Family life educators supporting pediatricians with parenting information

Karen DeBord, Ph.D.
North Carolina State University

Rebecca Stelter, M.S.

Abstract

Pediatricians report seeing 40 to 60 patients per day. Many parents of these patients have specific questions about behavioral and developmental issues such as discipline, sleep, nutrition, and toileting, all of which are topics that family life educators are prepared to address routinely. Collaboration between Extension educators and pediatricians can benefit patients, parents, and pediatric practices, as well as family life education programs.

Introduction

Among the basic developmental needs of young children is a healthy relationship with their parents or significant caregivers. It is through these relationships that children learn to develop trust, empathy, compassion, generosity, and conscience — the qualities necessary for healthy relationships in life, cognitive development, and school readiness. What young children learn, how they react to the events and people around them, and what they expect from themselves and others are deeply affected by their relationships with parents, the behavior of parents, and the environment of the homes in which they live (Bradley et al. 1988, Collins and Laursen 1999, J. Dunn 1993, Hartup and Rubin 1986, Maccoby and Martin 1983). The Institute of Medicine (Shonkoff and Phillips 2000) reports that positive developmental interactions with parents improve young children’s social competence and their overall capacity to learn, and that 54 percent of parents want more information on how they can help their young children learn. Parents’ desire for more information is a need that must be met by society to assist families and provide a first line of defense against later developmental problems.

One method of helping parents meet the basic developmental needs of their children is parent education programs designed to prevent child maltreatment, reduce parental stress, and enhance an array of protective factors for children, including pro-social development, school readiness, and emotional stability. However, differences exist between and among groups in how they prefer to receive parenting information. For example, African-American parents more often than others turn to immediate family members, primarily their own parents as primary sources of information, while Hispanic parents prefer to turn to their medical practitioners as a source of information (DeBord 1996). Although an abundance of family support services may be available in communities, parents often do not use services until problems arise or a child is found to have developmental delays. However, one service provider that parents generally do use is their “medical home.” Pediatricians in North Carolina report that issues related to children’s social development and behavior absorb an inordinate amount of time during child check-ups where they are seeing 40 to 60 patients per day (NC Pediatric Society/AAP NC Chapter Mental/School Health meeting January 2006). The establishment of a medical home for patients ensures that the child’s mental health needs accompany their physical growth needs.

In North Carolina, the dismantled state-administered mental health system no longer meets the ever-growing mental health needs for children, as one in five children is estimated to be suffering from social or emotional problems (Surgeon General’s report, Department of Health and Human Services 1999). In another state, it was estimated that 15 percent of the young children in child care had emotional or behavioral problems enough to disrupt classrooms and distress teachers (Kraft-Tharp 2004). Researchers have found that even infants experience mental health issues, and that their mental health status directly correlates with the quality of the parent-infant relationship (Huff 2004). With the increased demand on the medical community to attend to the needs of the whole child, an explorative study was done to examine the nature of parent needs for information during child examinations. Findings from this study are useful for researchers who are interested in the kinds of questions parents often have for pediatricians that fall outside of children’s basic health needs. Study findings will also benefit pediatricians and family life educators who work to improve parents’ child-rearing knowledge and skills.

Teaming pediatricians and family physicians with family life educators may be one way to address the need of parents. Family life educators contribute to the array of community support services for families who are seeking parenting information and skills. Research focusing on common questions and concerns that parents address to their child’s pediatrician is scarce. Of particular interest for the current study are the questions parents have that do not deal directly with the child’s physical well-being, such as issues related to their child’s socio-emotional development, the parent-child relationship, and mental health. The current study has three objectives: (1) assess parents’ primary areas of concern for their child’s well-being, (2) assess the type of information that physicians would like to share with parents outside of the child’s physical well-being, and (3) determine avenues of future research for how Cooperative Extension family life educators can assist physicians and parents in meeting children’s socio-emotional and mental health needs. The study was designed to forge partnerships with pediatricians and family practices so that medical professionals will begin to use and refer parents to Cooperative Extension as a key resource for families, particularly in rural communities. Pediatricians and family physicians are in a unique position to identify parents who have limited knowledge of children’s normal developmental progression. To identify specific areas of risk, we surveyed pediatricians about what they commonly observed and heard from parents in their practices.

