician/PNP is often the only professional who sees the
infant and the family, especially in the first few months. Healthy Steps practices will have the
time and personnel to provide families with individualized information on child growth and
�development, home visits, parent groups, a telephone advice line for developmental and
developmental questions, and links to a network of informal parental and community resources
which can help them feel less alone in the task of raising their children.
The themes of Healthy Steps require that a clinical perspective be applied to the
interactions we have with children and families. In each chapter, the general word clinician is
used to refer to a pediatrician, a pediatric nurse practitioner or the Healthy Steps Specialist.
These professionals all share the clinical focus in their work of creating those teachable moments
which serve to enhance the relationship between parents and the practice. For specific roles and
responsibilities of all members of the Healthy Steps team, see Chapter 7.
Levels of Care
Healthy Steps provides three levels of care for children and families.
1.
Monitoring the child's health and development, with an eye to detecting potential
problems or areas of concern. Monitoring includes the physical exam and laboratory
tests, assessment of the child's development, and a brief assessment of family
functioning. Bright Futures offers age-specific examples of trigger questions,
developmental milestones, and parent-child observations to help monitor child and family
functioning and identify potential problems. The Healthy Steps Quick Check Sheets in
the Appendix are designed to remind the pediatrician/PNP and the Healthy Steps
Specialist which milestones, parent-child interactions and trigger questions they should
be addressing at each contact with the family.
2.
Promoting positive health and development for children and families. Healthy Steps
7
�offers another professional—the Healthy Steps Specialist—to work with the
pediatricians/PNPs to promote child health and development. Healthy Steps Specialists
have the time and expertise to provide information to parents about how to encourage
their child's language or how effectively to set limits with toddlers.
•
They offer families unhurried time to explore next steps in development.
•
They provide mothers and fathers with child development information geared
towards the specific needs of their unique child, supplemented by parent
handouts and suggestions for appropriate books or videos available from the
practice.
•
Families can use the child development information line to get additional
information about promoting their child's growth and development. They can talk
directly with the Healthy Steps Specialist by phone or make an appointment to
meet personally.
3.
Problem-solving is the third level of care. The Healthy Steps team works with
families to determine together how to address developmental issues or medical
concerns. The pediatrician/PNP and Healthy Steps Specialist can help families to
respond to a child's asthma, temper tantrums, sleep problems, refusal to take
medication or separation difficulties. As parents become more knowledgeable
and feel more confident in their problem-solving, their discussions with the
Healthy Steps Team can move beyond simple medical management to broader
considerations of child behavior. By providing information to parents which
demystifies common childhood illnesses and their management, parents
8
�become more confident as the child's primary caregiver.
While most pediatricians or nurse practitioners by themselves clearly lack the resources for
adequately addressing each of these three levels of care, adding the Healthy Steps Specialist to
the pediatric team gives families ready access to all three levels of care. This is what we mean
by calling Healthy Steps an expanded system of health care.
Building a Caring Relationship
The relationship that pediatricians/PNPs and Healthy Steps Specialists develop with
parents and children is a critical ingredient in their ability to promote children's health and
development. There are three key principles to building a caring relationship between parents
and the Healthy Steps team. First:
Parents are in love with their children and deeply proud of them.
When a pediatrician/PNP or Healthy Steps Specialist shows interest in the child as a person,
parents take notice. Of course the reverse is also true. Hurried interactions and vague praise
diminish the parents' sense that you know their child as an individual.
Second:
Parents worry about whether their children are normal, and whether
their parenting is "good enough."
�They need a sympathetic ear as they voice their worries. Some parents flood the team
with questions. Others hide their fears and insecurities from the team and from themselves. In
either case, they need reassurance that their child's troubling behaviors are normal. They also
need to know that their self-doubts are normal and that it is okay to voice negative or
uncomfortable feelings. Parenting is a tough job. So just as clinicians need to counsel parents on
parenting problems, they also need to praise them for their successes and efforts. But only
sincere praise is effective, especially praise in response to concerns which the parents raise.
Third:
As children grow, their relationship with their parents inevitably
changes, challenging the equilibrium between parent and child.
It's inevitable. Just as parents begin to feel comfortable with a particular stage of
development or child behavior, the child matures and the behavior changes. Such changes in the
child and in the parent-child relationship creates a teachable moment for the clinician, a moment
where parents can learn about their own adaptive styles and responses to stresses.
Healthy Steps: The Challenge
As we approach the 21st century, the stresses on American families have never seemed so
intense, nor come from so many different quarters. Economic pressures often mandate that both
parents work, even as appropriate child care options dwindle. Many families must cope with the
unavailability of extended family and the loss of family and community resources. The media,
ever more ubiquitous, often presents unsavory role models for children. Children seem to be less
10
�ready to cope with the rigors of school, and the incidence of behavior and developmental
problems appears on the rise.
No wonder parents are concerned that these stresses may overwhelm their ability to
provide for what their young children need. Where can families go when they seek good
information, relationships that support and empower them as parents, respectful dialogues on
childrearing strategies, carefully selected pamphlets, brochures, video tapes, and books that offer
parents reliable information about medical, behavioral, and developmental issues?
The most obvious answer is the pediatric pediatrician/PNP. But are we really prepared to
fill the broad range of needs parents have? Unfortunately, we're not nearly as prepared as we
would like to be. Many of us have become increasingly frustrated by our inability to address the
increasing stresses and the frantic pace of social change faced by the families in our practices.
While the social context in which we practice has undergone dizzying changes, our ways
of delivering care have not. Consider the typical well-child visit.
•
A 20-30 minute time allotment, where a single pediatrician /PNP is expected to deal with
all aspects of the child and family's world—from sibling rivalry to school readiness.
•
A waiting room filled with tired and/or ill children accompanied by parents at the end of
an exhausting work day.
•
Families seeking guidance about an ever-increasing list of non-medical concerns.
•
Inadequate preparation during pediatric residency training to deal with non-medical
issues.
•
Economic pressures to streamline our care and see more and more patients.
11
�Given these constraints, it is little wonder we sometimes feel we have fallen short of our goal of
treating the whole child and the whole family.
Healthy Steps: The Opportunity
The Healthy Steps approach to pediatric care aims to capitalize on the untapped potential
of pediatric practices to help mothers and fathers optimize health, behavioral, and developmental
outcomes for their children. These outcomes include raising children who are not only
physically healthy, but who are also curious and eager to learn, who enjoy positive self-esteem,
who are cooperative, prosocial, and use non-violent means of conflict resolution, who evidence
good self-control when needed, who can form positive enduring attachments, and who can
communicate well with others.
Listening to Parents
To better understand the demographics, the needs and the experiences of today's parents,
Healthy Steps conducted an extensive parent survey focusing on families with children under
three years of age. We found that many parents of infants and toddlers are anxious to have
access to expanded resources for helping them become good parents.
12
�The Commonwealth Fund's Parental Need Survey
Over one-third of parents surveyed reported having had no chance
to talk with a doctor or nurse about how to care for their newborn
during the maternity stay at the hospital.
Almost 20% of parents surveyed say they could use more parenting
information.
Many parents reported getting little or no enhanced advice and
information from their pediatricians on behavioral and
developmental issues related to parenting.
Over 70% of parents receiving three or more "enhanced" services
from their pediatric practices gave their child's doctor an
"excellent" rating.
Only 48% of those who did not receive these enhanced services
rated their pediatricians as "excellent."
Over half of the surveyed parents felt that enhanced pediatric
services would be useful for them.
Healthy Steps seeks to restructure the way pediatric care is delivered in order to
creatively address this daunting objective. It is this focus on how, specifically, to effect a change
in pediatric practice that allows us to achieve these more subtle goals in the first three years and
sets Healthy Steps apart from most previous initiatives.
13
�How does Healthy Steps differ from previous programs that have aimed to promote
children's development in the first three years of life?
•
Unlike "early intervention" programs. Healthy Steps is focused on all children and
families, not just those at biologic and/or social risk.
•
Healthy Steps focuses more on the high prevalence, low severity stresses of everyday
parenting (e.g., autonomy struggles, sleep problems) than on low prevalence, high
severity issues (e.g., child abuse, major illness).
•
The evaluators of Healthy Steps in large measure will be parents, insurers, and
pediatricians/PNP's who, in the end, will decide on the efficacy and utility of the model.
The Components of Healthy Steps
By adding a number of new components to the traditional pediatric practice, Healthy
Steps expands the range of resources available to parents and children. Healthy Steps adds
eight new components to the traditional office practice of primary pediatric care.
Our well-child visits will follow American Academy of
Component 1
ENHANCED WELL-CHILD
CARE.
I Pediatrics (AAP) guidelines for scheduled visits and
|1
immunizations. A parent's natural interest in their
baby's health can serve as a bridge to help strengthen the crucial relationship between the parents
and the clinicians. Clinicians will use the Brazelton scale (NBAS) for intervention during the
perinatal period and will use other measures to assess issues of temperament, physical behavior
14
�and "goodness-of-fit" during later stages of the child's development. Expanded well-child care
focuses on each of the three levels of care central to the Healthy Steps philosophy: monitoring
health and development; promoting health and optimal development for children and their
families; and problem-solving together with the family in dealing with their children's health and
development.
Component 2
HOME VISITS
p
J
Home visits allow the Healthy Steps Specialist to
observe the child in the home setting. It is also a good
place to develop a special relationship with the parents. At home, mothers and fathers often feel
more comfortable about voicing their concerns about their children's health and development.
The Healthy Steps Specialist can provide parents with infonnation that fosters their child's
intellectual and emotional development. Home visits during the early infancy period will focus
on infant health, nutrition, sleep and strategies for comforting babies. As the child grows, the
home visits will shift their attention to issues of toddler autonomy and management of behavioral
and developmental issues like tantrums, eating, and toilet training, in addition to basic health
issues.
Component s
CHILD HEALTH AND
DEVELOPMENT RECORD
i
The Child Health and Development Record serves as a
I
way for parents to communicate regularly with the
Healthy Steps team. It is completed in cooperation
with parents, who regularly write responses to questions about their child's specific attributes,
milestones and activities.
15
�Handouts on a variety of medical, developmental or
Component 4
PARENT HANDOUTS
practical topics are made available to parents at both
office and home visits. Handouts include suggestions
from "expert parents," guidelines about when and how to contact the pediatricians/PNP,
references to good childcare books, and, where appropriate, places to write or call for specialized
information on children.
All Healthy Steps families have access to a userComponent 5
CHILD DEVELOPMENT
INFORMATION LINE
friendly call-in phone line where they can get answers to
their questions about child development or behavior
issues. The practice continues to provide a separate medical call in line. Medically related issues
called in to the advice line are referred to the child's pediatrician or PNP.
Parent discussion groups are offered at the practice or in
Component 6
PARENT GROUPS
the community in collaboration with local parenting
- •;•>• ;•• ": ¥ ^ groups. Groups focus on providing child-rearing
• • •>:><
•
information and facilitating support from other parents.
Component 7
CHILD AND FAMILY
HEALTH
DEVELOPMENTAL
CHECK-UP
Starting at six months of age, the development of each
Healthy Steps child is informally assessed every six
months using the Denver Developmental Screening test
16
�along with a language screen assessment. In addition each family completes a questionnaire
dealing with the home environment and health-related issues such as smoking, substance abuse,
depression and domestic violence.
Through a parent-to-parent bulletin board in the office, a
Component 8
FAMILY AND COMMUNITY |
NETWORK
practice newsletter, and an Internet Home Page, Healthy
Steps provides ways to connect families within the
practice to each other and to community resources like
child care and family-oriented activities.
Summary
Healthy Steps bridges the gap between traditional pediatric care and the conditions of
modem parenting. Healthy Steps provides children and their parents with a personalized
orientation to a child's health and development in the context of that child's family life and social
relationships. Healthy Steps adds home visits and regular developmental assessments to
supplement the traditional office visit. Together with a wide variety of new ways to keep parents
informed about their children's health, growth and development, these components add up to an
expanded system of pediatric care.
17
�Table 1
Bright Futures Newborn Visit (3-5 days)
Objective: • • *
T'^
Parent
Q^^t^
itss >
XX
XX
XX
X
Explore delivery
Siblings
Family issues
Expectations
oo
JCarpveiMii^M
|/interaction: ^i'-V:"'l^plKResponsiveness
Comfort level
Supports
Nutrition
Breast feeding
Bottle feeding
AnHcipatory Guidiiiice
/:
Injury Prevention
Illness Prevention
Infant care
> Cord care, circ care
Proj^Mra of enjoyable parentinfwfimteractioh
Temperament
Nurturing
Promotion of cbftstructiw fSmily
relationships ,
, , .,
Promotion of community
interactions
XX
XX
XX
X
X
X
X
XX
X
XX
X
FIS
InllidoufS
^illolione
'Mm-: •:
•
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1
XX
XX
XX
X
X
X
X
X
�Bright Futures Two Week Visit
XX=Priority
msmm
HSS
X
X
XX
XX
XX
X
XX
XX
X
X
X
XX
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
XX
XX
X
X
X
X
X
X
FDW^iniiraii isiir^iiiii^
AiHcipatbry Guidance ^
Injury prevention
Illness prevention
Illness Recognition
Nutrition:
Breast fed
Bottle fed
Parent Goinmuhitv
Videp FIS : TelebUohe
Group ••->
Advice
Based
Oreanization
Line
X
Health Supervisidii
••!vliM- X
Interview •
Family Concerns
X
Baby's personality
XX
Siblings
X
X
rand'Milestoiies:;;f|.^'-;^'-g^
Responds to Sounds
Fixes and follows
Moves all extremities
gBi^ifiStiqii of %W-^7v;'^
Jai-iegivef/Parerityin
/Interaction: ,
Postpartum depression
Read and respond to cues
Comfort level of caregivers
Parent,
Handout
X
X
X
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures Two Week Visit
XX=Priority
fOBfe&ive
;
-
^<
-
Oral Health
Infant Care
>cord care, circ care
O
«FIS
4 y i rviiit;
-
my::
parent-mfant interaction
Temperment
"Fussy" periods
Nurturing
^roMiHSn^faKltraav^
?faniily.rela.tipnships
PromottcM^commuiily i
interactions
• #vt;U.-'v:f
Handout
X
XX
XX
X
X
X
X
X
X
XX
XX
XX
X
XX
X
XX
XX
XX
X
XX
XX
X
X
X
(
I
fitted :, • ;
Oreanization
X
X
\•
X
X
X
XX
l:' 'Si''"'
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures One Month Visit
XX=Priority
Objective
: •
\ \ ^ fO'fficeSM Hoinel fGffite
Visit uVisit
• • ^Xr-.'.^v-,;; Clinician
HSS •HSS
^
Parent
Parent
Handout Group
Communitv Vide6
Based
Organization
FIS
Telephone
Line
J
Health Supervisibii
Interview
Family Concerns
Reading Baby's Cues
Planning ahead
Developmental Surveillance
and Milestones:
Responds to sound
fixes and follows
lifts head
sleep pattern
Ojjserv'atibn Of __
Care^ver/Parerit/Ihfant
/Interaction:
Comfort level of caregivers
Postpartum depression
PKysical Exam .
Screening Procedures
Immunizations
Anticipatory Guidance
Injury prevention
Illness prevention
X
XX
X
X
XX
X
X
XX
X
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
XX
X
XX
X
X
X
X
X
:
X
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures One Month Visit
XX=Priority
Home?,
Illness Recognition
to
to
Nutrition:
Breast fed
Bottle fed
Oral Health
Infant Care
>cord care, circ care
parent-infant interaction
Temperament
"Fussy" periods/colic
Nurturing
Promotion ofconstructive
family relationships
Promotion of community
interactions
IS ;
Parent
Handout Groiip
X
X
X
X
XX
X
X
X
XX
X
XX
X
X
XX
X
X
XX
X
X
XX
X
X
X
X
X
X
XX
XX
XX
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
Goinmuhitv Video
Based
Oreanization
XX
X
X
X
X
X
X
X
X
X
X
X
F I S . Telephone '
AdviceLine
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures Two Month Visit
XX=Priority
'Objective
Health Supervision
Interview
Family Concerns
Baby's personality
Family supports
Need of child care
Parent Relationship
Developmeiital Surveillahce
and Milestones:
Vocalizes
Attentive to Voice
Interested in visual and
auditory stimulus
Smiles responsively
Better head control
Observation of ;
Caregiver/Parent/Infaht
/Interaction:
Reading baby's cues
Baby responsive
Physical Exam
Screening Procedures
Immunizations
Anticipatory Guidance
Injury prevention
*irenfm Parent
Handout Group
lomm ^ ViitSi
.vilify diiiician HSS
X
X
X
XX
XX
X
X
X
X
XX
XX
X
X
X
XX
XX
XX
X
X
X
X
X
X
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
XX
X
Telephone
AdVicie
Lihie
X
X
X
X
X
X
X
Communitv Video FIS
Based
••'u'
Oreanization
X
X
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures Two Month Visit
ObiecHve
>i
waff
mmmfWfficef:
visit
Ms
Earent
Handout
Parent ' Community
Group Based .
Oreanization
X
X
X
X
X
X
X
X
X
Video FIS
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
XX
X
X
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
XX
XX
X
XX
XX
XX
XX
XX
X
XX
XX
XX
X
X
X
Illness Recognition
Nutrition:
Breast fed
Bottle fed
Oral Health
Infant Care
XX
XX
X
X
X
X
X
XX
parent-infant inferatliSn
Temperment
"Fussy" periods/colic
Nurturing
Toys
Reading to baby
Establishing bedtime
routine
Promotion of constructive
J
Prdniotibri of community
interactions
^
, X
..
Telephone
Advice
Line
X
X
X
X
X
X
:
X
X
X
X
X
X
X
�Bright Futures Four Month Visit
XX=Priority
ISl 111
11
mm*
•ifPSfrntfi? Communitv
tlinabtfr.; Group
HSS
Interview
Family Concerns
Baby's personality
Family supports
Child care
Parent Relationship
Developmental Stfin^iUanc^^
and Milestones: .
£
Language
Motor
Social
Play
Observation of .;^ -; -";V^ T '
Carjbgiv^r/Parent^
/Interaction:
Reading baby's cues
Baby responsive
Comforting
PhysicalExam
Screening Procedures
i
Immunizations
X
X
X
X
X
X
XX
XX
XX
XX
X
XX
XX
XX
XX
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
!
:
X
X
X
X
Videos FIS MteiiBfibnfe
Advice «
'•ii^-,Organization
:
X
X
X
�Bright Futures Four Month Visit
iPiilifsip!
fiiijigflipiGrouos;
tslsisit^
Injury prevention
XX
Illness prevention
XX
Illness Recognition
XX
Nutrition:
XX
XX
Breast fed
Bottle fed
X
Solids
XX
Oral Health
X
Promotion of enjoyable ,
parent-infant interaction
X
Encourage vocalizations
Nurturing
XX
Play
X
X
Toys
X
Reading to baby
Establishing bedtime
X
routine
Pfoinbtion of constructive
X
family relationships
1 .
Promotion of community X
interactions
XX
X
X
XX
XX
XX
XX
X
X
X
X
XX
X
X
XX
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
XX
X
X
X
X
X
mm. FIS
Oreanization
.'t^l; i f , ; , <:
r
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
XX
X
X
X
X
X
X
X - library
XX
X
X
X
X
XX
X
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Telephone
•^dvicef:'!':Line
X
X
X
X
X
X
X
�Bright Futures: Six Month Visit
Otijective
^Office^,; eiinig i H o m ^ f sParmfPf® ppirSir;; !?Gommunitvv
VisH
Visit}
.Group J S ^ i ^ .
