The birth of a new baby heralds significant changes in the life of a family. Parents feel excited, joyous, uncertain, and confused by the monumental shifts that occur in their child's development, particularly during the early years. These complex and shifting parental emotions are influenced by many factors, including the unique patterns of their child, their own experiences and memories of their upbringing, and the current circumstances in which they are raising a child. Parents often have many questions and seek information and support as they grapple with the enormous challenge of parenthood.
Pediatricians are well positioned to support the healthy growth and development of children and families by establishing a supportive, ongoing, and empathic relationship with a family. This type of pediatric care has been well described by pediatrician and psychoanalyst D. W. Winnicott. During the first year of a child's life, families will see their physician on average at least six times for well-child health maintenance visits and for any additional ill-visit encounters. Under optimal circumstances, a well-trained pediatrician is able to use these visits to explore the impact of the new child on the existing family structure, to promote a sensitive and well-attuned parent-child relationship, and to listen to and contain the anxieties and vulnerabilities all parents experience while monitoring the development of the child.
We know, however, that such a relationship between pediatrician and parent often does not happen, and the opportunity to develop an unhurried relationship is limited. Managed care has created new pressures on practitioners to see more patients in less time and has promoted more transient relationships due to frequent changes in insurance carriers. In addition, many pediatricians are inadequately trained and lack sufficient skills in family assessment and child development to provide the support and surveillance described above.
Within the inner city, it is even harder to use pediatric visits to enhance parental knowledge of child development and support healthy parent-child relationships. Clinics are primarily staffed by pediatric residents, who are focused on simply mastering the basics of pediatric care. Busy clinics often keep faculty from devoting adequate time to teaching residents about child development and psychosocial issues. Families who receive care from inner-city clinics often live in poverty and struggle with issues of violence, substance abuse, poor education, and limited parenting skills. These problems may dominate the visit with the pediatrician.
Nevertheless, abundant research has demonstrated that the early years of a child's life are critical ones. It is essential for children to experience a nurturing, reciprocal relationship with a caring and responsive parent. This is the rationale for developing the Yale Pediatric Parent-Child Project. My training as a behavior and developmental pediatrician included treating a few young children with analytically informed psychotherapy. Thus I am well aware of the importance of listening to and communicating with children and families.
“It is essential for children to experience a nurturing, reciprocal relationship with a caring and responsive parent.”
The project involves pediatric residents implementing a brief, uncomplicated intervention during well-child visits. They engage the infant with a developmentally appropriate toy and invite parents to observe together with the physician the infant's responses. The residents use these observations to discuss with parents key milestones in the social-emotional development of their child.
Some of these important milestones illustrate an infant's capacity in the first year of life for increasingly differentiated social-relatedness and more complex attachment relationships. For example, at the nine-month visit, residents use a reversible puppet with a rabbit on one side and a turtle on the other to illustrate a child's emerging capacity for object constancy. As the child plays with this toy, residents and parents can observe the child's affective, cognitive, communicative, and motor responses to the appearance and disappearance of the animals on the puppet. Residents can then emphasize the significance of a parent's appearance and disappearance to a child of this age and how this might affect that child's behavior.
Using this strategy, the concept and importance of separation awareness may be easier for the resident to communicate to parents and may become more vivid and meaningful for the parent. Grant funding has enabled us to give families the toys used at each visit along with handouts about child development and a suggestion sheet on additional ways to play with the child at home.
With these interventions we hope to achieve the following goals.
Pediatricians will become more active and effective observers of infant behavior and parent-child relationships. By introducing the toy during the well-child visit, the physician can observe the baby's reactions and skills and explore how the infant and the parent relate to each other. We are training pediatricians to communicate more effectively to aid parents in understanding their unique child.
Parents will become more active observers of their children. The intervention gives parents an opportunity to be more engaged in their infant's visit and observe their child's responses to new stimuli. Since this intervention occurs on multiple visits, parents and pediatrician will be able to notice changes in the child's behavior and development over time. We believe this will enhance parents' understanding and empathy for their child and diminish their frustration.
Pediatricians and parents will be permitted to develop an intimate, respectful relationship. The intervention is designed to create an environment where parents feel comfortable in bringing their questions or concerns about their child-rearing skills or their child and can receive help in a non-judgmental, informative way.
Parents will become more knowledgeable about the social-emotional development of the infant and the integrated nature of child development. We hypothesize that parents can more fully support the development of their child when they are more knowledgeable about understanding each stage in a child's growth and development.
Parents will feel more supported and confident in their role. We believe that as pediatricians reinforce positive parent-child relationships, parents will feel a greater sense of competence and confidence as a parent.
If this early project is successful, we hope to intensify the intervention with additional measures, such as home visiting, and to implement this project in additional sites. The Yale Pediatric Parent-Child Project is designed to train pediatricians to ensure that each child is offered a healthy and nurturing start in life.
Carol Cohen Weitzman, M.D., is an assistant professor of Pediatrics and Child Study Centers at the Yale University School of Medicine.