SAN DIEGO — The physical exam and the behavior of both child and parent during an office visit provide good opportunities for pediatricians to teach parents about child development and to help them improve their child-rearing skills, Dr. Barry Zuckerman said at a meeting sponsored by the Los Angeles Pediatric Society.
Parents' understanding of their own childhood and behavior can be a key factor in these “teachable moments” because such understanding promotes a healthier relationship between parent and child, said Dr. Zuckerman, chief of pediatrics at Boston University.
“The most obvious teachable moment is when the parent comes in and has a question,” Dr. Zuckerman said. But pediatricians can also create such moments. For example, pediatricians can narrate the goals and findings of the child's physical exam.
During office visits, Dr. Zuckerman also watches for parental behavior that might signal a deeper problem. Ignoring the child who is being disruptive or out of control might mean the mother is preoccupied with her job or marriage or is suffering from depression. Pediatricians can model setting limits for the child and try to help the mother understand why she isn't setting limits herself. (See box.)
A mother who intrudes considerably on her child's behavior may be overly anxious and impair the child's need to explore and learn from his environment. The mother may benefit from increased self-understanding of her inability to be comfortable exercising some self-control.
How a parent and child interact during an office visit also reveals important information, Dr. Zuckerman said. In a healthy relationship between a mother and 3-month-old, for example, both are completely engaged, entertaining, able to read social cues correctly, and strongly focused on each other—like Fred Astaire and Ginger Rogers, he said. The baby watches his mother, vocalizes, and waits his turn to contribute to the exchange.
This kind of positive give-and-take may be missing in an unhealthy relationship.
Dr. Zuckerman cited two worrisome behaviors he has seen in about 5% of parents of 1− to 3-year-olds: not setting any limits (letting the child rifle through everything in the pediatrician's office) or setting limits that are too extreme (constantly fussing over the child and pulling him back, discouraging exploration).
Behaviors like these during an office visit provide immediate teaching opportunities, he said. With feedback from the pediatrician, the parent can acknowledge her own behavior and learn how to correct it.
Teachable moments require a certain finesse on the pediatrician's part, according to Dr. Zuckerman. It's important to engage the parent—perhaps through humor or by enlisting the parent's help in getting to the root of a problem—and to provide positive feedback rather than blame or putting the parent on the defensive.
Indeed, thorough assessment of the child may reveal a neurologic deficit for which no one is to blame, he said.
Questions to Aid Self-Knowledge
By asking important questions at critical times, pediatricians can foster self-understanding in parents, Dr. Zuckerman said.
This gives parents insight that, as they raise their children, makes them much less likely to repeat “maladaptive patterns” they learned in their own childhoods, he said.
Here are some questions physicians can consider with parents to promote self-understanding. These questions need not be asked at any one visit, but rather, over many visits:
▸ What was your parents' philosophy about raising children, and what did you like and dislike about it?
▸ How did you get along with your parents?
▸ How did your relationship with your mother differ from your relationship with your father? How were they similar? Give three words that describe those relationships.
▸ How did your parents discipline you as a child? What impact did this have on you, and how does it affect your role as a parent now?
▸ Did you ever feel rejected or threatened by your parents?
▸ If there were overwhelming or traumatizing experiences in your childhood or later, do they still influence your life?
▸ Did anyone significant die during your childhood or later in life? If so, how does that loss affect you now?
▸ How did your parents communicate with you when you were happy/excited or unhappy/distressed?
▸ How has your childhood shaped the ways in which you relate to your children?