Cunician HSS
HSS
Oreanization
r
Health Superv ision
Interview
Concerns of family
Parent Roles
Child Care
Siblings
l^velopmehtal
^rveillance and
^lestones
Language
Motor
Social
Play
Developmental
Concerns
MdMei^atpr/-\;
Caregiver Interaction
Responsiveness
Attention
Stranger Anxiety
Comforting
:.PB^iciil:pMmif £.;-. • .
Screening Procedures
Immunizations
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Video
'•.I
FIS
Telephone
AIMictLiii^
X
X
X
X
X
X
X
X
X
�Bright Futures: Six Month Visit
XX=Priority
©Bjective
'Parent
mmm
rHlciffi
Nutrition
Feeding
Oral Health
frofflotio&ofenjoyable
00
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
XX
X
Discipline/Routine
XX
XX
XX
Sleep
Transitional object
Toys
Separation Anxiety
XX
X
X
XX
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
Caregiver interaction y :
Developmetal
stimulation
|Pif^^of:->£^|;;|f;
vcoisti^iive family;
:ipfflp|o|p|n
FIS
^oinmumiviK'K
-Based" ? W
Oreanization ^
••i^ivi«^laiie^r
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
X
X
1
"
X
;
�Bright Futures: Nine Month Visit
Objective
to
Health Supervision
Interview
Concerns of family
Parent Roles
Child Care
Siblings
Developmental
Surveillance and
Milestones
Language
Motor
Social
Play
Developmental
Concerns
Observation of
Mother/Father/
Caregiver Interaction
Responsiveness
Attention
** Stranger Anxiety
Comforting
Physical Exam
Screening Procedures
Immunizations
Clinical
Visit
Clinician
Clinical Visit
HSS
Home
Visit
HSS
X
X
X
X
X
X
X
X
XX
XX
X
X
XX
XX
XX
XX
XX
X
X
X
X
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
XX
X
X
XX
XX
XX
X
X
Parent
Handout
X
Parent
Group
X
X
X
X
Community
Based
Organization
Video
Internet
X
X
X
X
X
X
X
X
X
X
X
Other
�Bright Futures: Nine Month Visit
Clinical
Visit
Clinician
Clinical Visit
HSS
XX
X
X
X
X
X
XX
Discipline/Routine
** Sleep
Transitional object
Toys
Safety
** Separation Anxiety
Promotion of
constructive family
relationships
Promotion of
community interactions
Objective
Anticipatory
Guidance
Nutrition
** Feeding
Oral Health
Promotion of enjoyable
Mother/Father
Caregiver interaction
Developmetal
stimulation
o
Home
Vbit
HSS
Parent
Handout
Parent
Group
X
X
X
X
X
X
X
X
XX
X
X
XX
X
XX
X
X
XX
X
X
XX
XX
X
X
X
XX
XX
XX
X
XX
X
XX
XX
XX
X
X
X
X
X
X
XX
X
X
X
X
X
XX
X
X
Community
Based
Organization
Video
Internet
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
X
XX
X
X
XX
X
X
Other
�Bright Futures One Year Visit
XX=Priority
Clinic
Clinic ^
Visit
CUnician HSS
^
Mj'eclive "
"lib rHealth Supervision
Interview
Concerns of family
Parent Roles
Child Care
Siblings/Sibling rivalry
p^elopmental
^^yeillancie and ; •:
^MMtohes':'''''
Language
Gross/Fine Motor
Behavior
Play
Developmental Concerns
^^rv^ibn^of-tS"'
TOtm^aihei/';;:^.
Caregiver/Infant/ •
Interaction
Responsiveness
Attention
Support of toddler
Autonomy/Independence
X
X
^
'
Parent 7 Parent Community
Video
Handout> Groiip ^ Based
Organization .
;
M* .
m »
HSS
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
XX
XX
X
X
X
FIS Telephone
Advice Line
X
X
X
X
XX
X
5
V:
lipicaI|EMl^; '
Screening Procedures
Imtnuhizations
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
�llpsi
i:imcS
Injury Prevention
Nutrition
XX
XX
X
Parenf
Handout Group
iBllMmmm
X
X
XX
X
X
X
X
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
pil3B FIS ,r|aviceiLitfe:-,:
llpia
m
•mm
X
X
X
Proimbtioii of Social m:
NJ
Language Development
Discipline
Rules/Consistency
Aggressive Behavior
Sleep
Toilet training
Promotion of |
constructive family
relationships
Promotion of "
x
,
community interactions
X
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
X
community
board
�Bright Futures 15 Month Visit
Parenf Community
fHandout Group Baled
Organization
Clinician HSS
^«iltIi|Supervision
Concerns of Family
Personality/Behavior
New changes/Stressors
Family Supports
Igjvelbpmeiital
»|rveillance and
fjlliestones
Language
Gross/Fine Motor
Social
Play
Developmental concerns
i^ari^verlnteratction
Parent/toddler play
Responsiveness
Sibling/Toddler
interaction
Screening Procedures
Immunizations;
Video
> FIS Telephone
Advice Line
|.
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
�Bright Futures 15 Month Visit
(Clinic :" ^' ^ iHoffeW-' ]>amit ^Parent
Handout Group
Vs£ ' Visit ' , '<)
C inician HS_S- :;;
HSS r
Clitfic
Objective
v
Anticipatory Guidance
Injury Prevention/Safety
Nutrition
Oral Health
promotion of Social !
fCompetence
'i
Language development
Autonomous Behavior
Limit Setting/Discipline
Aggressive Behavior
Sleeping Habits
Transitional Objects
Toilet Training
m t,
XX
XX
XX
XX
X
XX
X
X
X
XX
X
XX
X
XX
X
XX
XX
XX
XX
X
XX
X
XX
XX
XX
XX
XX
XX
XX
XX
XX
X
X
X
X
X
X
Community
Based
Organization
Video
IfIS Telephone
Advice Line
X
1
wmmmm^m:,.
constructive family my
IrelatafmshipsjI- ^/w- x-^'
Promotion of
coininuiiity interactions
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XX
X
�Bright Futures 18 Month Visit
XX=Priority
jfiinim
5
IE" M
^^^^^^^
CUtaiciaii
^ppSupfvisioii
mmmm «v'V' .'vr .?•'••••iyidco- •
••mi,i >
Based
•
nmm
Interaction
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��CHAPTER 2
THE FIRST THREE YEARS:
OVERVIEW OF THE DEVELOPING CHILD
Fifty years ago, everyone "knew" that newborn babies could neither hear nor see. Today,
there is wide recognition that infants only a few hours old will turn toward the sound of their
mother's voice or gaze with apparent fascination at a human face. The popular press is full of
stories of the rapid pace of brain development before birth and in the earliest months and years
of life.
Our new and remarkable perspective on early human development can be credited to the
work of a variety of academic researchers and practicing clinicians who have been observing
infants ever more closely. New technology—from the video camera to the PET scanner—has
dramatically extended our
powers of observation. Additionally, individual researchers and organizations concerned with
child development are now exchanging clinical and research findings among previously
isolated disciplines. And they are translating discoveries into language meaningful to parents,
front-line practitioners, and policy makers.
Early Brain Development
With developments in neuro-imaging, science has gathered more knowledge about human
brain development in the last decade than it had accumulated in the past five centuries
(Carnegie Task Force on Learning in the Primary Grades, 1996). New insights into molecular
41
�biology have shed light on the workings of the nervous system. At the same time, powerful
new research tools, including sophisticated brain scans, have been created, allowing scientists
to learn more about the developing brain than ever before. With these tools, researchers have
confirmed what parents and other caregivers have long suspected: early brain development
hinges not only on an individual's genetic endowment, but also on the impact of experience
and environment, including the quality of relationships with parents and other caregivers
(Carnegie Task Force on Meeting the Needs of Our Youngest Children, 1994).
Positron emission tomography (PET) studies show that by a baby'sfirstbirthday, the
biochemical patterns of the brain qualitatively resemble those of the normal young adult. This
is a dramaticfinding,considering the complexity of early brain development. From a few
initial cells, the brain develops billions of brain cells (or neurons) over a period of several
months. Once these neurons are formed, they must migrate to the exact locations they are
meant to occupy on a very precise schedule. If anything goes wrong in this process, brain
function may be compromised (Rakic, 1996).
By the time a baby is bom, brain cell formation is virtually complete, but the brain is far
from mature: the next challenge is the formation of connections among the brain cells—up to
15,000 connections (or synapses) for each brain cell. These synapses constitute the "wiring"
that allows learning to take place.
In the months after birth, this process proceeds rapidly, and the number of synapses
increases twenty-fold reaching a total of 1,000 trillion. Indeed, early brain development is
characterized by the overproduction of synapses. As the brain matures in thefirstdecade of
life, it retains and reinforces those connections that are repeatedly used, and eliminates those
42
�that are not. In this way, excess synapses are "pruned"—a process of refinement that responds
to experience and therefore proceeds differently for every individual. In other words, the
brain "learns."
This fine-tuning is particularly intense in the first three years of life. Neuroscientists
believe that the considerable changes in the number and density of synapses in the brain,
especially in the cerebral cortex, are associated with the mastery of basic skills and the
formation of intellectual capacities. Brain scan research confirms that children's brains are
indeed more than twice as active as those of adults (Chugani, 1996).
Scientists are also building a bridge between biology and psychology by studying the
regulatory processes associated with attachment and separation to mothers or other primary
caregivers very early in life Research by developmental psychobiologists is shedding light on
the dynamics of early attachment, and the long-term effects, including vulnerability to later
stress in life, that may result from inadequate nurturing or early separation (Hoffer, 1995).
The implications are profound. Children's early experiences—the amount and kinds of
stimulation they receive, and the cognitive challenges they encounter—don't just affect their
mood or affect; they actually alter the way the brain is "wired." And the kind of nurturing
children receive very early in life does not just affect their disposition; it appears to affect their
emotional resilience later in life. Moreover, early experiences do not only affect the brain;
they affect all of the functions (physiological, emotional, cognitive, and behavioral) that are
mediated by that complex organ.
The quality of the parent-child attachment in the early years also affects the regulation of
the infant's central nervous system in ways that produce different long-range outcomes. We
43
�now know for example, that when this early attachment is absent or severely compromised,
children don't act in anti-social ways later in life only because they are angry or resentful.
They may fail to develop fully the biological systems that allow and regulate the expression of
emotion. Studies on a wide range of young children - including infants with depressed
mothers, toddlers in Romanian orphanages, and survivors or severe childhood trauma confirm these findings.
In short, the early years of life are rife with risk and opportunity. When parents are
chronically unable to "read" their babies and toddlers' signals or respond to them with a
reasonable degree of sensitivity - due to misconceptions about what young children need, or
due to a parents' illness, depression, substance abuse, or intense stress - the damage may be
difficult to remedy later in life.
On the other hand, when children form strong, trusting attachments to caregivers in the
early years, and when they receive sensitive care and appropriate stimulation, they can develop
capacities that will hold them in good stead later in life, enabling them to bounce backfromthe
stress and trauma that life inevitable brings. The kinds of experiences children have in the first
years of life, including the kind of nurturing they receive, appear to affect their ability to meet
new challenges and to learn effectively later in life. These findings suggest that it is
impossible to assess a young child's health or development without considering the quality of
caregiving she is receiving. Healthy Steps takes fully into account the crucial importance of
the early years and places great emphasis on prevention. New insights into brain development
indicate that in order to improve results for children, we have to focus on the full range of
their developmental needs and provide parents and other caregivers with the information,
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�support and resources they need to meet those needs.
Picturing the Developing Child: Scenes from the Nursery
Physical and neurological development are not automatic maturational processes, but occur
in the context of complex and changing social relationships. These relationships, and the
messages they carry for the child, have an important influence on the child's development.
The following vignettes, which come from the work of Jeree Pawl, reflect the impact of
day to day experience on the development of very young children and the opportunities for
Healthy Steps to help parents promote important yet subtle learning during the child's
everyday interactions with mothers and fathers. The first vignette describes how one
event—the ringing of a bell—begins a very different experience for two different babies.
The bell and the babies
A bell rings, the sound registers, and baby Jane experiences a sense of
pleasure, and of interest that alerts her and produces a turn toward where
the sound is. Her face is alert, arid she anticipates more. The bell rings
again and is followed by more pleasure, more movement, and a gurgle of
delight, which creates an imitative response in her partner.
When baby Caroline hears the bell, there is, so to speak, an inner
splintering. It feels bad in her ears, bad in her stomach, and reverberates
throughout her nervous system in a jarring and unpleasant way. She turns
inward; she turns away, tenses, her face sours, and the next ring will
produce a wail and unregulated movement. Her partner will move to
soothe and to comfort.
The bell is exactly the same bell, making exactly the same sound. But the experience of
that bell for these two babies is utterly different. From the beginning, each of us experiences
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�the world in our own way. Every human being will always possess a unique filter which puts a
unique stamp on everything that comes in from the outside. Perception is as personal as the
feel of one's own body and its movement.
Feelings are powerful filters, with a deep impact on perception. The bell feels bad to baby
Caroline. The bell feels good to baby Jane. The experience comes in that way. They don't
do anything to it; that is the way the sound of the bell is received and perceived. Whatever a
baby's (or an adult's) response is, it is different (grossly or subtly) than anyone else's response
would be, and is determined by who one is. The baby's response also has an immediate effect
on the caregiver: Baby Jane's caregiver smiles and rings the bell again; baby Caroline's
frowns sympathetically, deadens the bell, and moves to comfort the baby.
1
The next three vignettes remind us that no two relationships that develop between babies
and those who care for them are entirely alike. Yet within the relationships available to them,
all babies are learning about the same things—about their bodies, objects, who they are, how to
feel about themselves, and what they can expect of those who care for them. Such basic
human capacities as the ability to trust, to experience intimacy with others, and to negotiate
with others begin to develop from the earliest moments of life.
1
These three pairs of vignettes are excerpted from Heart Start: The Emotional
Foundations of School Readiness, with permission from ZERO TO THREE/The National Center
for Infants, Toddlers, and Families.
46
�Three a.m.
A young mother hears a cry from her 5-week-old baby in the nearby
crib. It is 3 a.m. The mother's initial dismay quickly turns to anticipation
of the feeding that will now begin.
The baby senses the light turned on; feels the touches and cradling
of her body and, though hungry, begins immediately to calm from the cues
that tell her that her discomfort is about to end. For half-an-hour the baby
nurses, pausing between bursts of sucking and gazing up into her mother's
eyes, woozily but with what the mother feels is pleasure and recognition.
During the pauses the mother speaks softly to her new daughter. The baby
smiles, watching her mother's shifting expressions. "Hi, Emma - sweet
Emma - you are very pretty. Were you hungry ? Do you want more ? Do
you need a burp? I am glad to see you even if it is 3 am." The baby slowly
begins to drift o f f . Her mother puts her in the crib, kisses her, covers her,
and says "Sweet dreams."
What is happening is utterly ordinary; a mother is feeding her baby. But what is
happening to the baby is extraordinary. Because while being fed, she is learning about
gentleness, about cries being answered, about her ability to make giants come running. She is
beginning to feel effective and secure. She is beginning to sense the subtle rhythm of exchange
with her mother. It is the beginning of learning that she is worth responding to, that she is
important, and that something or someone can be counted upon.
47
�"Shut that baby up!"
A young mother hears a cry from her 5-week-old baby in the crib nearby. It
is 3 am. The mother tenses. She has just fallen asleep after a fight -with the
baby's father. The baby's cries rapidly intensify. "Oh be quiet," says the y
mother exhaustedly. "I can't take one more thing. " The baby cries more
and more loudly.
•:: "Shut that baby up " comes a shout from beyond the thin wall— "shut
that damn baby up!" The mother slams her fist against the wall and shouts,
"Shut up yourself." She rolls out of bed and approaches the crib. "I'm
coming - I'm coming. Damn it - shut up." She lifts the baby up and he
quiets a bit. "Already think you can just cry and get what you want, don't
you? That won't last long, I can tell you. Come on let's get it over with."
As the baby begins to nurse, the mother stares fixedly ahead, going over the
recent angry fight. The mother grows more agitated as she recalls the
details. The baby responds to his mother's tension by squirming restlessly.
Finally, the baby stiffens, arches, draws back from his mother's nipple and
yelps. "You don't want to eat? Fine, don't eat," says the mother and
abruptly puts the still hungry baby back into the crib. The baby cries and
the mother feels a surge of anger. "Shut up—just shut up." The mother
leaves the bedroom, shuts the door and in the kitchen turns up the radio ;
loudly enough so that she cannot hear the baby cry. He cries until he falls
into an exhausted sleep.
This baby is also learning. He is learning that to be handled and held can be uncomfortable
and distressing; that desperate crying may lead only to a sharp and angry voice; that his needs
and wants are not important and that there is no one to count on.
Either of these experiences could occur to the same baby at different times, under different
circumstances. But when either one of these experiences is typical, the effects on that baby's
sense of self and of the world are profound. The first baby's sense of security and of her
feelings about others will be primarily positive; the second baby's will be mainly negative.
Essential qualities and attitudes are already beginning to be shaped.
48
�Daddy's home!
This little boy is 8 months old. He has been sitting in a jump seat
for several hours during the last of which he has slept. He awakens when
the door slams and he hears a deep voice. Immediately he begins to bounce
and crow. Every inch of him is excited. His father enters the room, puts
down his lunch bucket and walks toward him. Now the baby nearly
catapults himself out of his jump chair as his father smiles and reaches for
him, saying, "And hello to you—big guy—come and give your old man a
hug." The baby grips his father 's shirt and reaches for his cheek and his
father nuzzles the baby's hand with his mouth. The father asks if his son is
ready to watch some of the ball game. The baby mirrors his father's happy
feeling and responds with a chain of babbling. The father widens his eyes
and listens, then asks his son's opinion of today's starting pitcher. The
baby looks away—calming himself—the father waits and the baby turns
back: locks eyes with his father and produces a long string of syllables,
ending in a laugh. His father grins and says, "You may be right." The
baby's mother asks the father if he'll change the baby's diaper. The father
grimaces but agrees. Throughout the diaper change, the baby and his
father continue a dialogue full of body movements, facial expressiveness :
and vocal exchanges.
This baby anticipates the pleasure he will have with his father. He has already learned that
most of the time his father feels very good with him and he feels very good with his father. He
has also learned to have "conversations" with his father - to initiate, be intentional, take turns,
listen and respond. He feels respected, understood. He likes himself.
49
�Okay, Stinko!
This little boy is 8 months old. He has been sitting in a jump seat for several
hours, dur ing the last of which he has slept. He awakens when the door
slams and he hears a deep voice. Awake, he wiggles restlessly and looks in
the seat's tray for something to handle. Everything is on the floor. He
makes a noise offrustration - not loud - just expressive of his feelings. He is
not trying to communicate.
The father comes in and tosses his coat over a chair. The baby
grunts and brings his hand to his mouth. The father glances at him and then
glances away. The mother calls to the father and says probably the baby
needs changing. Would he change him while she finishes dinner?
The father says, sarcastically, "Thanks a lot - is that a special
present for me?" He disappears briefly and then suddenly the baby is
abruptly lifted out of the seat from the rear. The baby is surprised but only
stiffens and is quiet. "Ok stinko - let's clean up your load." The baby is
placed on his back to be changed. He lies still - chewing on his hand. Once,
he twists, extends his arm to grasp an object and lifts his leg. The father
pulls him back flat, lightly slaps his thigh and says sharply, "Stay still - I'm
almost done." The baby's eyes widen but he stays quiet—just chewing on his
nd. The father finishes quickly and returns him to his jump chair.
This baby is also learning. He is learning to be wary in what he communicates to his
father. He has learned to be passive and to curb his curiosity. He has no sense that his father
enjoys him. He feels neither understood nor confident. He has learned nothing about turn
taking, or mood sharing, or dialogue with his father.
50
�The puzzle
A l-'A-year-oldgirl approaches her busy mother with some threedimensional puzzle pieces that are not fitting together. She is distressed and
a bit whiny. Her mother glances down, smiles, and says - "What has caused
that misery?" The little girl says, "Ican't do it:" The mother continues
sorting the papers she's working on but leans over to study the pieces. "I
think if you put the green one on top it will work " The little girl stops
whining and tries it. Then she whines again and says, "It doesn't - it doesn't
work " 'Well," her mother says, "I can't help until Ifinish this-later." She
gets only this far when her l-'A-year-old daughter hurls the pieces on the
floor and they all come apart. Her mother looks at her ruefully and then
says, "Come here." The little girl comes and leans against her. "Old dumb
puzzle made you mad - it's ok We '11 fix it later. Could you help me put
away my work?" The 2-%-year-old pullsherself together, smiles, and helps
her put her papers away.
This little girl is learning about her importance, about help, about mutual respect and about
how feeling bad can be followed by feeling good. She is learning a lot about being understood
and about cooperation. She expects to be listened to and she listens. Despite the frustration of
the puzzle, she feels basically competent, appreciated and responsible. She is now in control.
Given experiences such as these, she is likely to enter school with enthusiasm and eagerness to
take part.
"Don V bother me now!"
A 2 'A year-old girl approaches her busy mother with some threedimensional puzzle pieces that are not fitting together. She is distressed and a
bit whiny. Without looking ot her, her mother says, "Stop that blubbering - I've
got enough to do without listening to that." The little girl tries to show her
mother the puzzle. "Don't bother me now—I've got to finish this." The little girl
walks away and suddenly hurls the pieces to the floor. Her mother turns to her
and says, "You know better than to throw things. If you're going to cry and carry
on, just go to your room and stay there or you '11 get something to cry about."
The girl screams louder, runs to her room and slams the door.
51
�This child is getting the message that her needs are not important, that she is not
understood, that feeling bad means more feeling bad and that you can't really count on anyone
when you need them. She is not respected nor does she respect, and she feels out of control.
If that exchange is typical of her relationship with her mother, she is unlikely to enter school
with enthusiasm or possessing the complement of feelings which would help her succeed.
Each of these vignettes represents characteristic interchanges in the lives of children. In
each, important feelings and abilities are being created or strengthened. In the give and take of
our interactions with children, there are powerful implicit messages, many of which have a
deep impact on the child's developing sense of self. Over time, the very different qualities of
these contrasting relationships will heavily influence the repertoire of behaviors that are
characteristic of a particular child.
Obviously, the child's own temperament also matters greatly. So do the more universal
features of biological development. But the children in these different relationships reach their
third birthdays with markedly differing capacities, feelings and expectations. These will
profoundly influence how they approach the opportunities and challenges their homes, schools,
and communities have to offer them. Primary relationships decisively influence the growing
mind and body of the child. Taken together, the continually transforming body, mind and
social world of the child are the complex matrix we usually call "child development."
Some Basic Concepts for Understanding Child Development
Researchers have not been able to agree on a single theory embracing the complexity of
52
�young children's development. But a number of core concepts have emerged to help organize
what is known about infants and families and to point to what is yet to be understood.
Child Development: Some Core Concepts
Endowment
Maturation
Individual differences in the first three years of life
Developmental processes and their interrelationship
Risk
Coping
Adaptation
Mastery
Attachment between infant and caregiver, involving protection and
a sense of security
A transactional model of development, in which the child is
understood to develop in a continuous and dynamic interaction with
his or her family and social context
An ecological perspective on development, stressing the child's
close relationships with a wider social world beyond the walls of the
household.
We need to remember that what we "know" is subject to constant revision. And, like
many other aspects of our lives, theories are subject to change in the light of new experience or
information. Fifty years ago, prevailing theories of development acted as blinders on
professionals' ability to recognize newborns' sensory competence. Now it seems obvious that
53
�infants seek and regulate stimulation. More recently, the term "crack baby" suggested the
prevailing wisdom that a child exposed to cocaine in utero was likely to suffer substantial,
irreparable harm. But perspectives change as more is learned, and such fatalistic predictions
turned out to be of limited value to clinicians. Today we tend to think in terms of the risk and
protective factors for each child and his environment.
"Temperament" is another case in point. For decades the idea of "temperamental"
differences among children has helped researchers, practitioners, and families make sense of
some of the widely differing behavior exhibited by children, even in the same family (Carey &
McDevitt, 1995). Yet even though researchers have identified three major "clusters" of
temperamental characteristics, 40 percent of children combine the qualities of the "difficult"
child, the "easy" child, and the "slow-to-warm-up" child.
Core concepts like these are extremely useful in organizing our understanding of child
development—for parents and pediatric professionals alike. But concepts or categories should
never keep us from careful observation of real children developing in real-world conditions.
The most distressed parents in a primary care consulting room may be those whose children
"aren't in the books" or are "off the charts." Careful observations of individual children are
critically important not only to monitor their health and development but also to confirm or
challenge current concepts and theories of development. Table 1 provides an overview of
typical developmental milestones for children from birth to age 3.
54
�Developmental Milestones of
Children from Birth to Age 3
iitiii
The Early Months
(birth through 8 months)
Crawlers and Walkers
(8 to 18 months)
Toddlers and 2-Year-Olds
(18 months to 3 years)
• Newborns prefer ihe human face and
human sound. Within the first 2 weeks,
they recognize and prefer the sight,
smell, and sound of the principal caregiver.
• Social smile and mutual gazing arc
evidence of early social interaction
Can initiate and terminate these interactions.
• Anticipates being lifted or fed and
moves body to participate.
• Sees adults as objects of interest and
novelty. Seeks out adults for play.
Stretches arms to be taken.
• Sucks fingers or hand fortuitously.
• Observes own hands.
• Places hand up as an object
comes close to the face as if to
protect self.
• Looks to the place on body
where being touched.
• Reaches for and grasps toys.
• Clasps hands together and fingers them.
• Tries to cause things to happen.
• Begins to distinguish friends
from strangers. Shows preference
for being held by familiar people.
• The young infant uses many
complex reflexes: searches for
something to suck; holds on when
falling: turns head to avoid obstruction of breathing; avoids
brightness, strong smells, and
pain.
• Puts hand or object in mouth.
Begins reaching toward interesting objects.
• Grasps, releases, regrasps, and
releases object again.
• Lifts head. Holds head up. Sits
up without support. Rolls over.
• Transfers and manipulates objects with hands. Crawls.
'•Exhibits anxious behavior around unfamiliar adults.
• Enjoys exploring objects with another
as the basis for establishing relationships.
• Gets others to do things for child's
pleasure (wind up toys, read books, get
dolls).
• Shows considerable interest in peers.
• Demonstrates intense attention to
adult language.
• Models adult behaviors like vacuuming, setting table, putting on coat and
carrying purse to "go work." using a
telephone or another object as a telephone.
• Enacts simple dramatic play scenarios
with others, like caring for dolls, acting
like an animal, or riding in a car or
train.
• Knows own name.
• Smiles or plays with self in mirror.
• Uses large and small muscles to
explore confidently when a sense
of security is offered by presence
of caregiver. Frequently checks
for caregiver's presence.
• Has heightened awareness of
opportunities to make things happen, yet limited awareness of responsibility for own actions.
• indicates strong sense of self
through assertiveness. Directs actions of others (e.g., "Sit there!")
• Identifies one or more body
parts.
• Begins to use me. you, 1.
• Sits well in chairs.
• Pulls self up. stands holding furniture.
• Walks when led. Walks alone.
• Throws objects.
• Climbs stairs.
• Uses marker on paper.
• Stoops, trots, can walk backward a few steps.
• Shows increased awareness of being
seen and evaluated by others.
• Sees others as a barrier to immediate
gratification.
• Begins to realize others have rights
and privileges.
• Gains greater enjoyment from peer
play and joint exploration.
• Begins to see benefits of cooperation
• Identifies self with children of same
age of sex.
• Is more aware of the feelings of others.
• Exhibits more impulse control and
self-regulation in relation to others.
• Enjoys small group activities.
• Acts out simole dramatic nlav themes
• Shows strong sense of self as an
individual, as evidenced by "NO"
to adult requests.
• Experiences self as a powerful,
potent, creative doer. Explores
everything.
• Becomes capable of sell-evaluation and has beginning notions of
self (good, bad, attractive, ugly).
• Makes attempts al self-regulation.
• Uses names of self and others.
• Identifies 6 or more body parts.
• Scribbles with marker or
crayon.
• Walks up and down stairs. Can
jump off one step.
• Kicks a ball.
• Stands on one foot.
• Threads beads.
• Draws a circle.
• Stands and walks on tiptoes.
• Walks up stairs one fool on
each step.
• Handles scissors.
• Imitates a horizontal crayon
stroke.
55
�Note: This list is not intended to be exhaustive. Many of the behaviors indicated here will happen earlier or later for individual infants.The chart
suggests an approximate time when a behavior might appear, but it should not be rigidly interpreted.
Often, but not always, the behaviors appear in the order in which they emerge. Particularly for younger infants, the behaviors listed in one domain overlap considerably with several other developmental domains. Some behaviors arc placed under more than one category to emphasize this
interrelationship
• Cries to signal pain or distress.
• Smiles or vocalizes to initiate
social contact.
• Responds to human voices. In
the first month can distinguish familiar human voices from all
other sounds. Gazes al faces.
• Uses vocal and nonvocal communication to express interest
and exert influence.
• Babbles using all types of
sounds. Engages in private conversations when alone.
• Combines babbles. Understands
names of familiar people and objects. Laughs. Listens to conversations.
• By about 6 months, distinguishes sounds of home language
from other speech.
• Comforts self by sucking thumb
or finding pacifier.
• Follows a slowly moving object
with eyes.
• Recognizes expected patterns of
objects in motion (such as arc,
bounce, or slide).
• Reaches and grasps toys.
• Looks for dropped toy.
• Remembers intricate details of
an object (such as a mobile) and
shows signs of recognition on seeing the object again.
• Identifies objects from various
viewpoints. Finds a toy hidden
under a blanket when placed
there while watching.
• Predicts a sequence of events
after seeing the sequence a number of limes.
• Observes own hands.
• Grasps rattle when hand and
rattle are both in view.
• Hits or kicks an object to make
a pleasing sight or sound continue.
• Tries to resume a knee ride by
bouncing to gel adult started
again.
• Exprevses discomfort and
comfort/pleasure unambiguously.
• Responds with more animation and
pleasure to primary caregiver than to
others.
• Can usually be comforted by familiar
adult when distressed.
• Smiles and shows obvious pleasure in
response to social stimulation. Very interested in people. Shows displeasure
al loss of social contact.
• Laughs aloud (belly laugh).
• Shows displeasure or disappointment
at loss of toy.
• Expresses several clearly diffcrentialed emotions: pleasure, anger, anxiety
or fear, sadness, joy. excitement, disappointment, exuberance.
• Reacts to strangers with soberness or
anxietv.
• Uses eye contact to check back
with primary caregiver.
• By about 8 months, turns to
look at an object, like a ball, on
hearing the word "ball" in the
home language.
• Understands many more words
than can say. Looks toward 20 or
more objects when named.
• Creates long babbled sentences.
• Shakes head no. Says 2 or 3
clear words.
• Looks at picture books with interest, points to objects.
• Uses vocal signals other than
crying to gain assistance.
• Begins to use mf, you, I.
• Tries to build with blocks.
• If toy is hidden under I of 3
cloths while child watches, looks
under the right cloth for the toy.
• Persists in a search for a desired
toy even when toy is hidden
under distracting objects such as
pillows.
• When chasing a ball that rolled
under sofa and out the other side,
will make a detour around sofa to
get ball.
• Pushes foot into shoe, arm into
sleeve.
• When a toy winds down, continues the activity manually.
• Uses a slick as a tool to obtain a
toy.
• When a music box winds down,
searches for the key to wind il up
again.
• Brings a stool to use for reaching for something.
• Pushes away someone or something not wanted.
• Creeps or walks to get something or avoid unpleasantness.
• Pushes foot into shoe, arm into
sleeve.
• Partially feeds self with fingers
or spoon.
• Handles cup well with minimal
spilling.
• Handles spoon well for selffeeding.
• Actively shows affection for familiar
person: hugs, smiles at. runs toward,
leans against, and so forth.
• Shows anxiety at separation from primary caregiver.
• Shows anger focused on people or
objects.
• Expresses negative feelings.
• Shows pride and pleasure in new accomplishments.
• Shows intense feelings for parents.
• Continues to show pleasure in mastery.
• Asserts self, indicating strong sense of
self.
• Combines words.
• Listens to stories for a short
while.
• Speaking vocabulary may reach
200 words.
• Develops fantasy in language.
Begins to play pretend games.
• Defines use of many household
items.
• Uses compound sentences.
• Uses adjectives and adverbs.
Recounts events of the day.
• Identifies a familiar object by
touch when placed in a bag with 2
other objects.
• Uses "tomorrow," "yesterday."
• Figures out which child is missing by looking al children who are
present.
• Asserts independence: "Me do
it."
• Puts on simple garments such as
cap or slippers.
• When playing with a ring-slacking toy, ignores any forms that
have no hole. Stacks only rings or
other objects with holes.
• Classifies, labels, and sorts objects by group (hard versus soft,
large versus small).
• Helps dress and undress self.
• Uses objects as if they were
something else (block, as car, big
block as bus, box as house).
• Frequently displays aggressive feelings and behaviors.
• Exhibits contrasting slates and mood
shifts (stubborn versus compliant).
• Shows increased Tearfulness (dark,
monsters, etc.).
• Expresses emotions with increasing
control.
• Aware of own feelings and those of
others.
• Shows pride in creation and production.
• Verbalizes feelings more often. Expresses feelings in symbolic play.
• Shows cmpalhic concern for others.
56
�The Developing Infant in a Social Context
Several decades ago, British pediatrician and psychoanalyst Donald Winnicott shocked his
colleagues by declaring, "There is no such thing as a baby"— only a baby and a caregiver.
Today, practitioners and researchers assume we must understand an infant's development in
the context of his particular social environment. This chapter is a sketch of a child'sfirstthree
years of development. We introduce the key concepts of endowment, maturation, individual
differences, and the interrelationship of developmental processes. Taken together, these
concepts approximate what used to be called a child's "nature." We then examine in greater
detail several aspects of infant development— emotional development, the acquisition of motor
control, the development of communication and language, and relationships with others.
At birth, a child's biological endowment includes (a) limbs, organs and sensory systems
(intact or impaired) and (b) capacities for organizing experience and interacting with the
environment. While we normally think of an endowment as biologically "given," a child's
actual endowment is always found at the intersection of genetics and the particular uterine
environment, as well as the events surrounding birth. The mother's nutrition, infections, use
of drugs, and psychological experiences affect the unborn baby and influence his
developmental potential and his behavior. The baby's unique endowment calls forth and
begins to shape a particular spectrum of responses, most importantly from the caregivers
themselves.
Maturation, an inherent "push" toward growth at an expected rate and sequence, is
relatively independent of environmental influences. Interacting with environmental factors,
maturation ensures for a healthy child the attainment of major motor milestones, cognitive
57
�competencies, and emotional growth in a wide range of environments.
The notion of individual temperament—a blend of activity level, physical sensitivity,
adaptability, tempo, mood, persistence, and similar factors—is one way of conceptualizing
differences that influence how young children behave and how parents react to them.
Temperamental differences also affect babies' fundamental responses—emotional, perceptual
and cognitive— to their own bodies and to the wider world.
Newborn babies develop a distinctive emotional repertoire, motor abilities, communicative
skills, and social skills, in the process of becoming an adept "participant in the world." The
following brief discussion of several key developmental domains suggests each area's critical
contribution to the child's overall experience of the world.
First Feelings
The world of the infant or young child is a world of feelings. As psychologist L. Alan
Sroufe observes, "understanding emotional growth and understanding human development in
general are virtually the same task, since emotion is so integrated with other aspects of human
functioning." (Sroufe, 1996, p. 39). The young child's emotional capacities may be thought of
as the "glue" that holds the child's development together. Child psychiatrist Stanley I.
Greenspan (1995) identifies five stages of emotional development in the earliest years.
While these abilities underlying a child's "emotional intelligence" are termed "stages," it is
important to keep in mind that each set of capacities continues to develop as the child grows.
58
�Five Stages of Early Emotional Development
1.
2.
3.
4.
5.
Security and the ability to look, listen, and be calm
Relating, the ability to feel close to others
Intentional two-way communication, involving the infant's
learning to read others' body posture and facial expressions, and
communicating with nonverbal patterns
Putting feelings into words or into dramatic play
Using symbolic communication and dramatic play to express
complex emotional ideas and causal connections among events,
ideas, and feelings.
Table 2 outlines the themes and behaviors of socioemotional development in infants and young
children.
59
�Table 2:
Socioemotional Development of Infants and Children: Themes and Behaviors
Stanley I. Greenspan, M.D.
3 Months:
Regulation and Interest in the World
5 Months:
Forming Relationships (Attachments)
•
•
•
•
•
Can be calm.
Recovers from crying with comforting.
Is able to be alert.
Looks at one when talked to.
Brightens up to appropriate experiences.
•
•
Shows positive loving affect toward primary
caregiver (and other key caregivers).
Shows full range of emotions.
•
•
en
o
9 Months:
Intentional Two Way Communication
•
•
Interacts in a purposeful (i.e., intentional, reciprocal,
cause-and-effect) manner.
Initiates signals and responses purposefully to
another person's signals.
•
•
•
•
Shows an interest in the world by looking at (brightening)
or listening to (turning toward) sounds. Can attend to
visual or auditory stimulus for three or more seconds.
Can remain calm and focused for two or more minutes at a
time, as evidenced by looking around, sucking, cooperating
in cuddling, or other age-appropriate activities.
Responds to social overtures with an emotional response of
pleasure (e.g., smile, joyful vocalizations).
Can display negative affect (e.g., frown, negative
vocalizations, angry arm or leg movements).
Responds to caregiver's gestures with intentional gestures
of his or her own (e.g., when caregiver reaches out to pick
up infant, infant may reach up with own arms; a flirtatious
caregiver vocalization may beget a playful look and a series
of vocalizations).
Initiates intentional interations (e.g., spontaneously reaches
for caregiver's nose, hair, or mouth; uses hand movements
to indicate wish for a certain toy or to be picked up).
�13 Months:
Developing a Complex Sense of Self
•
•
18 Months:
Increasingly Complex Sense of Self
•
•
Sequences a number of gestures together and
responds consistently to caregiver's gestures, thereby
forming chains of interaction (i.e. opens and closes a
number of sequential circles of communication).
Manifests a wide range of organized, socially
meaningful behaviors and feelings dealing with
warmth, pleasure and assertion, exploitation, protest,
and anger.
Comprehends, communicates, and elaborates
sequences of interaction that convey basic emotional
themes.
•
•
24 Months:
Representational Capacity of Emotional
Ideas
•
Creates mental representations of feelings and ideas
that can be expressed symbolically (e.g., pretend play
and words).
•
Strings together three or more circles of communication
(interactions) as part of complex pattern of communication.
Each unit or circle of communication begins with an infant
behavior and ends with the infant's building in and
responding to the caregiver response. For example, an
infant looks and reaches for a toy (opening a circle of
communication). As the infant explores the toy and
exchanges vocalizations, motor gestures, or facial
expressions with the caregiver, additional circles of
communication are opened and closed.
Has the ability, with a responsive caregiver, to open and
close 10 or more consecutive circles of communication
(e.g., taking caregiver's hand and walking toward
refrigerator, vocalizing, pointing, responding to caregiver's
questioning gestures with more vocalizing and pointing;
finally getting caregiver to refrigerator, getting caregiver to
open door, and pointing to the desired food.)
Imitates another person's behavior and then uses this newly
learned behavior to convey an emotional theme (e.g.,
putting on daddy's hat and walking around the house with a
big smile, clearly waiting for an admiring laugh).
Can construct, in collaboration with caregiver, simple
pretend play patterns of at least on "idea" (e.g., dolls
hugging or feeding the doll).
�30 Months:
Greater Representational Elaboration of
Emotional Themes
cn
to
36 Months:
Emotional thinking
Can elaborate a number of ideas in both make-believe
play and symbolic communication that go beyond
basic needs (e.g., "want juice") and deal with more
complex intentions, wishes, or feelings (e.g., themes
of closeness or dependency, separation, exploration,
assertiveness, anger, self-pride, or showing off).
Creates pretend dramas with two or more ideas (e.g.,
dolls hug and then have a tea party). The ideas need
not be related or logically connected to one another.
Uses symbolic communication (e.g., words, pictures,
motor patterns) to convey two or more ideas at a time
in terms of complex intentions, wishes, or feelings.
Ideas need not be logically connected to one another.
Can communicate ideas dealing with complex
intentions wishes, and feelings in pretend play or
other types of symbolic communication that are
logically tied to one another.
Distinguishes what is real from unreal and switches
back and forth between fantasy and reality with little
difficulty.
In pretend play, involves two or more ideas that are
logically tied to one another but not necessarily realistic
(e.g., "The car is visiting the moon" [and gets there] "by
flying fast"). In addition, the child can build on an adult's
pretend play idea (i.e., close a circle of communication). For
example, the child is "cooking a soup" and the adult asks
what is in it. The child says, "rocks and dirt" or "ants and
spiders."
Engages in symbolic communication that involves two or
more ideas that are logically connected and grounded in
reality: "No go to sleep. Want to watch television."
"Why?" asks the adult. "Because not tired." Child can close
symbolic circles of communication (e.g., child says, "Want
to go outside." Adult asks, "What will you do?" Child
replies, "Play.").
�42-48 Months:
Emotional Thinking
Is capable of elaborate complex pretend play and
symbolic communication dealing with complex
intentions, wishes, or feelings.
Engages in "how," " w h y , " or "when" elaboration, which
give depth to play and communication. (Child sets up castle
with an evil queen who captured the princess. Why did she
capture the princess? "Because the princess was more
beautiful." When did she capture her? "Yesterday." How
will the princess get out? " Y o u ask too many questions.")
Deals with causality in a reality-based dialogue. ("Why did
you hit your brother?" "Because he took my toy." " A n y
other reason?" "He took my cookie.")
Distinguishes reality and fantasy. ("That's only pretend";
"That's a dream. It's not real.")
Uses concepts of time and space. (Caregiver: "Where
should we look for the toy you can't find?" Child: "Let's
look in my room. I was playing with it there." Caregiver:
"Not now; maybe in 5 minutes." Child: "No. Want it now!"
Caregiver: " Y o u can have the cookie in 1,2, or 5 minutes."
Child: " O K . One minute.")
�Motor Control: A Resource for Adaptive Coping
When does locomotion begin? One might say that locomotion begins at
about four months, when a baby first succeeds in turning over on his stomach.
He has to be able to do that before he begins to creep and crawl, which he
succeeds in doing in several weeks. Some babies, however, do hot creep or
crawl. They want to be able to see everything, so they have to discover a way
to manage locomotion while retaining a large visual area. I was told as a
child that I managed locomotion by maintaining a sitting position, extending
one leg, and hitching along. I couldn't move as fast as a crawling baby
moves, but 1 could see much more.
It is some time after creeping and crawling (or hitching) before a baby is able
to stand up and take hisfirststeps. The timing variesfromchild to child. At
a party for little children, I saw one eight-month-old boy running around the
room with perfect ease, while his 13-month-old host had not yet begun to try
to walk (and would not do so until 18 months). The bodies of the two
children were very different. The eight-month-old was slender and
beautifully coordinated; he had no problem in coping with his weight. In
contrast, his host was heavy, with a low center of gravity, and it was not easy
for him to stand up. However, he had beautifulfinemuscle coordination and
could thumb the pages of a magazine like an adult...." (Lois Barclay
Murphy) r
It is in large part through motor acts that the very young child develops and expresses
perception, emotion and cognition. An infant is born with all of the basic movements. The
newborn can extend, flex, move side-to-side, and rotate. What the newborn lacks are (a) the
postural control necessary to assume increasingly advanced developmental positions against
gravity, and (b) the coordination to use a wide variety of movement patterns in order to
accomplish a task. For an infant, to acquire motor skills is to organize the movements
available at birth into increasingly sophisticated adaptive movement strategies (Gilfoyle, Grady
& Moore, 1981).
64
�Postural control works against gravity and so develops from the head toward the feet.
Gradually the infant coordinates movement in a predictable sequence—extension, flexion,
lateral movement, and rotation, expanding his repertoire of coping strategies. Through play
and social interaction, infants learn to organize these movements for practical purposes.
Communication Skills
Children typically speak their first words anywhere between 12 and 20 months of age
(Bates, O'Connell & Shore, 1987). But they communicate actively from birth. Lacking
words, infants communicate in many ways and through numerous sensory channels. Looking,
listening, moving, touching, and reaching all support the development of joint attention
between parent and child, and are at the root of a child's ability to relate with others.
Why Do Infants Communicate?
1.
To regulate another person's behavior — for example, to request or
to protest an object or action.
2.
To attract or maintain another person's attention for social
interaction.
3.
To draw joint attention to objects and events.
I
4.
Because communicating is inherently pleasurable.
So long before they begin to talk, infants and toddlers learn to communicate with gestures
and sounds. With increasing motor skills, infants' interactions become more reciprocal, and
communication more complex. By the end of her first year a child begins to initiate, imitate,
65
�and express ideas and feelings through symbolic play and language.
Young children are persistent and intelligent strategists in their attempts to communicate
with caregivers. When communication fails—when a caregiver doesn't seem to understand or
care what the child wants—a young child will repeat or modify the signal in a sometimes
frantic effort to make contact. A mild vocalization becomes a loud demand. A strong tug on
the caregiver's clothing becomes a kind of punctuation mark.
Giving, showing, pushing away, reaching, pointing, and waving: these are the
communicative resources of the young infant. Later, infants learn the use of conventional
gestures such as head nods and head shakes to indicate affirmation or rejection. Toddlers
become fascinated by the use of words. Words are new tools for relating to peers and adults.
They listen and can follow simple instructions. They ask "why" repeatedly in order to engage
adults as much as to get answers. Words have power. Toddlers can use words to evoke what
is not present and to express strong feelings. In a child care setting, for example, toddlers
often repeat phrases like "mommy come back" in a ritualistic way to comfort themselves when
feeling the sadness of separation, and to reassure themselves that the separation is not
permanent.
Literacy begins long before formal education (McLane & McNamee, 1991). Through
exposure to
books, signs, cereal boxes and a world of readers, toddlers gradually become increasingly
aware of the importance of written language. Just as with spoken language, toddlers use their
keen powers of observation and desire to imitate the activities of adults and older children
66
�around them to learn about various forms of written language before they can read or write.
Social Development
Social Development: Birth-12 Months
Security needs
Early exploratory behavior
Issues of separation and attachment
Stranger anxiety
Communication maintained through eye-contact, vocalization and gesture
From birth to 12 months of age, the infant needs security most of all. It is through
responsive interactions with parents and a few other special caregivers that infants develop a
sense of a safe, interesting, and orderly world. Feelings about security influence the baby's
inclination to explore. Learning that they can count on being cared for helps infants build a
sense of security.
Exploration takes center stage as infants become more mobile. It is important for parents
to remember that at this stage infants practice independence but very much need trusted adults
as a secure base of support. Infants at this stage make use of new physical, cognitive, social,
and emotional abilities, and the connections among them, to discriminate between familiar and
unfamiliar people; almost all infants during this period show stranger anxiety among unfamiliar
people. Eye contact, vocalizing, and gesturing take on importance as tools for maintaining an
67
�attachment with loving, vigilant adults, on whom mobile infants rely to create an environment
safe for exploration and to reassure them of their safety.
Social Development: 12-36 Months
Exploration
Finding meaning in objects, actions and people
Issues of identity, independence and control
Situationally appropriate behavior
Culturally appropriate ways of interacting
Doing things and getting things with words
The period from 12 to 36 months is filled with exploration, questioning, discovery, and
determination to find meaning in events, objects, and words. At about 18 months of age, the
focus shifts to issues of identity, independence and control.
The social awareness of toddlers is vastly more complex than that of younger infants.
Through dramatic play, increasing facility with language, and negotiation of conflicts with
peers and adults, toddlers build a sense of themselves as social beings—competent,
cooperative, and emotionally connected.
Coping
Like their parents, infants and toddlers are constantly coping. Daily living means
68
�managing opportunities, demands, and frustrations—learning to drink from a cup, reacting to
the approach of a rambunctious puppy, or enrollment in a child care center. Shirley Zeitlin
and G. Gordon Williamson have observed that children cope by drawing on internal
resources— their beliefs about how the world works, their physical and emotional states, their
developmental skills, and their characteristic ways of dealing with threatening situations. They
also draw on external resources such as parents, and other caregivers. What we hope to see
are coping skills finely tuned to the demands, challenges, and expectations children encounter.
Parents and other caregivers can encourage a good fit between a child's coping skills and the
demands on the child by:
•
modifying demands in line with the child's capabilities
•
enhancing the child's coping resources, and
•
providing appropriate feedback to the child to reinforce desired coping strategies.
Regulation
Babies thrive on routine and structure. Without such regulation of their environment, they
become fiissy and disorganized in their behavior. Regulation begins at birth. For parents, a
new baby often disrupts their old routines, throwing their lives into what feels like chaos. Yet
parents need to regulate disorganization, rather than become part of it.
69
�Creating a Regulated Environment for a Baby
Listen to the baby: Why are you distressed? Can I read your
signals? Can I fix your distress?
Meet baby's needs: If 1 meet your needs, you will develop trust.
With time, you will learn to respect me also.
Determine your own needs: I need you in bed by 9 o'clock. Let's
eat a bit early.
Define a pattern or structure: We need to know what to expect
from one another. You have helped me to know your need; now I
will help you work toward a good schedule for us both.
Reinforce the pattern: I will try to always follow our rules so that
you can learn them. Our pattern will be clear so that your body and
your mind will know what to expect.
Be clear: You need quiet space now; you have had a busy day.
You can feel fed, warm, and loved. Now it's bed time. Good night;
I'm close; you're safe.
Be consistent: Follow the same pattern every night—same music,
same routine, same time, same toys, same leaving the room, same
opportunity for baby to self-quiet.
Play
"Play is a window through which we come to understand the child from both the outside
and the inside," write child development researchers Margaret Sheridan, Gilbert Foley, and
Sara Radlinski (1995, p. 4). Play seems to be a kind of all-purpose activity for children,
simultaneously serving a great variety of needs. Some researchers see play as a window on the
child's inner life and a way for young children to reduce tension, vent forbidden impulses, and
70
�transcend the limitations of their bodies and environment. Others emphasize the role of play as
a safe way for children to try out roles and relationships they see as part of the grownup world.
Still other psychologists view play as a key way of learning through guided discovery in a
prepared environment.
As the young child moves up the symbolic ladder, observes psychologist Serena Wieder
(1996), her play is likely to reflect themes or ideas related to developmental issues like
dependency, body integrity, separation, power, fears, and aggression. Toddlers' play abounds
in themes of getting hurt, doctor visits, car crashes, ambulances and fire trucks rushing to the
scene, repair jobs, playing family or teacher, monsters, power figures, and good guy-bad guy
battles. Such themes reflect toddlers' awareness of their separateness and vulnerability as they
strive for more autonomy, as well as their emerging assertiveness and ability to solve
problems. As children become more competent, they assume that virtually any feat is within
their power. They are Superman or a Power Ranger; they can be anyone and do everything.
Somewhere between three and four years of age children become realists. Now they know
they can only pretend to be powerful in play. But this realistic attitude does not come easily.
The symbolic world continues to provide a refuge where children (and adults) can experiment
with their identities. Through play children can work through the central themes of
dependency, assertiveness, and aggression.
Summary
Even before birth, the growing child brings a unique biological endowment into a crucial
relationship with a particular kind of social and physical environment. The interaction of the
71
�two is what we call child development. Humans are learners from the start. Their day-to-day
experiences in the context of their early relationships are inevitably powerful and enduring
lessons for young children. Through their earliest encounters they come to know who they
are. And they learn what they can expect from the world. Throughout the first three years of
life, the child uses his growing communication and language skills, emotional and intellectual
development, motor control and relationships with others to cope with inner needs and external
demands, to explore the world, and to create meaning from it.
72
�References:
Bates, E., O'Connell, B. & Shore, C. (1987). Language and communication in infancy. In J.
Osofsky (Ed.), Handbook of infant-development. New York: Wiley.
Carnegie Task Force on Learning in the Primary Grades (1996). Years of promise: A
comprehensive learning strategy for America's children. New York: Carnegie Corporation of
New York.
Carnegie Task Force on Meeting the Needs of Our Youngest Children (1994). Starting points:
Meeting the needs of our youngest children. New York: Carnegie Corporation of New York.
Carey, W.B. & McDevitt, S.C. (1995). Coping with children's temperament: A guide for
professionals. New York: Basic Books.
Chugani, Harry T. (In Press). Neuroimaging of developmental non-linearity and
developmental pathologies. In R.W. Thatcher, G.R. Lyon, J. Rumsey, and N. Krasnegor,
Eds., Developmental neuroimaging: Mapping the development of brain and behavior.
Gilfoyle, E.M., Grady, A.P. & Moore, J.D. (1981). Children adapt. Thorofare, NH: Charles
B. Slack.
Greenspan, S.I. (1995). The challenging child. Reading, MA: Addison-Wesley Publishing Co.
Hoffer, Myron A. (1996). Hidden regulators: Implications for a new understanding of
attachment, separation, and loss. In S. Goldberg, R. Muir, and J. Kerr, eds. Attachment
theory: Social, developmental, and clinical perspectives. Hillsdale, NJ: The Analytic Press.
McLane, J.B. & McNamee, G.D. (1991). The beginnings of literacy. Zero to Three, Vol. 12,
No. 1, pp. 1-8.
Perry, B.D., R.A. Pollard, T.L. Blakley, W.L. Baker, and D. Vigilante, Childhood trauma,
the Neurobiology of Adaptation, and "use-dependent" development of the brain: How "states"
become "traits." Infant Mental Health Journal, Vol. 16, No. 4, Winter 1995.
Rakic, Pasko (1996). Development of the cerebral Cortex in human and nonhuman primates.
In M. Lewis, ed., Child and adolescent psychiatry: A comprehensive textbook. Second
Edition. Williams & Wilkins, pp. 3-90.
Sheridan, M.K., Foley, G.M., & Radlinski, S.H. (1995). Using the supportive play model:
Individualized intervention in early childhood practice. New York: Teachers College Press.
73
�Sroufe, L.A. (1996). Emotional development: The organization of emotional life in the early
years. New York: Cambridge University Press.
Wieder, S. (1996). Assessing young children's symbolic and representational capacities
through observation of free-play interaction. In S.J. Meisels & E. Fenichel (Eds.) New
Visions for the developmental assessment of infants and young children. Washington, D.C.
ZERO TO THREE/National Center for Clinical Infant Programs.
Zero to Three/National Center for Clinical Infant Programs (1992). Heart start: The
emotional foundations of school readiness. Arlington, VA: Author.
74
��CHAPTER 3
RELATIONSHIPS A R E T H E K E Y TO DEVELOPMENT
Richard's father died when he was five. His mother needed to invest all of her
energy in his upbringing: She gave him few choices and demanded that he comply •
because "slie needed him to take care of her." Richard is now the primary caregiver
for his seven month old son Aaron. He is warm and loving yet rigid about schedules
and often is unable to read Aaron's signals or put Aaron's needs ahead of his own.
Richard readily argues ivith any advice given to him and dismisses suggestions with,
"Tliat won't work for us."
Clinicians are always lamenting that so many parents are unable or unwilling to follow
their suggestions. Providing parents with child development information alone is simply not
enough.
Why do parents seek help over and over for the same concerns? Often it is because these
suggestions have not taken into account the complex nexus of sometimes invisible
relationships involved in child-rearing. Although parenting is indeed a normal
developmental process, it is not the only process that is going on for parents. Mothers and
fathers add the task of parenting to their own relationship tasks, bringing strength and
comfort, as well as a host of unresolved conflicts and unmet needs. This affects not only
their childrearing abilities, but also their ability to listen to and act on child development
information and suggestions for parenting approaches.
Parents' key relationships fall into three primary family patterns:
•
the parent-parent or adult-adult interactions;
•
the parent-child relationship; and
75
�•
the child system, an arena of childhood rituals, games, fighting and competition,
providing siblings with "legitimate" outlets for power struggles.
The Parent-Parent Relationship
There are many parent-parent relationship issues that come to the attention of clinicians,
as parents play out issues of power, control and equity within the relationship.
•
•
;
:
Two people fall in love, get married and negotiate the tasks of living
together. He does the dishes, trash and lawn. She takes responsibility
for cooking and laundry. They share cleaning the house. He does
bathrooms. Then baby makes three. Mom is home now with the baby so,
of course, she can do all the chores, right?
A nineteen year old mother is disappointed because her boyfriend (the
father of her child) brings their three year old daughter a valentine, not
y: herfmm
•
Parents refer to the "good old days" when they had a sex life:., before
children.
Parents (together or divorced) work out patterns of communication about their relationship.
Children challenge those patterns. It is wise for clinicians to keep in mind the influences of
the parent-parent relationship since it lays the groundwork for future family dynamics. It is
the configuration into which the child attempts to "fit." From this relationship, children also
learn to disagree, argue, make up, cope with conflict and observe what it means to be an
adult.
Parents are rightly concerned about the effects of their stress and fighting on their infants
76
�and young children. Even very young infants are aware of parents' emotional states and react
to their moods, facial expressions and verbal responses (Tronick, et. al., 1978; Emde and
Sorce, 1983). Some children respond with distress. Others cope surprisingly well during
periods of family stress only to fall apart when the parents' relationship improves enough to
give attention and energy to the child.
Table 1 describes four categories of marital stress as seen from the child's perspective.
Children in category I are clearly at risk, whereas children in category IV are likely to show
few signs of distress due to their parents' relationships. While the extremes are clear,
categories II and III are likely to pose many challenges to Healthy Steps clinicians.
77
�Table 1:
CHILDREN'S REACTIONS TO PARENTS RELATIONSHIP PATTERNS
I
II
Ill
IV
ABUSE
DISSONANCE
DENIAL
BALANCE
Couple Behavior
Violent,
hostile,
unpredictable
& physical.
Violent,
predictable,
physical &
verbal
Consistent,
Consistent
affective conflicts.
disturbance w/o
resolution
(under the surface)
Conflicts are
avoided.
Difficulties are
settled quickly
and quietly and
away from the
children.
Regular or
occasional
conflict. Can be
loud and
aggressive,
always nonviolent.
Resolution and
period of peace.
From The
Child's
Perspective
Who will keep
me safe?
What's really
going on here?
My instinct says
they are mad or
upset. They say
they're ok. Is it
me? Please stop
banging the pots.
Negative feelings
are wrong and to
be avoided at all
costs. When
someone's upset
with me it feels
like the end of
the world.
Sometimes
people who love
each other get
very angry or
disappointed or
hurt and they find
ways to recover
and grow.
Clinicians are often called upon to address these issues when a parent's report of family
life reveals domestic violence, divorce, separation or intense conflict. Much less obvious are
the normal everyday stresses and strains of adult relationships on the child. Children are not
skillful enough to report the effects of unexpressed, "simmering" or unresolved marital
conflicts until well into their adulthood. Yet they can communicate their distress through
behaviors such as inconsolable fussiness, excessive limit testing, sleep disruptions, eating
difficulties and toileting regressions.
Although parental discord is a prime cause of a host of behavioral and emotional
78
�difficulties for children, it is rarely considered as a cause of child-behavior problems. Family
systems theory suggests that we also consider the parents' relationship as a possible source of
stress for children although clinicians commonly look to the child alone or parent-child
relationship for explanations of behavior.
As the following case vignettes demonstrate, unresolved relationship issues between
parents can unwittingly affect parent-child relationships.
Power and Control
Cora is a secretary at a large manufacturing company. She and her husband Otto
have one child Joy, who is J 6 months old: Cora regularly attends a parenting
support group and often discusses her frustration at her inability to set
limits for Joy. Cora speaks of her desire to be less controlling than her mother,
yet every suggestion made by the group is met with resistance. An observation of :
Cora and Otto together revealed a relationship dominated by Otto, leaving Cora
too intimidated and self- doubting to be effectively in control of her daughter. By
focusing group discussions away from child discipline strategies towards the
effects of marital patterns on parent-child relationships, Cora was gradually
able to use these new insights to rethink her relationship with her child. In
time she was able to begin to implement limit-setting suggestions with a renewed
self- confidence.
The parent-parent relationship should be an arena for balancing power, for influencing
another to get needs met, and for managing conflict. Parents who feel powerless in their
adult relationships often become overly controlling with children and are unable to avoid
power struggles with them. Other parents have difficulty setting limits, reacting to marital
oppression by giving children all the power and influence they wish they had. The power and
control imbalances in couples is also seen in many routine child-rearing concerns, even in
discussions about feeding schedules. They need to control may be evident in discussions
79
�about feeding schedules.
After a home visit, the Healthly Steps Specialist reports intense resistance on the part of
parents to child proofing suggestions. The father: says "why do we have to move all these
things; we should teach the baby not to touch. " The mother says, "we '11 spend all our "
time saying no. " What she doesn't say is "I'm the one who has to enforce this and I don't
' care
about a few broken things. " What he doesn't say is "It's my money that buys the things ".
Instead of working out their conflict with each other, this couple fights with the
Healthy Steps Specialist.
One young mother who talks often of being verbally abused by her husband reports that
although the PNP says she should be following a modified demand schedule, she plans to
train her child to wait four hours between feedings.
Equity
Parents are sometimes unable to make the shift from the equal-equal relationship of
marriage to the authority-nurturer roles required of parents. This is especially true when the
parent-parent dynamic itself closely resembles a parent-child relationship.
80
�Andy is an attorney. His wife Serena is a hospital administrator. They have two
children, Steven, 3 'A, andTyla, 7 months. Their pediatrician became concerned
; about Steven's intense reaction to Tyla's birth. In talking with the parents, much
information on the parent-parent relationship was revealed. The father sits in
the back of the car with both children, ostensibly to keep the peace while the mother
drives. Tyla sleeps with the mother in the parent's bed arid the father sleeps on
a cot in Steven's room. Structural symbols like where children eat, sleep and
travel often aid in our understanding of a family. Rather than spending a lot of
unproductive andfrustrating time attempting to help with Steven's "normal" sibling
jealousy without progress, a referral was made to help the parents focus on the
marital dynamic. Parents' relationship issues sometimes play out in somatic arid
even hypochondriacal behaviors in the children. When considering concerns in
children's behavior and development, one must consider the quality and context of
the child's life in the family, including the parent-parent relationship.
The absence of a parent-parent relationship is often (but not always) the case in single
parent families. This can create yet another problem for young children when they are
expected to grow up quickly, meet their own needs by themselves or take care of their
parents.
Linette is a 22 year old single mother. Her son A lexander is 23 months and is
indeed
the man of the family. Line tie's concerns surrounded her recent move from another
state. Many resources were available to aid her toddler's adjustment, yet he still
"refused" to leave her. One phone consult to the advice line revealed that Alexander
was not happy at any of the child care centers Linette had tried and she was
planning
to quit her job and move to yet another city. Linette had given her toddler the
responsibility of deciding whether a place was goodfor them. Wanting children to
be our friends, companions or even substitute mates is a fairly common phenomenon
in today's families. In this case Alexander's heightened separation anxiety was
relieved when Linette became aware of the pattern andfocused oh the nurturing and
limit-setting tasks ofparenting Alexander. He felt relieved of his responsibilities
to his mother and could return to the job of being a child.
81
�Parent-Child Relationships
Parent-child relationships are fundamentally different from those between adults. The
parent's job is nurturance and caring, balanced with authority and boundaries.
Difficulties in the parent-child relationships stem from problems with this balance. Most
parents struggle with their ability to accept, acknowledge and nurture children while
setting limits, building boundaries, and fostering internal controls. Parents' memories,
hopes, fantasies and fears are inevitably engaged, as the separation-individuation process
unfolds (Mahler, et. al., 1975; Brazelton and Cramer, 1990). Parents will also have
varying abilities to cope with each stage of their child's development. For some parents,
holding on is easier than letting go. For others, the dependency of a newborn is
insufferable and the self-reliant surge of toddlerhood brings relief. In addition,
temperament differences between parent and child can affect a parent's ability to respond
to a particular developmental task. This is especially true when those temperament
differences mirror temperament differences in the parent's other (past or current)
relationships. Finally, developmental issues in the parent's history can further interfere
with the normal developmental process of parenting.
Attachment
Children need to emerge from the first year of life confident that they can get their
needs met most of the time. This basic trust then allows them to learn in the second year
that sometimes they cannot. There are many obstacles to this attachment process for
parents, obstacles related to their own trust issues as well as to their ability to focus on
another person at their own expense. In some cases, parental depression interferes with
82
�the attachment process. In addition, temperament differences between parent and child
can affect a parent's ability to respond to a particular developmental task. This is
especially true when those temperament differences mirror differences in the parents'
other (past and/or current) relationships. Finally, developmental issues in the parents'
histories can further interfere with the normal developmental process of parenting.
Nearly every parent-child group will contain at least one infant or toddler who will
display indiscriminate attachment responses (any warm body will do if I need something).
Attachment disruptions such as these are obvious to clinicians when they are the result of
prolonged separations, maternal depression, chemical dependence and other neglectful or
abusive patterns. Insecure attachment (indiscriminate or ambivalent infant responses to
parent after a brief separation) also results when apparently engaged parents defend
themselves against feeling too deeply or loving too much, as is sometimes the case in
families who survived a premature birth, or endured a medically complicated neonatal
period and who now perceive their child as vulnerable. These are normally functioning
parents and children with a potentially dangerous parent-child relationship pattern that
needs to be modified.
Autonomy
For some parents and children the problem is detaching. The toddler who
simultaneously needs dependence and autonomy can trigger the same ambivalence in
parents. Sleep struggles in the second year or toilet training in the third year often brings
these issues to a head. Toilet training can be frustrating or confusing for both parents and
children, not because they lack information, but because of issues or power struggles
83
�within the relationship. Typical toilet-training advice often focuses on controlling the
when-and-where of a toddler's bodily functions rather than examining attachment and
autonomy issues between parent and child.
The real toilet-training issues for children (and the rage in parents) often spring from
feelings of powerlessness in the relationship. Told when and what to eat and when to
sleep, they unconsciously try to wrest control by using their bodies in a way that
contradicts parental expectations, rendering parents powerless. The result may be
continuous power struggles. Toilet-training issues are almost always part of the larger
autonomy crisis. Clinicians can reframe toileting concerns for parents by helping them to
look at ways to empower their child in other areas by giving choices about food and
clothing and play activities, in addition to giving specific advice about toilet training.
Reframing toilet training as a struggle for control and autonomy within the
parent-child relationship and offering strategies for empowering children can take the
heat off of the parents, helping them see the child's autonomy urges in a more
constructive way. In other cases, children may be getting subtle messages from parents
that it's best for them not to grow up. When children are approaching four and have not
trained themselves, it may mean that they are waiting for parents to be ready!
Clinicians must be careful not to simply give toileting advice without attending to the
feelings and reactions of parents. Ask questions such as: How do you feel about letting
the child be in charge of this process? Are there pressures on you to have him out of
diapers? How much power does she have in food, clothing or sleep choices?
84
�Father-Child Relationships
Although we take great care to refer to parents in gender-inclusive language and to
include fathers in our examples, the reality for most children is that the mother is the
primary caregiver. Yet many fathers are discovering that they are critically important to
the development of their very young children. Some serve as primary caregivers. Others
have been given the opportunity to parent in new ways as a result of divorce. Many are
struggling with the conflicts between career and children and between traditional male
roles and pressures from partners to participate more fully in child-rearing.
Clinical observations, however, have consistently supported the positive impact that
fathers have on young children (Pruett, 1987). While some fathers may be becoming more
involved in childrearing, mothers may still view this as "their domain." Negotiating
maternal and paternal roles is a frequent source of conflict in a relationship. Mothers who
work all day long (either at home or away) often recognize their resentment when they are
expected to assume the major burdens of child care. Less obvious perhaps is the
ambivalence they feel when fathers do try to share equally in child care responsibilities.
Both mothers and fathers need help in developing the skills necessary for sharing
parenting responsibilities. Pediatricians/PNP's who hand the baby to the mother after a
procedure, or fuss over a father who brings in a sick child, actually perpetuate the pattern
of mother dominance. In some cases these responses fuel mothers' turf-protection
reaction. Parent groups that schedule a Dad's Evening are equally guilty of continuing to
separate parenting roles. Literature, programs and communications must be designed to
include mothers and fathers as equal partners. While fathers do need positive
85
�reinforcement for taking the initiative as parents, mothers may need support and
validation in their role as "primary" parent before they can give up some of the power to
the father.
Child-Child Relationships
One of life's eternal searches is to be chosen. Sibling rivalry is, at its core a contest to
see which child the parent will choose. Thefirst-bornchild arrived into an adult system.
Naturally a first child resents being ousted from it upon the arrival of the second child.
This fundamental resentment manifests itself in many of the day-to-day problems in
families. The sibling system in the family gives children an arena for practicing skills in
negotiation with peers, imitating adults and coping with competition and resentment.
Parents, however, may have great difficulty with this process. They often hold images
of children who are loving and kind and supportive of each other. Sometimes, ghosts of
parents' own siblings have made their way into the family room. Parents may be anxious
to raise siblings who are the "best friends" they had or missed in their youth. Yet
brother-sister relationships are far too complex to be idealized. Parents often need help in
accepting sibling rivalry as necessary and helpful to the development of relationship skills
needed in the adult world.
When Information is Not Enough
Practitioners in manyfieldshave developed strategies for explaining aspects of
children's behavior, interpreting developmental stages, and equipping parents with
information and strategies for coping. But the parents' perspective, needs and feelings
must also be equally addressed. Child-rearing is fraught with the land mines of criticism
86
�and judgements that come from grandparents, spouses, teachers, and even the well
meaning shopper who tells you that "that child needs a hat." Issues related to a parent's
need for respect, avoidance of embarrassment and real concerns about ones'
responsibility to train children to act in a certain way must also be considered. Otherwise,
parents may silently accept or reject our information or advice and then struggle with
resultant feelings of inadequacy, self doubt or mistrust of the clinicians when strategies
fail. Often, parents are afraid to report their failures. They have little or no understanding
of the obstacles that undermined their efforts and caused things to go wrong. They
become frustrated and hopeless or angry and demanding.
What are these unseen forces that position themselves between parents' questions and
clinician's responses? What stops parents from implementing our best suggestions?
Endless difficulties can be avoided when clinicians understand that past issues in the
parents' lives - their ghosts - are overriding themes and constructs that must be identified
for parents.
87
�Ghosts in the Nursery
Some Common "Ghosts" in the Nursery
•
•
•
•
•
•
Parents' own parents who were unable to attach securely with their
children.
Parents' overly-controlling parents, from whom they had trouble
detaching.
An absent parent, who may have a troubled connection or even a
non-relationship with the primary caregiver, but whose memory
may "show up" in the child's looks or characteristics, or in the
child's insistent questions.
A deceased child or grandparent, whom the child "replaced."
A hoped-for child of a different gender.
The "ghosts" of neurotic guilt and gratitude for a child bom after a
long struggle with infertility or other medical problems with
conception.
Selma Fraiberg (1980) described "ghosts in the nursery" as visitors from the
unremembered past of parents. All parent-child relationships include the shadows of
past (and present) others. Some ghosts will leave, others will stay. And still others will
visit from time to time, often "invited" by a developmental conflict or symbolic event.
These "ghost" issues are rarely noted in the context of routine health care. Yet they
can contribute significantly to personality development and parent-child relationships.
Tactfully asked questions about who or what parents want this child to be like can
establish connections between the child and these ghosts. Clinicians who listen for clues
of the existence of ghosts in the parents' stories and reports, may not have to probe too
much to get this information.
88
�Extended Family
"Parents get the first real evidence of how well they parented
their children when they watch their children parent. "
A Grandparent Support Group Participant
The parents, grandparents, aunts, uncles and siblings of parents often create the
greatest paradox of child rearing: a support and safety net often filled with emotional
irritants. When adult children follow their own parent's model of parenting, grandparents
feel complimented and validated. But this is often not the case, as young parents make
their way in a new era, filled with new ideas. Parents sometimes recreate their childhood
in their parenting in order to undo what was painful or ineffective. Grandparents feel
insulted when the rejection of their ideas is felt as a rejection of a lifetime of child
rearing.
In some families, inter-generational dynamics reflect a history of physical and sexual
abuse in addition to emotional abuse and neglect. Such abuse can create the most
extreme forms of disruptions in attachment and autonomy development. Adult survivors
of sexual abuse, for example, rarely are able to trust their own instincts since a
fundamental distinction between what is nurturing and loving and what is threatening
and hurtful was blurred or obliterated. For some parents who have experienced abuse, a
question about such a possibility is a welcome overture. For others, the childhood fear of
"telling" remains and discussion of this issue is not possible. For still others, naming the
potential obstacle to parenting gives them the motivation to seek help.
For many families, extended family members act as primary caregivers for infants and
89
�toddlers. For others their role as mentors or "nay sayers" can critically impact on parents'
confidence and skill. Whenever possible clinicians should include extended family in
some aspect of the health-care process.
Parental Depression
One of the problems that can get in the way of strong parent-child relationships is
parental depression. Everyone feels sad from time to time; for most of us, ups and downs
are simply part of life. And new parents are more prone to mood swings than usual. In
particular, mothers may feel more than usually "blue" in the weeks after giving birth, as
hormonal changes take place. Fathers and adoptive mothers are also vulnerable to mood
swings as they cope with dramatic changes in their lives, disrupted routines, and chronic
sleep deprivation.
The mood disturbance known as depression is more severe and persistent than the
common experience of feeling "down." It involves a loss of interest or enjoyment in
things that have usually given pleasure for two weeks or more; an emotional emptiness;
and a feeling of "flatness." Depression often affects a person's self-esteem, appetite,
sleep patterns, energy level, and ability to concentrate. Depression is easier to recognize
when these symptoms are very intense and interfere with day-to-day functioning; but it is
often hard to distinguish between the expected, ordinary mood swings that come with
significant life changes and the more debilitating problem of parental depression
(Zuckerman, Amaro, & Beardslee, 1987). After all, most new parents experience
90
�disruptions in their sleep patterns, energy level, and ability to focus.
People from every social and economic group, and from every kind of family
structure, can suffer from parental depression. Statistically, higher rates of depression
are found among those parents who experience the kind of environmental stressors
described below. Younger mothers and mothers of young children are also more prone to
depression (Osbom, 1995).
Postpartum Emotional Conditions
Many women experience dramatic mood swings in the days and months after
childbirth. It is important to distinguish among different kinds of emotional
conditions:
•Postpartum blues is very common. More than half of all new
mothers find themselves crying easily or frequently for a few days
after they give birth.
•Postpartum depression affects about one in five new mothers and is
more severe. It generally lasts from six to eight weeks. Its symptoms
are similar to depression at other times in life.
•Postpartum psychosis is quite rare, occuring in only one or two new
mothers per thousand. Its symptoms are similar to non-postpartum
depressive psychosis.
Recognizing parental depression is especially difficult because many new mothers and
fathers are eager to project an air of competence and may be reluctant to initiate discussions
of emotional distress or depression with health care providers, including their children's
pediatrician/PNP, however, they are more likely to speak to clinicians who routinely inquire
91
�about parental emotional health. Because Healthy Steps Specialists usually see new parents
at home and have more time to discuss the adjustments that come with an expanding family,
they can be very helpful in picking up signs of parental depression.
In some cases, depressed parents will get relief from talking to someone who can listen
closely and sympathetically, and who can provide reassurance without dismissing or
trivializing their concerns. Parent groups have also been found to alleviate mild parental
depression. But more severely depressed parents need attention from mental health
professionals, not only to relieve their own distress but to protect the well-being of their
children. Parental depression has been found to interfere with effective parenting. Depressed
parents are more negative and more irritable than other mothers, and may respond erratically
to their children's needs. Their children are at higher risk for learning, behavioral, and
psychiatric problems (Osbom, 1995).
Environmental Stressors
Additional influences on parents' abilities to adequately nurture and protect their children
include such things as economic stress or poverty, unemployment, chemical
dependence/substance abuse, or divorce. These influences often combine with relationship
issues and equally contribute to the overall state of a child's health and development.
Psycho-social and environmental issues which have a demonstrated impact on family
functioning and child health often fall into two related but discreet categories as illustrated in
Table 2.
92
�TABLE 2:
ENVIRONMENTAL STRESSORS ON FAMILY RELATIONSHIPS
I
HIGHER SEVERITY:
Domestic violence
Terminal illness or death of parent sibling or close family
member
Incarceration of parent or caregiver
Chronic addictions and chemical dependence
Poverty
History of sexual/physical abuse
PROBABLE EFFECTS:
Danger to child and/or parent
Causes traumatic events
Eliminates or limits parents capacity to focus on child, read
signals or meet needs
Children experience trauma and cannot be comforted within the
primary (parent/child)relationship
Implications to clinicians:
Referrals for counseling, therapy and/or social services are
necessary
II
LOWER SEVERITY:
Parental job stress
Temporary unemployment
Frequent or abrupt care giver changes
Illiteracy
Marital infidelity/discard
Occasional drug/alcohol use
PROBABLE EFFECTS:
Raised anxiety
Diminished capacity to focus on the child, read the child's
signals and meet his/her needs
Predictability and consistency is compromised
Child experiences stress/distress, but may be able to be
comforted in the parent-child relationship
Implications to clinicians:
Resources, written infonnation, acknowledgment and support
are offered to families
Referrals would be available as needed
III
VARIABLE SEVERITY:
Moving
Parental eating disorder
Divorce
Parental depression
Addictions and compulsions: gambling, exercise, work
PROBABLE EFFECTS:
Reactions of children and parents can include those listed in
columns I and II
Impact is contingent on family's ability to cope
Implications to clinicians:
Assessment of the impact of risk factors is necessary to
determine level of intervention
Information, writtenresourcesand referrals may be necessary
�Most Healthy Steps clinicians will encounter situations and family dynamics that suggest
the existence of one or more qf these societal conditions. The quality of the relationship
between parent and clinician will determine the extent to which parents will reveal the
painful and sometimes self incriminating details of their lives. Clinicians can frame
psycho-social stressors as examples of obstacles to effective parent-child relationships. This
approach builds trust and facilitates more discussion than questioning parents directly about
their lives. It is only within the context of trust that parents can move beyond the powerful
force of denial which operates to veil many symptoms and symbols of societal and
environmental risks in families.
Cultural and Ethnic Relevance
Our country's families represent a diverse collection of cultural and linguistic traditions
which deeply affect parenting. Key developmental issues such as thumb-sucking, pacifiers,
sleeping arrangements, temper-tantrums and toilet training trigger reactions from parents that
are often based on cultural norms.
Reframing the infant's need to mouth a toy as a normal part of development may not
comfort a parent for whom mouthing is culturally unacceptable. Parents are often open to
discussing their traditions and views and need only to be asked. Ignoring the contextual
meaning of behaviors to a parent, particularly one of a different ethnic group than the
clinician, can result in decreased trust. Questions must be carefully framed to gain
information about the cultural, religious or racial influences on parents' perceptions of illness
and/or development without offending parents. Clinicians should:
•
learn from parents about their cultural norms/practices
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�•
understand the influences of culture on their patients,
•
acknowledge the parents' views as valid for this family, and
•
incorporate culturally acceptable treatment practices whenever possible.
Discipline: The Cornerstone of Family Relationships
"Healthy children do need people to go on being in control, but discipline must be
provided by persons who can be loved and hated, defied and depended on;
mechanical controls are of no use, nor can fear be a good motive for compliance.
It's always a living relationship between persons that gives the necessary elbow
room which true growth needs. "
Winnicott (1993) reminds us that it is the relationship between parent and child that is the
fuel and the matrix for growth. And discipline is the aspect of parenthood that brings it all
together...the scripts from one's own childhood, the embarrassment and lack of validation as
a parent, the confusion over which way to do it, and the awesome sense of responsibility for
shaping the character of this very young child.
Discipline is never simply child training. It always engages the dynamics of family
relationships. Discipline brings together the scripts from one's own childhood, the confusion
over which way to do it, and the awesome sense of responsibility for shaping the character of
this very young child. The goals of discipline are to teach children to:
•
Understand the effects of their behavior on others
•
Respect the needs of others
•
Weigh the needs of self with the needs of others
•
Make choices and behavioral decisions based on balancing the needs of self and
the needs of others
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�Discipline is grounded in the parent-child relationship and in the
separation-individuation process. When the six month old infant realizes that her hands
belong to her and almost simultaneously that her mother's eyes belong to Mom, she has
made the primitive discovery of disconnectedness! But, it must be tested. So baby pokes
Dad's eyes or pulls Mom's hair to confirm this realization that there are two of us—me
and you, self and other. With this proof comes another lesson—that the baby's curiosity,
impulses and the practicing of new skills sometimes cause pain or discomfort to others.
This scenario will play itself out over and over for years to come. With mobility
comes testing the strength of the attachment over distance (running away in the parking
lot) or challenging the strength of independence in the face of limitations. (Refusing to
pick up a toy or stop touching the VCR.) Understanding the developmental conflict,
acknowledging the feeling behind the behavior and making the choice for the toddler
1
("77/ have to carry you i f you won 7 hold my hand' ) are essential steps to keeping them
safe, but no further disciplinary actions are necessary.
When language emerges as an arena of power and control, children will borrow words
that have power and test the limits of the parent's love with angry outbursts of " I hate
you" and "I'm getting another mother." Conventional wisdom and some behavioral
theory says ignore something and it will go away. Perhaps it will, but then the message or
emotion behind the words or behavior will find another vehicle for delivery.
When parents acknowledge the anger, frustration or disappointment while still letting
children know that those words are not acceptable, then discipline is effective. Effective
does not mean, however, that it has eliminated the negative behavior. It may mean that
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�the child has moved a bit further along the path of understanding self and other, of
controlling impulses and of learning empathy.
Discipline involves a complicated series of choices and decisions that are affected by
many emotional, psychological, societal and cultural factors. It is a mistake to reduce the
discipline process to a formula that ignores such complexity. Table 3 gives clinicians a
framework for understanding discipline concerns in the context of the parent-child
relationship.
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�TABLE 3:
DISCIPLINE IN THE CONTEXT OF PARENT-CHILD RELATIONSHIPS
Behavioral Categories
"Normal" Behavior
I.
A. Developmental: toddler tantrums, not sharing, bathroom
language
B. Temperamental : sensory overload, slow to warm up,
clinginess, high activity level
II.
oo
A. Awareness of the effects of family interactions on child's
behavior
B. Structuring the environment to support child's
competence and meet his/her needs
A. Balancing child's need (or each child's needs) with
adults' needs
B. Guiltover family issues (i.e. divorce)
C. Power and control needs
A. Acknowledging feelings to show understanding
B. Stating parents' feelings
C. Clearly making the distinction between parent feelings I'm angry at you and child feelings - you look very sad.
A. Myths, images, introjects and projections
B. Denial of child's negative feelings as a coping
mechanism for parents
C. Inability to trust (i.e. if he's angry, he doesn't love me)
D. product orientation (if I acknowledge she's sad, then
what do I do about it and if I can't do anything about it then
why acknowledge the feeling?
Powerlessness:
Power= the pursuit of influence over another to get ones
needs met
V.
A. Need to be validated as "good " parent
B. Embarrassment at certain normal behaviors
C. Egocentrism
D. Affinities and intolerance
E. Need to prevent "future" problem behavior
F. Parents' developmental issues (past and present)
Communication of Feelines and Needs:
Most child behavior is a feeling children are not able to put
into words. If the sadness, anger, disappointment or
resentment etc. is not "heard" by the parent, the child will
need to speak it louder.
IV.
A. Knowledge of ages and stages, temperament
characteristics and interaction styles
B. Observation skills: What is normal for this age and this
child.
C. Acceptance: choosing battles, letting something go.
Obstacles for Parents
Environmental
A. Family dynamics: 1st bom, bossiness, parentifies child,
the child as the mouth piece of parents' anger
B. The setting: child care mismatch, environmental chaos,
disruptive events, overstimulation
III.
Effective Parenting Skills
A. Empowering children-giving them choices
B. Clarity and reality in sharing control - sometimes children
can be in charge of their behavior
C. Balancing dependence and independence it's ok to be
both
A. Parental powerlessness
B. Adult needs for control
Limit testing:
Children want power. They also want to trust that parents
will keep safe from the world and from their own impulses
A. Three part limit setting process: giving children the
opportunity to make a behavioral choice.
B. Enforcing consequences consistently
C. Positive reinforcement
A. Need for immediate gratification
B. Perceived cause of child's behavior as lack of respect
C. Myth of punitive discipline
D. Acute need to "control" children
E. Conflict avoidance needs
F. The misguided use of praise
�Summary
The questions parents ask and their responses to advice are often layered with
meaning, history, and symbols. In this chapter we have developed a framework for
viewing child health and development in the context of these and other relationship
patterns. We focused on three basic kinds of relationship: parent-parent, parent-child and
sibling ties. We also noted the importance of the many potential "ghosts" of often
invisible relationships that can have a profound impact on child-rearing. Healthy Steps
clinicians bring to the parent-child dyad an awareness of that relationship, skills in
acknowledging parents' feelings and concerns and information that identifies the
connections between parents' relationships (past and present) and the health and
development of their children.
99
�References
Brazelton, T.B. & Cramer, B.G. (1990). The earliest relationship: Parents, infants and the
drama of early attachment. Reading, MA: Addison-Wesley.
Chess, S. & Thomas, A. (1984). Origins and evolution of behavior disorders: From infancy
to early adult life. New York: Brunner/Mazel.
Emde, R. & Sorce, J. (1983). Emotional availability and maternal referencing. Frontiers of
Infant Psychiatry. 1.
Fraiberg, S. (1980). Clinical Studies—Infant mental health: The 1st year of life. New York:
Basic Books.
Kohlenbert, T., Joseph, H., Prudent, N. & Richardson, V. (1995). Culture and the family's
response to a child's problem. In Zuckerman, B. & Parker, S., eds., Developmental and
behavioral pediatrics: A handbook for primary care. Boston: Little Brown.
Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant:
Symbiosis and individuation. New York: Basic Books.
Osbom, L. (1995). Parental Depression. In Zuckerman, B. & Parker, S., eds., Developmental
and behavioral pediatrics: A handbook for primary care. Boston: Little Brown.
Pruett, K. (1987). The nurturing father. New York: Warner.
Tronick, E., Als, H., Adamson, L., Wise, S. & Brazelton, T.B. (1978). Infant response to
entroponent between contradictory messages in face to face. Journal of Child Psychiatry.
17. 1-3.
Winnicott, D.W. (1993). Talking to parents. Reading, MA: Addison-Wesley.
Zuckerman, B., Amaro, H., & Beardslee, W. (1987). Mental Health of Adolescent Mothers:
The Implications of Depression and Drug Use. Journal of Developmentaland Behavioral
Pediatrics. 8(2). 111-116.
100
�II. Clinical Strategies for
Home and Office Visits
4
�CHAPTER 4
BUILDING CARING RELATIONSHIPS
The relationship between the professional and the parent is the foundation of all
therapeutic efforts. If that relationship is collaborative, respectful, and nurturing—in short, a
caring alliance—then much is possible. But if the relationship is built on one-sided advicegiving, on a superior attitude, on a lack of respect for cultural, ethnic and class differences, then
achieving the Healthy Steps' goals will be extremely difficult. A caring relationship is the
prerequisite for all successful interventions.
There are many strategies for forming a therapeutic relationship with mothers and fathers.
It is useful to begin the visit with a comment that implies recognition of the mother and/or father
as individuals in their own right, with needs and interests of their own. Most parents appreciate
a little time spent chatting or "schmoozing" as a peer about non-clinical topics. In this way, a
respectful, friendly tone is established from the outset and will well serve any potential
interventions to come.
Next, parents should be encouraged to voice their expectations and goals for the visit.
This lets them know that you value their opinions and want to be responsive to their wishes. It
also implies that they can have some say in the decision-making process about their child and
implies a collaborative stance by the clinician. We know that parents' satisfaction with a
pediatric visit is based, in large part, on whether their expectations have been met. Unless the
Healthy Steps Team actively elicits those expectations, parents are likely to leave dissatisfied,
and an opportunity to cement the relationship is lost. It is critical to actively elicit and address
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�parental expectations for the visit in order to avoid unrealistic hopes and fears, to establish
collaborative goals, and to further the relationship. This is why Healthy Steps utilizes the previsit information like the Linkletter to ensure that the parent concerns are addressed.
A caring relationship is furthered by maintaining a non-judgmental attitude and
demeanor towards parent and child. This can be hard to accomplish if the Healthy Steps
clinicians views the parents as somehow deficient. Such an attitude—however warranted by
perceptions of parental misbehavior—is anathema to any hope for a beneficial alliance and,
therefore, any real hope of helping the family. Parents should not be given any reason to believe
that the team views them as incompetent, overly rigid, or unobservant.
The relationship between parent and clinician is complex and bears some examination. In
establishing a relationship, parents generally take their cues from the clinician. If a clinician
avoids asking parents about their child's behavior and development, parents avoid raising such
issues. If a clinician has a relentlessly upbeat, optimistic demeanor, some parents may feel
inhibited to bring up worries and negative feelings.
Since the key goal of Healthy Steps is to help to foster the early parent-child
relationship, clinicians must begin to think about how their style furthers or impedes that goal.
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�Assessing Your Own Professional Style
How do you view your own role with children and families
you work with ?
To what extent do you define your work as limited to
assuring the child's optimal physical health and
development?
How much do you enjoy addressing behavioral or social
issues concerning your patients?
What are your preferred strategies for changing the behavior
and attitudes of parents? Lecturing? Giving out literature?
Asking rhetorical questions? Addressing their deepest
feelings?
It is the answers to questions like these that define your relationship with families and set
the boundaries of that relationship. Your answers will determine, in large measure, your ability
to establish a strong relationship with the family.
Asking Evocative Questions
Asking evocative questions creates a non-judgmental atmosphere in which parents can
feel they have permission to request specific information about their child or family situation. If
one simply asks, "How are things going? " you are likely to get a similarly brief response:
"OK. " Yet if you begin by recalling specific issues and concerns from the past visit, you are
much more likely to get a detailed reply, perhaps one that reveals the parents' level of anxiety or
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�stress. Starting out with questions or comments that focus on the positive attributes of the child
can create a supportive environment. For example the clinician might ask who the baby was
named for and who he/she reminds the parents of. This often leads to a discussion of how the
parents see the child, what role the child might be expected to play in the family and what the
parents' aspirations are for this child.
When a parent responds that the baby was named for a grandparent who recently died,
something important is revealed about the parent's history and the special connection which the
parent may feel towards this new baby. Such small, shared intimacies of conversation often
serve as the initial steps in forming a caring relationship. Asking what frustrates the parent in
caring for the child can suggest that caring for a baby is not always rewarding and wonderful, but
is full of concern, frustration, and perhaps anger. Open-ended questions like these legitimize the
parents' range of both positive and negative feelings about their child and their role as parents
and open these issues for discussion.
Enhancing the Relationship Through Well-Child Visits
At six months of age, Ryan has become a social and active explorer. No
longer content to sit on his mother's lap, he has turned into a busy crawler,
using his whole body to explore toys, people arid the environment. For his
parents, this has been a kind of "honeymoon period" in their relationship
with their son; Ryan has been delightful and rewarding. But now he's taken
to mouthing and banging everything he can get his hands on. During his
six-month office visit, Ryan's parents express some concern about his
sudden wild ways with objects.
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�The timing andfrequencyof well child-visits, especially in the first year of life, offers a
wonderful opportunity to strengthen the relationships between the Healthy Steps team and the
parents. The following three linked techniques, focusing on the child's behavior, can be used to
enhance this relationship in the context of a well-child office visit.
Enhancing the Relationship Between
the Healthy Steps Team and Parents
1. Observing and reading the baby's cues together with parents
2. Modeling constructive interactions with the child
3. Reframing the child's behavior for the parents
1. Observing and Reading the Baby's Cues
First, read the baby's behavioral cues together with the parents. This technique can start
at the initial visit in the hospital, at the 3-5 day visit with the NBAS, or at the 2 week well-child
visit. For example, when the baby begins to fuss, opens his mouth and turns his head in search
of a nipple, the clinician can ask the parents if they know what the baby is "saying." When
parents report that the baby is probably hungry, the clinician can support their ability to "read"
their baby's cues. Translating the act of fussing into a communicative act helps parents
understand that the baby is an active participant in the relationship and reinforces their
confidence in their care-taking abilities. In the above example of Ryan, when both clinician and
parent observe his exploratory behavior with objects, they can discuss what banging and
105
�mouthing mean to a 6 month old.
2. Modeling Constructive Interactions with the Child
The clinician's interactions with the infant and toddler serves to establish a positive
relationship with the child. Equally important, it also models positive ways of interacting with
the child. Office visits are especially effective contexts for influencing parents, who are
generally vigilant and often anxious observers of the clinicians.
Modeling is one of the most powerful means of influencing parental behavior. The
clinician is in effecting modeling desirable parenting behaviors when she
•
calms and sets limits for the slightly out-of-control toddler
•
offers an appropriate mouthing toy to an actively exploring 6 month old like Ryan
•
elicits a happy laugh from a recalcitrant one year old by acting just a little bit silly
•
helps the child to defuse a potential tantrum through redirection or by calming an upset
baby with gentle rocking
Parents may (consciously or otherwise) incorporate these behaviors into their own interactions
with their child. Through the clinicians' enjoyment of their child, parents also can better
appreciate the positive side of their child. The clinicians must be aware that how they interact
with the child may of be of more significance to mothers and fathers than what is actually done
or said.
3. Reframing Child Behavior
Finally, clinicians can use their own reactions to behavior to explore the parents'
responses and to provide information and support. A simple statement of empathy like "How
106
�frustrating it is not to be able to calm your baby, " can bring great relief to anxious parents by
normalizing negative feelings towards the baby. In this way, clinicians' words, as well as deeds,
can encourage parents to see their own reactions in a new light. This communication is also a
kind of modeling, but rather than providing a model for the parents simply to imitate, the
clinician gives the parents a new perspective on their own attitudes and behaviors.
For example, although Ryan's mouthing and banging are developmentally appropriate
ways of learning about objects and offer him hours of delightful exploration, his parents'
reactions to these behaviors are frequently more negative in tone. Continual banging can get
annoying, and mouthing is seen as dirty and dangerous. By reframing the infant's behavior as
normal learning behavior, the clinician can also praise the child's curiosity and active exploration
and explain to the parents how these behaviors support later, more complex learning. Parents
often respond with relief and pride in their child. They also feel more comfortable discussing
with the clinician their child's developing strategies for exploring the world. The clinician can
discuss choking, poisoning and other injury prevention strategies with parents, based on the
child's actual behaviors which they have both observed. Parents are more likely to follow these
suggestions when they are grounded in actual infant behavior which they have shared with the
clinicians.
Summary
There are many strengths to this approach, not the least of which is the shared
responsibility which the clinician and Healthy Steps Specialist have with each family. The
Healthy Steps Specialist provides the time for the kinds of discussions that the pediatrician or
107
�PNP usually lacks. Taken together, the pediatrician/PNP and the Healthy Steps Specialist
comprise a childcare team that makes it possible to meet the goals of Bright Futures. Healthy
Steps Specialists bring their own skills to the team, and an emphasis on child development. They
have a broad view of health supervision which allows for a more comprehensive and systematic
approach to child development and family support. The Healthy Steps approach provides
parents with an expanded opportunity to develop a caring relationship with a team of pediatric
specialists by having two uniquely qualified professionals with complementary perspectives on
their children's health and development.
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��CHAPTER 5
CREATING TEACHABLE MOMENTS
During her six month visit, Sarah mouths all the toys given to her. She puts the blocks
in her mouth, tries to eat the bell, and sucks on ihe red yarn. Her mother is visibly
embarrassed by her daughter's behavior and keeps trying to pry the items out of her
mouth. Sarah protests loudly and then refuses to continue playing.
Creating Teachable Moments
Sometimes a child's particular behavior, like mouthing everything at six months or
throwing blocks at 12 months, creates a wonderful opportunity to promote parental
understanding of child development. The child's action allows the Healthy Steps clinicians to
reframe the behavior for the parents giving them insights about their developing child. The
child's behavior creates a "teachable moment," when parents are most open to new information
about their child. Using such teachable moments enhances the relationship between the Healthy
Steps clinicians and parents. The child's behavior also serves as a vehicle for promoting
problem-solving and for working with parents to develop parenting approaches which feel
comfortable for them.
Responding to a Teachable Moment
"All children mouth toys/throw all kinds of objects, even food, at this age as away of
learning about objects and what they are usedfor, and sometimes to relieve the pain
of teething^
"When she mouths things that are not OK, you might try offering her an acceptable
alternative, like a teething ring.'"
109
�By observing the baby's increasingly complex behaviors and interactions with people and
objects, parents are challenged to think about new ways to interact with their child.
Although the baby may create the teachable moment through his behavior, sometimes it
is up to the pediatrician/PNP or Healthy Steps Specialist to create a teachable moment. Parents
become naturally curious when they sense a tension between what they know (or thought they
knew) and a new piece of evidence or information.
How to Create a Teachable Moment
Ask an evocative question.
Elicit a behavior from a child that points to a general
developmental process.
Describe the child's behavior and explore parent's
understanding of that behavior.
Turn a parent's statement or observation about their
child into a question.
Point out a discrepancy between what parents assume
about their child and something that they have just
observed about their child.
Each office and home visit can also be a vehicle for creating that constructive tension that teachable moment—when the parent is receptive to learning something new about her child.
Each of the Healthy Steps components offers the opportunity to create that teachable moment
when the parent is most invested in what's going on for the child at that moment.
110
�Where to Find Teachable Moments
Home visits
Office visits
When a parent calls the child development information
line
While watching and commenting on children at play
During physical exam of a child
Taking a child's health history with parents
Sick visits
Well-child visits
During the psycho-social screening
Any interaction with parents
Teachable Moments Which Reframe Child Behavior
During the physical exam or home visits, children often demonstrate a new
developmental skill or a behavior linked to an emotional stage of development. For example, the
12 month visit heralds a transition for the family. The baby is much more mobile and competent,
persistent and demanding. Many parents misinterpret their children's behaviors as willful
attempts to undermine parental authority. Parents describe their newly mobile children as "into
everything, " or "stubborn," or simply as "bad " For example, parents describe how the child
111
�throws his food off the high chair tray, making a mess for the parents to clean. They often
respond by controlling the feeding and not allowing the child to feed himself. The clinician can
join with the parents around how messy babies can be. They can reframe the throwing behavior,
explaining how shaking and throwing are the infant's way of exploring objects to discover what
they can do. This can easily be demonstrated by giving the child a toy in the office and watching
him bang, shake and throw it. The clinician can create a teachable moment by narrating the
child's actions, reframing them as acts of exploration rather than as deliberate attempts to make a
mess. The clinician can explain how seemingly unimportant tasks, like using a pincer grasp to
pick up a cheerio, are important windows into the baby's development and learning.
Refraining Behavior
"When I realized that all the mess he was making with his food was really
helping him to learn, 1 told my husband to stop worrying about the kitchen:
floor. Our baby is learning. "
Teachable Moments Which Support Parental Problem Solving
Yes, their baby is learning. And so are the parents. Of course the parents' needs must
also be taken into account. Parents and clinicians can discuss alternative strategies for balancing
the child's desire to learn through exploration and the parents' reasonable wish for less mess.
Parents might be advised to give the child one piece of finger food at a time or to put a plastic
sheet under the high chair. And children can be told which objects can be thrown and which
cannot, i.e. "balls are for throwing, cheerios are for eating. " Teachable moments are also
112
�moments for problem-solving.
Teachable Moments Which Normalize Behavior: Stranger Anxiety
Many children are visibly upset by the 12-15 month visit because of their heightened
stranger and separation anxiety. They may express this anxiety by actively refusing to cooperate
with the exam and by protesting when the pediatric clinician tries to examine them. This
behavior, often embarrassing to parents, can be used as a teachable moment to discuss stranger
anxiety, its normal developmental function, and to explore its ramifications for the families.
Raising the Issue of Stranger Anxiety
"Are you finding all of a sudden that, after months of happy good-byes,
Billy now becomes frantic when you leave him at child care? What do you
think is going on?"
:
: : ;
"Have you noticed that Jenny, who was so serene and open to people a ';--::-y
couple of weeks ago, now screams in protest when grandparents come to
Parents are usually relieved to understand why it is a developmental inevitability for their baby
to actively and loudly resist separation. They are also pleased to learn that separation protest is
linked to cognitive growth in object permanence. For those children whose temperament allows
them to respond to new events in a more low-key way, it is important to ensure that parents
understand that their infants' more subdued reaction to separation is still a form of separation
protest and should be respected as such.
113
�Night-Waking
It is during this visit that many parents comment on their child's renewed night-waking.
By acknowledging the child's fears directly to the child ("It's scary when you wake up and
mommy and daddy aren't with you, isn 't it? ") the clinician provides information to the parents
on why the child is engaging in the behavior and also models using verbal explanations with the
child. Discussion of night-waking, fear of strangers and the "velcro" phenomena (when children
refuse to let go of their parents) can help parents put all of these behaviors into the context of the
baby's developing emotional and social skills.
Dependency and Discipline
This visit presents a teachable moment for discussing the parents' fears of "spoiling" their
child, on one hand, and fears of breaking the child's spirit on the other. For example, a father
might explain, in a slightly hurt and angry tone, how the baby cries whenever his wife leaves the
room because she has spoiled him. Issues about dependency, discipline and the management of
anger for the family are available for discussion. The clinician can start by acknowledging each
parent's feelings and describing how it may feel for the baby, while also explaining separation
protest.
Toddler Control and Limit Testing
By the toddler period, the child enters a period of development which most families find
very stressful. The 18-24 month period is marked by struggles over control, by limit testing, and
by the toddler's ability to get herself into serious trouble as she climbs too high or runs away too
114
�quickly from a parent. The physical exam and immunizations usually produce enough negative
responses from the toddler to bring these issues to the surface. Most toddlers will protect
themselves from being undressed or examined by clinging to their parents or having a tantrum.
Many will also demonstrate their active exploration by trying to climb onto the examining table,
touching the equipment or trying to run out of the room.
Since clinician and parent have both observed these behaviors, they create yet another
teachable moment, giving the clinician insight into how the parents understand the behavior and
how they respond to it. It is important at moments like these to empathize with the parents.
They need assurance that their child's behavior is normal, as is their frustration and
embarrassment or anger at their child. The clinician can explain that a toddler's autonomy
struggles often feel like the child is "refusing to listen." Modeling verbal and behavioral
strategies to help the child cope with the experience of being in the office for an exam is also
appropriate, demonstrating for the parents the importance of setting safe limits for the child while
trying to avoid unnecessary power struggles regarding parental control. Finally, the clinician can
help the child feel like she has mastered a stressful situation by commenting on her attempts at
control: " I know it was hard for you, but you did a good job when I looked in your ears." Instead
of the child feeling like a failure and the parents feeling embarrassed or angry or both, the family
can feel that you understood and accepted their reactions and that you still like their child and
respect their parenting efforts.
During each well child visit, the pediatrician/PNP can create a teachable moment by
engaging the child in a simple activity or maneuver which demonstrates to the parent a particular
behavioral/temperamental quality about their baby or a developmentally appropriate skill. Table
115
�1 lists examples of behaviors that occur naturally or can be elicited during an office visit which
lend themselves to creating teachable moments.
Paradoxically, we spend relatively little of our clinical time actually engaged in
promoting the health-supervision goals of Healthy Steps. Typically we squeeze them in the last
few minutes of the visit. In reality, we spend most of our time monitoring the child's health and
development: eliciting history, observing the parent and the child and the parent-child
interaction, performing physical examinations, weighing and measuring, obtaining laboratory
data. It's no wonder that promoting child development and problem-solving about child
behavior appear to take a back seat to this assessment and monitoring during the office visit.
And, given the complexity of issues presented to us by families and children, it is hard to see
how it could be otherwise. But if we take advantage of the time spent doing our many clinical
examinations also as a chance to help families and children, then the balance shifts. Any
interaction with a parent or child can be seen as a potential teachable moment and intervention.
Teachable Moments During History-Taking
Teachable Moments While Taking Histories
Inquire not only about the child but also about parents' health, stress,
anxieties, etc.
Ask about child's temperament and about parents' responses to it.
Acknowledge the changes in the child since the last visit and how much of a
challenge they can be.
Note how hard the parents have been working to keep up with their child's
physical and behavioral changes.
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�The creation of a teachable moment often begins during history-taking. It is during this
time that the clinician can give mothers and fathers permission to broaden the topics for
discussion beyond purely medical topics (or to subtly discourage them by avoiding non-health or
emotion-laden topics).
Ask how the parents are doing. Their health, signs and symptoms of depression, fatigue,
stress, economic worries, cigarette, alcohol and/or drug use, excessive time demands, support
from family and friends are all relevant to their child's welfare. Concern for the parents'
condition also strengthens the relationship between parent and clinician (see Chapter 9 for more
details on family assessment).
Questions about the child's behavior and development give parents license to discuss
such issues. Especially useful in the first three years are questions about the child's
temperamental characteristics (see Chapter 6), developmental milestones (see Chapter 2),
behavioral issues, and how the mother and father respond and feel about these issues (see
Chapter 3). Clinical judgment is always required to distinguish when it is appropriate to expand,
and when to narrow, the content of the discussion. Also, clinicians need to remember that
parents are all different: some find it helpful to discuss their feelings, whereas others experience
personal questions as intrusive. Sensing when not to intrude on the parents' privacy is as
important as knowing what, how, and when to probe.
The baby changes so rapidly during the first three years that parents often find themselves
behind the curve. Just when they have adjusted to the latest developmental or behavioral
achievement, the infant changes again! Acknowledging how challenging some of these changes
can be allows parents to talk about their feelings and concerns about caring for their baby.
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�Healthy Steps clinicians can create a teachable moment simply by noting how hard the parent is
working to change along with the baby.
Teachable Moments During Well Child Visits
Teachable Moments During the Examination
Pediatrician/PNP comments on the child's general response
to being examined
Pediatrician/PNP provides an unambiguous and informative
running commentary for parents as their child is examined
Pediatrician/PNP demonstrates the child's skills during the
interactions involved in the exam
Comments and concerns from the observing parents serve as
a springboard for discussions with Pediatrician/PNP
Pediatrician/PNP reframes parents' observations and
concerns
Pediatrician/PNP's interactions with the child serve as a
model for parents
During physical examinations many pediatrician/PNPs lose sight of the opportunity to
create teachable moments. We focus on the heart, although no murmur has been heard before.
We meticulously auscultate the lungs, although the child is free of symptoms. We compulsively
feel for an enlarged spleen and liver, although there is no clinical reason to worry about it. We
carefully check deep tendon reflexes that have been normal from day one. Barring historical or
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�clinical reason to be suspicious, the chance of identifying an unexpected medical problem during
the physical examination of a well child is remote. Still, scrupulous medicine requires a
thorough physical examination. So how are we to use the physical examination as an
opportunity for achieving the goals of Healthy Steps?
The examination provides the pediatrician/PNP with a window onto a wealth of
information about parent and child. The pediatrician/PNP is in a good position to compare how
this child at this age responds to the examination, compared to another child of the same age.
The examination can be a time to provide important information to the mother and father (and,
when old enough, to the child). Finally, the physical exam also provides an opportunity for
demonstration of the child's skills and abilities through his interactions with the clinician.
As the pediatrician/PNP performs the examination, she should narrate a running
commentary about the findings: "Heart sounds great....Good, strong heart'....Lungs are
clear...No sign of that bronchitis...Ears have a little bit offluid—do you think she is hearing
Old" This running narrative serves, first and foremost, to reassure mothers and fathers that
their child is healthy. In this regard, the pediatrician/PNP should avoid ambiguous statements
such as: "Well, he doesn't sound too bad" or " I can't find anything wrong." Such equivocation
does little to reassure and may set the anxious parent's mind racing.
The examination also serves as a natural springboard to elicit more information or
concerns from the observing parent. Neutral, non-judgmental comments about the child's
behavior (e.g., "He certainly is an active child, isn't he?) may trigger a host of parental concerns,
elicited all the more easily by focusing ostensibly on the child's physical examination, and not
the parental feelings.
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�Finally, the physical examination is a wonderful opportunity for the pediatrician/PNP to
reframe the child's behavior in order to enhance the parent-child interactions. The
pediatrician/PNP's demeanor towards the child serves as a model for the parent. Certainly, the
physical examination must be approached with respect for the child and sensitivity to issues of
power and control. For example, the obstreperous toddler who resists examination offers the
opportunity to discuss the child's attempts at autonomy, individuation, and his understandable
desire to maintain control of his body. The child who cries but then consoles himself sets the
stage for a discussion of her coping skills.
Teachable Moments During Sick Visits
Teachable Moments During Sick Visits
Parents' anxieties during sick visits are potentially powerful
motivators for their learning
Pediatrician/PNP strives to demystify illness
Demonstrate to parents what to look for in monitoring the
child's progress through an illness
Parents' anxiety can be transformed into confidence in
dealing with illness
When parents bring their sick child in, they are already anxious about the child and about
what the illness may mean for the family. Helping parents to master the first ear infection or
fever with a sense of confidence and success can set the stage for how the parents will respond to
the next illness. The illness presents a teachable moment for providing information about the
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�illness and how to treat it. For example, "his mouth seems moist and he has big tears when he
cries; that tells us that his fluid balance is adequate".
The key is first to demystify the illness through a clear, jargon-free explanation of the
issue and then to empower the parent to care for the problem by carefully explaining the
treatment plan, what to worry about and when, and how to handle most contingencies. The
parent's sense of confidence in mastering an acute illness will be transmitted to the child by
teaching them how to use the practice when their child is ill.
Teachable Moments During Developmental and Behavioral Check-Ups
Teachable Moments During Developmental Check-Ups
•
Parents' anxiety about how the child is developing leads to greater attention to the
child's attempts to complete specific developmental tasks
•
Parents are focused on observing what their child can do and how their child
approaches new challenges
Developmental check-ups are excellent vehicles for creating teachable moments. Parents
are mildly anxious about how their child will do and they watch with interest, often expressing
pride and surprise at how much their child can accomplish. At this time, they have a strong
desire to learn the way present skill levels build towards greater proficiency and more complex
behaviors. These teachable moments create disequilibrium and thus offer parents a way to
understand their child's behavior in a new way. Parents are encouraged to step back and observe
their child, leading to comments such as, "I didn 7 know she could do that" or "/ never knew why
he behaved like that. "
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�When the Healthy Steps pediatrician/PNPs conduct the family psycho-social screening
at regular intervals, they create the opportunity for parents to discuss adult issues. Such concerns
may not relate directly to the child, but often have a crucial impact on the child. Maternal
depression, for example, has a clear-cut effect on child development by limiting emotional
availability and/or leading to inconsistent limit-setting. Over a third of the mothers participating
in our parent survey reported feeling depressed in the first few weeks after birth. When a mother
reports that she is feeling sad and blue, the pediatrician/PNP can use that opportunity to explore
therapeutic options for the mother. Similarly, asking questions about how a family handles anger
or resolves disputes can create an opportunity to discuss domestic violence and its effects on
child behavior and development.
Teachable Moments During Home Visits
Teachable Moments During Home Visits
Unhurried private time for parents to set agenda
Opportunity to observe child in his/her familiar environment
Home visits offer a special opportunity to visit parents on their own turf, thereby shifting
the balance of power from the clinical practice to the parents. Parents often feel more
comfortable talking about their child in their home where the baby can play on the floor in her
own space. The Healthy Steps Specialist can observe the parents and child interact as they do on
a daily basis, note whether the house has been child proofed, and observe whether the child has
developmentally appropriate toys and books. The Healthy Steps Specialist can observe the child
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�in an environment that is comfortable and familiar, unlike the pediatric office which may hold
anxious memories. Home visits have a different tone. There is often no emergency illness to
manage. There is no one else in the crowded waiting room planning to see the Healthy Steps
Specialist. This unhurried time allows the parents more opportunity to create their own agenda
for the visit. The Healthy Steps Specialist should be attuned to those teachable moments, to
elicit from the parents what their agenda for the visit might be, and to nurture the parent's role as
an expert on their child and in their relationship with the Healthy Steps team. (For more
information on home visiting, refer to Chapter 8.)
Teachable Moments Using the Child Development Information Phone Line
Teachable Moments During Telephone Call In
Timeliness of parent initiated request for information
Opportunity to talk with parents without child present
When parents calls the child development information line, they are initiating their own
teachable moment. They have a desire to learn and they want information now about their child.
Although the Healthy Steps Specialist may not be able to respond immediately, when she calls
them back with timely information that addresses their exact questions she helps build a
supportive relationship between the family and the practice. Parents may call the information
line with a fairly simple question, which then creates the opportunity to talk about other issues
of concern. Although pediatric pediatrician/PNPs do not usually have the time to ask openended questions during the medical call-in, the Healthy Steps Specialist does have the time to
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�talk with parents about a broader range of behavioral and developmental issues. See Chapter 10
for more information on the Child Development Information Line.
Summary
The medical examination, sick visit, assessment, home visit and child development
information line are all opportunities to help parents better understand their child's development
and their own feelings about childrearing. Sometimes structured evaluations (such as the child's
physical examination) provide teachable moments by enabling pediatrician/PNPs to observe and
comment on the child's behavior and reactions to the exam. At other times, the pediatrician/PNP
or Healthy Steps Specialist can create teachable moments by interacting directly with the child or
simply by talking with the parents. The Quick Check Sheets (Appendix A) lists specific
maneuvers which the pediatrician/PNP and Healthy Steps Specialist can do to create teachable
moments at each well-child or home visit.
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�Table 1
Creating Teachable Moments
NEWBORN TO TWO MONTHS
Behavior
Comment
1. Model face-to-face
interaction with the
infant. Elicit infant
responses by using
different tones of voice,
facial expressions, and
head movements.
If the infant's eyes and head follow your face in a
coordinated fashion, use that behavior to explain
to parents that this reflects a higher level of coordination of multiple nerves than either of these
responses individually: Infants appear to be predisposed to look at faces, especially at contrasting
areas, like the hairline or eyes.
|
2. Demonstrate the
ease and/or difficulty of
consoling or arousing
the infant to an alert
state.
Demonstrate
different
Behaviors,
especially using your
voice, touch or picking
up the baby to quiet
her. Show parents how
bringing the baby to a
horizontal position on
the parent's shoulder
brings the baby to an
alert state where she is
ready for interaction.
Some infants use minimal environmental input to
get to an alert state. Others need more input.
Parents and/or pediatric clinicians have to work
harder to get some infants to an alert or quiet
state. Parents may feel disappointed in or rejected
by such a non-responsive baby. By showing
parents that this task is difficult for the pediatric
clinician, parents can understand that it is not their
fault. This same baby may be difficult to console
as well. The pediatrician/PNP's empathetic comments can be the start of a discussion of the
baby's temperament and self-regulatory mechanism and can give parents energy to try new
approaches to consoling or arousing the baby.
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�3. When the infant puts Hand-to-mouth represents self-consoling. It is the
beginning of infants' independent attempts to
hand to mouth
comfort themselves when irritable or distressed.
Giving the infant or toddler the opportunity to selfcomfort will build the child's confidence to become
increasingly independent. Discuss the benefits of
hand-to-mouth vs. a pacifier, because the infant
always has his hand and can therefore "regulate
himself and not have to cry to get parents to put
the pacifier back in his mouth.
These behaviors and interactions become more
readable over the first two months of life. The
pediatric clinician can comment at each visit on the
growing capacity of the infant to provide clearer
cues and on the parents' increasing ability to
"read" their child's cues.
4. Demonstrate how
the baby can track a
rattle 180 degrees with
his eyes. Also use the
rattle to demonstrate
reflex grasping.
Discuss how the baby follows the rattle with his
eyes in an arc over his face. Emphasize the
importance of this "looking schema" to the development of later cognitive skills. Identify with parents things that the baby likes to look at and
encourage them to expose the baby to new visual
stimulation while gently describing it to the baby.
Put the rattle in the baby's hand to demonstrate!
the power of the grasping reflex. Explain how the |
reflex will gradually fade so that coordinated
reaching and grasping can emerge. - .
.. •
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�TWO MONTHS
Behavior
Comment
IGive the baby a soft
block or a textured
squeaky toy like a
hedgehog.
Discuss how the baby explores the feel of the
objects by grasping, mouthing, shaking and looking at the object. Explain the relationship between
exploring the properties of objects and later intellectual development.
|
|
FOUR MONTHS
Behavior
Comment
1. Reciprocal face-toface interactions between mother and infant.
These interactions represent normal affective
development (child's smiling, happy affect) normal
language development (vowel sounds, aah's or
coos) and cognitive development (turn-taking).
The mother makes a sound followed by the infant
doing the same and they continue to take turns.
Turn-taking is an early sign of cognitive development in infants.
2.The clinician can Explain that while infants smile at all strangers at
elicit a smile from the this age, they smile more readily and more fully to
infant
their primary attachment figures. Mothers and
fathers will get a bigger smile quicker than the
pediatrician/PNP. This can lead to a discussion of
who else gets bigger smiles and to prepare the
parents for the time when this generalized friendliness with everyone will be replaced by stranger
anxiety.
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�3.After an engaging Infants are learning to use their voice to maintain
verbal interaction with social contact since they cannot use words or walk]
the child, deliberately after the adult at this age.
look away. The infant
will use his voice to try
to
get
the
pediatrician/PNP's and/or
parents' attention.
SIX MONTHS
Use the baby's rapidly developing reaching and grasping abilities to
demonstrate and explain the beginning sequence of fine motor development (pincer grasp) and visual motor coordination.
Behavior
Comment
1. Have an infant pick
up a cheerio. At this
age, the infant will use
his thumb and all fingers in a raking, somewhat
uncoordinated
manner.
Over the next three months, the infant will soon
use the thumb and forefinger in a raking motion
and the thumb and forefinger overhead, which is
called a "neat pincer grasp." This represents the
suppression of movements of the three lateral
fingers as part of ongoing neuro-maturation and
fine motor coordination. This also provides an
excellent opportunity to tell parents to keep small
objects away from children because now they can
pick them up and choke on them. But it also
means that the child is becoming more independent and can get the things he wants by himself
rather than relying on parents to get desired items
for him. This often results in reduced crankiness
on the part of the baby.
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�2.Have the infant reach Over the next three months, the infant's attempts
for a pen which you to grasp that pen will involve greater visual-motor
hold out to him. The coordination.
child's reach will be
undifferentiated regardless of whether pen is
held horizontal or vertical.
3. Give the baby a
hand held non-breakable baby mirror and
observe with the parents how she examines
her reflection.
Point out all the different strategies (schemas) she
uses to explore the mirror—mouthing, looking,
shaking/ banging, dropping, etc. Discuss the
various ways that the baby is learning to identify
her own body through earlier hand regard, play
with feet, pointing to body parts and identifying the
image in the mirror.
4.When the baby is on
his stomach, place a
favorite toy slightly out
of reach on top of a
blanket.
Describe how the baby uses the blanket to pull the
toy closer. Explain how this is the beginning of
problem-solving—using other things to get what he
wants and using objects as tools, as extensions of
the hand.
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�5. Demonstrate the
beginning of stranger
anxiety. When the
pediatrician/PNP approaches the infant
between six and eight
months of age, the
infant will visually
check with the parent
to see if it is okay for
the stranger to
approach. If the parent
smiles and appears
comfortable, the child
will allow the
pediatrician/PNP to
approach. If the
parent is frightened or
shows concern on her
face, the child will reflect that concern, or
turn away from the
pediatrician/PNP, or
clutch tighter to the
parent.
Infants look at the facial expression of parents for
approval. This behavior also marks the beginning
of stranger anxiety, as the infant differentiates
people that she knows from those she doesn't
recognize.
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�NINE MONTHS
1
Nine months often marks a rapid developmental shift to autonomy in the
baby.
Behavior
Comment
1 .Gently place the baby
in the usual, supine position for examination.
The infant will actively
resist being in this position and frequently cry.
The infant's emerging autonomy leads to resistance to such a dependent position. Striving for
autonomy might also be seen in feeding or diapering. Children will riot let their parents feed them,
but are happy to finger-feed themselves.
2. While the child is
struggling in the supine
position, distract that
infant with a new object
like a tongue blade.
Even a tongue blade, which is relatively boring, will
get the infant's attention because it's new. Explain
the thrill of novelty for babies and explain that even
babies get bored with familiar objects. You can
distract children more effectively by having a
variety of new objects.
3. Play Peek a boo with Note the affective components of the game—the
range of emotions expressed (surprise, expectathe baby.
tion, fear, delight), the turn taking as the baby
hides her eyes, and the expectation which the
baby has that your face will re-appear. Stop the
game and comment on the strategies which the
baby uses to get you to continue the game
(fusses, smiles, laughs, puts up her hands,
touches your hands, etc.). While playing, deliberately violate the expectations of the game - don't
say peek a boo if you have been routinely saying
it. Comment on the baby's reaction to that violation of expectation and relate it to cognitive development.
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�4. Hide a favorite ob- When the infant takes the cloth away, discuss how
ject under a cloth while this demonstrates his beginning understanding of
the baby is watching. object permanence. The knowledge that objects
continue to exist even when the baby can't see
them adds to his knowledge that the world has
some consistency arid dependability to it. Infants
are beginning to have a mental representation of
the object which explains why they can search and
find the hidden toy now when they could not do it
at six months of age. Compare this ability to
understand object permanence with person permanence. Discuss how separation anxiety and its
protest when the mother leaves the room demonstrates that the baby now has a mental symbol of
the mother and the discrepancy between that
symbol and her not being there evokes crying and
protest in an attempt to get the mother to return.
5. Engage the child in
reaching for a pen
which is extended to
him.
The pediatrician/PNP can again demonstrate
improved visual-motor functioning. The infant will
shape his fingers midway through the reach,
depending on the placement of the pen. This
again is a reflection of neuro-maturational development and greater efficiency of the visual motor
process.
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�TWELVE MONTHS
Behavior
Comment
1.Again offer the ex- Starting at about twelve months, stranger anxiety
tended pen to the child. prevents the child from reaching towards a
stranger. .
2.Give the baby a pop- Discuss the strategies which the child uses to
up toy or busy-box to figure out how to get the toy to perform. The baby
who uses a variety of schemas like banging,
play with.
shaking, poking has developed more ways to use
objects and to extract meaning from objects. This
broadens his cognitive understanding of how the
world works. Relate these exploratory schemas
for discovering causality to the classic complaint of
most parents of one-year-olds that they are "into
everything." Emphasize that while this can be
annoying to parents, and cause for safety concerns, it is the toddler's way of learning about the
objects in her environment. Discuss ways to
amuse busy toddlers while the parents cook, eat,
and go about their normal routines.
3. The child's autonomy and stranger anxiety can be seen when
the child tries to fend
off the physical examination.
This presents an opportunity to discuss with
parents the child's temperament, level of persistence and intensity, and autonomy regarding
everyday activities.
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�FIFTEEN MONTHS
Behavior
Comment
1. In many cases, the
pediatrician/PNP need
not do anything to provoke an example of the
child's growing autonomy. Most children
scream as soon as
they get into the room
with strangers.
The pediatrician/PNP can model how to slowly
approach the child, using her voice as a distraction
technique. If that approach is unsuccessful the
pediatrician/PNP can point to her own frustration
and how other family members or friends who see
the child infrequently may feel rejected by the
child.
2. Place a string toy
just out of reach of the
child with the string
near his hand.
Note the baby's efforts to get the toy. Discuss the
use of the string as an extension of the hand and
how at this stage the child must still actively try out
each solution to solve the problem. Soon he will
begin to think about how to get things which are
out of reach, but now he still needs to actively
experiment to figure out how to achieve his goals.
This is an example of means-ends relations. The
toddler has to separate the means—grasping,
from the ends—to get, by inserting another
operation—pulling the string to get the toy.
3. Give the child a toy
telephone and see if
she can demonstrate
functional use by putting the phone to her
ear. Ask her to let a
doll talk on the phone.
Discuss the child's ability to represent the use of a
toy phone on a doll. This stage of cognitive development signals the beginning of symbolic
representation, when the child can use one object
to represent another object that is not present.
Children at this age can demonstrate the functional use of cars, dolls and caregiving activities
like feeding, and can imitate housework like vacuuming and washing dishes.
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�EIGHTEEN MONTHS
Behavior
Comment
1. Give the child a con- Note the seemingly endless delight which toddlers
tainer and blocks.
have in dumping and filling. There is a sense of
satisfaction and fulfillment to the activity. There is
also a cognitive component. Toddlers are learning
about the properties of objects in space, about
completing a task (when the bucket is full), and
about a parent's reaction to the toddler's goal of
filling and dumping. This also gives you the opportunity to talk about throwing objects and offer
suggestions for how to handle limit setting with
young toddlers.
|
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�TWO YEARS
Behavior
Comment
LGive the child a sim- Talk about the child's attempts at problem-solving.
ple 2-3 piece puzzle to Does she try to bang the pieces in to place? Does
work.
she examine each one first? This activity also
offers the opportunity to talk about the child's
persistence and frustration level. You can point
out how highly persistent children can excel at
sticking with a task until they get it, focusing for
long periods of time. Also note how persistent
children are when they want an object that they
can't have. Similarly, children who are easi
frustrated by new tasks are easier to distract. Use
the opportunity to view persistence in children as
having both a positive and negative impact on
parent-child relations. Ask the parent to help the
child complete the task. Comment on "joint attention," ways to support problem-solving and following the child's lead in play.
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�THIRTY MONTHS
Behavior
Comment
1. Demonstrate the
child's receptive language skills by asking
the child to complete
two and three step
commands using
symbolic representation. For example,
using a doll, bottle and
tissue, ask the child to
feed the baby (or pose
the question—"The
baby's hungry, what
should we do? Put
the baby to sleep" The
same activity can be
done with a car and
little people to fit into
the car.
Watching their child perform these tasks correctly
can be particularly important for parents who are
worried about their child's language development.
Demonstrating the sophistication with which the
child can follow directions often calms the fears of
a parent who is worried about a child who is not
talking as well as her age mates.
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�THREE YEARS
Behavior
Comment
|
|
Use a ball to introduce While playing ball-games with the child, point out]
the child's ability to take turns, understand reci-|
simple games.
procity, keep the ball within the physical limits set l
by the game (i.e., between your legs and his) and 1
kick it forward.
|
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�6
�CHAPTER 6
PROMOTING "GOODNESS-OF-FIT" BETWEEN PARENTS AND CHILDREN
The first time Amy's mother gave her a bath. Amy turned solemn and quiet. When she
tried herfirstfood, she turned away from the spoon and then let the food dribble out
of her mouth As she got older, Amy's response to new events was fairly consistent.
She quietly refused to participate, preferring to sit with her mother and observe the
event before trying it herself. But after tasting new foods over and aver again, or
seeing a new person many times, she gradually came to accept and enjoy these new
experiences. Amy took a long time to warm up, but given the opportunity to reexperience new situations without pressure, she gradually embraced each new
opportunity. Amy's parents learned that when she went to the playground, she needed
about fifteen minutes to quietly watch the other children before she venturedforth to
play herself. Thefirsttime they went to the beach, Amy refused to go near the roaring
ocean. But over time, she grew to enjoy playing at the edge of the waves. Her parents
gave her plenty of time to "warm-up " to this new experience without forcing her into
the water before she was ready.
Children are born with a unique combination of temperamental characteristics that define
their particular behavioral style. We might think of temperament as the how of a child's
behavior, as opposed to the what or the why. Temperamental characteristics are what is
sometimes thought as the "innate" foundation on which a personality is built. Derived from a
combination of constitutional, intrauterine, central nervous system, and postnatal environmental
factors, temperamental characteristics are not exactly "fixed," but are likely to be persistent and
consistent over time.
Conducting a modified Brazelton Neonatal Assessment Scale (NBAS) when the baby is
between 3-5 days and two weeks old creates one of the first opportunities to talk in depth with
the parents about their child's unique characteristics. It helps families to get to know their child
by giving them useful information about their baby's personality, to identify with his/her unique
139
�characteristics, and to see that babies are capable of communicating immediately with their
parents (see Chapter 8 for more details on administering the NBAS during a home visit).
Temperamental Characteristics
Researchers have identified nine aspects of temperament which can be used beyond the
newborn period:
1.
Rhythmicity is the degree of predictability and rhythm in the
timing of biological functions.
2.
Activity Level refers to the motor component of the child's
functioning.
3.
Approach/withdrawal refers to the nature of the child's initial
responses to new stimuli.
4.
Adaptability is the ease with which a child's response to
situations can be modified.
5.
Threshold of Responsiveness refers to the intensity of
stimulation that is necessary to evoke a discernible response
from the child
6.
Intensity of Reaction is the energy level of the child's
response to stimuli.
7.
Quality of Mood is a summary term for the overall positive
or negative tone of the child's behavior.
8.
Distractibility is the ease with which a child can be diverted
from ongoing activity by extraneous peripheral stimuli.
9.
Attention Span and Persistence refer to both the length of
time a child will pursue a particular activity and the continued
interest in that activity in the face of obstacles.
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�Using these nine temperamental characteristics, several clinicians have identified
common constellations of behavior which characterize different children as having easy,
difficult, and slow-to-warm-up temperamental styles. An easy, adaptable baby would make any
parent feel reasonably confident in their childrearing abilities, whereas a temperamentally
difficult child would cause most mothers and fathers to question their competency as parents.
Because each child has distinct temperamental characteristics, parents who understand their
child's unique strengths and weaknesses will be in a much better position to create a home
environment which complements the child's innate temperament.
Parents also need to understand how their own temperamental style affects their
interactions with their child. Individual temperamental characteristics do not, in and of
themselves, cause behavioral or parent-child problems. Rather, it is the "fit" (or lack of fit)
between a child's temperament and the demands and expectations of the parents that can cause a
struggle. Clinicians are often in an excellent position to see whether parents and child
complement or antagonize each other. This is what we mean by the issue of "good fit" between
child temperament and parental expectations. If there is a compatiblefit,optimal child
development is likely. On the other hand, if parental expectations are not consistent with the
child's temperament, the resulting tension between parent and child can cause stress and
potential behavior problems.
For example, if the parents are fairly quiet and introspective, valuing reading and
conversation, but their child is outgoing, intensely interested in the world around him and very
active, there is the potential for a serious mismatch between parental expectations and child
behavior. When a child with a similarly active, intense temperament has parents who are also
141
�very active and value intensity in social and physical interactions, then there will be a goodnessof-fit with less potential for behavioral disturbances. The concept of "goodness-of-fit" is
situational; it is not the temperamental characteristics per se that cause the potential for problems,
but the expectations of the adults in the child's environment.
Promoting Goodness-of-Fit
Enhancing Goodness-of-Fit
Help parents understand the concept of temperament.
Help parents to see their children's striking reactions to
certain experiences as windows onto their particular
temperamental styles.
Show parents how they can use their understanding of their
child's temperament to predict how their child is likely to
respond to various experiences.
Encourage parents to clarify for themselves their own
temperaments.
Help parents to see goodness-of-fit as a way of reframing
their understanding of their relationship with their children.
When researchers evaluated the outcomes of temperamentally difficult children, they
were surprised to find only a modest relationship between having a difficult temperament and
long-term behavioral problems. They found instead that it was how the caretakers responded to
the child's innate temperamental traits that best predicted long term outcomes. So a
temperamentally active, inquisitive child can do well with parents who support his curiosity and
142
�pizzazz, but could have lots of problems in a more rigid, controlling family. In one family, an
active child is rewarded for his spirit. In the other, he is constantly punished for his innate
curiosity and relative lack of inhibition. In the first case, the child is accepted for who and what
he is, in the second, his self-esteem suffers for not being the type of child his parents want.
An explicit goal of Healthy Steps is to identify and enhance the goodness-of-fit between
parent and child. This can be done in a number of ways, involving both the pediatrician/PNP and
the Healthy Steps Specialist.
First, the Healthy Steps pediatrician/PNPs can help parents understand the concept of
temperament. If parents can see the child's intense responses to the environment, his
unpredictable moods, his often negative affect, his hypersensitivity to stimulation as inborn traits
- like the color of his eyes - then parental guilt for causing these difficult traits is lessened. And,
equally importantly, the onus is off the child. It makes all the difference in the world for parents
to view their child as temperamentally difficult rather than as willfully difficult. In the first case,
parents are more apt to be supportive and helpful, in the second to be blaming and critical.
Parents can begin to appreciate their child's unique temperamental characteristics by
recalling the intensity of their child's reactions to happy events and comparing it to the intensity
of response to unhappy events. When parents see a consistent style of expression in "good" as
well as "bad" behavior, they can understand the child's behavior as a pattern of unique
temperamental characteristics. They also have easier time predicting how their child might
respond to a new situation. Parents need to see their child's temperamental characteristics not as
necessarily good or bad, but as part of the child's unique personality. In fact, many
characteristics, like persistence, have both positive and negative associations, depending on the
143
�situation. For example, a persistent toddler will be very difficult to distract from touching
forbidden things like electrical cords, but that same persistence will allow the child to work a
puzzle for a long period of time without getting frustrated. A pediatric practice that can help
parents see both the positive and negative aspects of any given temperamental characteristic also
promotes positive parent-child interactions.
Pediatrician/PNPs can seek to integrate the child's temperament and parental caregiving
style into a constructive and nurturing "fit." Though many parents would love to change their
child's temperament, "a good fit" almost always begins with changes in the parents' style of
caregiving. Each child's temperament interacts in a unique way with the parents' own
proclivities. Together with the usual differences in birth order, and gender, these differences in
"fit"lie behind the old adage that "each sibling grows up in a different family."
In the long run, helping parents understand their children's different temperamental
characteristics can free them of a good deal of unproductive guilt around their children's
behavior. For example, once parents feel "off the hook" from responsibility for their child's
intense temper tantrum, they can be much more supportive of hisfrustrationin the face of
parental prohibitions or the limitations of his own body. Parents can learn to appreciate their
child's unique style and develop behaviors which complement the child. When parents feel
assured that they are not inept or totally responsible for their child's intense reactions to new
situations and that their child is not willfully difficult, they can develop the mutual adaptations
necessary to support positive parent-child interactions.
It is almost impossible to overestimate the importance of goodness-of-fit to the wellbeing of children. The pediatrician/PNP, via regular well-child visits, and the Healthy Steps
144
�Specialist through regular office, home and phone contact, are perhaps in the best position to
notice early mismatches between parent and child, and to provide timely interventions.
145
�
Dublin Core
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Title
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Health Care Reform
Identifier
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2006-0810-F
Description
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
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Clinton Presidential Records
Publisher
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William J. Clinton Presidential Library & Museum
Text
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Paper
Dublin Core
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Title
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Putting Health Steps Into Practices - Healthy Steps Training Manual [1]
Creator
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First Lady's Office
Nicole Rabner
Source
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7763278
42-t-7763278-20060810F-Seg2-020-003-2015
Identifier
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2006-0810-F Segment 2
Is Part Of
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Box 20
<a href="http://clinton.presidentiallibraries.us/items/show/36145" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/7763278" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Preservation-Reproduction-Reference
Date Created
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5/27/2015