Method

Participants. Members of the North Carolina Pediatric Society were invited to participate in an online survey regarding the common questions heard from parents in their practice. A one-time email was sent by the North Carolina Pediatric Society Executive Director to a list of 900 pediatricians in the state.

Measure. A questionnaire was created through the Zoomerang ™ online survey service and emailed to pediatricians. The email directed them to the online survey where they responded to four questions. The first question was to assess the pediatrician’s length of experience in their field. They were asked, “How many years have you been in practice working with infants and parents?” to which they responded with one of the following options: less than 3 years, 3-5 years, 6-10 years, 11-15 years, or 15 + years. The next three questions were open-ended, and an unlimited amount of space was provided for a response. These questions were as follows: “List the primary issues (outside of physical health and immunizations) that parents are expressing concern about (social, emotional, feeding, toileting, behavior)”, “If you had more time to spend with parents, what is the primary information that you would want to share with them?”, and “What sources do you use for referral for parents to information about parenting?” After responding, the participants submitted their results, which were tabulated by a faculty member and a graduate assistant in the Department of Family and Consumer Sciences at North Carolina State University.

Coding. Participants submitted their responses online over a period of two months. Following this, the results were compiled and reviewed for common themes. These themes were used to create a coding scheme, and all responses were coded into mutually exclusive and exhaustive categories. For example, the second question asked pediatricians to list major areas of parental concern. Multiple responses were elicited. When participants gave more than one response to the question, each response was coded.

Description of codes. A unique set of codes was generated for each question based on the major themes that were observed in the participants’ responses.

For the second question, six codes were generated: 1) behavior/discipline, 2) nutrition, 3)sleep, 4) school, 5) toileting, and 6) other. The behavior/discipline code applied to any mention of the words either behavior or discipline, for example, “child behavior and discipline issues,” or specific examples of behavioral issues “temper tantrums, hyperactive behaviors.” Nutrition was applied when the participant replied with statements such as feeding, eating habit, appetite issues, or obesity (for example, “picky eating/only wants sweets or junk.”) The third code was for responses related to sleep. Examples include “sleep patterns, sleep issues.” Responses related to school issues, such as school performance or school problems, were the fourth code. The last specific code was toileting. “Toilet training, overactive bladder, and incontinence” are examples of this category. Finally, all other responses that did not fit into one of these five codes were coded as “other.” Examples of responses that were coded as other are ADD, ADHD, car seat use, motor development, and peers. None of these responses emerged as a significant or consistent theme, and none of them was mentioned with a noticeably greater frequency.

Question 3 asked participants to respond to the question “If you had more time to spend with parents, what is the primary information that you would want to share with them?” During the review of participants’ responses, four themes were observed, and corresponding codes were generated. The first related to the theme of behavior and discipline. Similar to question 1, any mention of either behavior or discipline was coded in this category. Examples of several responses include “providing guidance and discipline”, “discipline techniques and positive reinforcement early in development.” The second theme was termed general parenting advice or responses that included parenting skills, advice on socio-emotional issues, or routines. For example, (parents need to) “spend more time with their children, monitoring their activities … children need that time more than the things money can buy”, “need for consistent quality family time and routines.” The next code addressed issues of normal developmental processes. Statements related to educating parents about the progression of development, such as milestones or developmental limitations and an understanding of the variability in normal development. Examples include “norms and variations in child development” and “appropriate play/stimulation.” Responses related to nutrition emerged as another theme. These consisted of advice for helping parents to get their child to eat more healthy foods and have a healthier lifestyle. The last theme was anticipatory guidance or advice on how to avoid future problems and an understanding of preventative measures.

The fourth and final question was asked to get a sense of where pediatricians currently refer parents for information about parenting. Publications by the American Academy of Pediatrics (AAP) were the most common resource for pediatricians; these included books and the association’s website. Any response that mentioned AAP resources was coded in this category. Professionals such as social workers (who are authorized to charge and accept third party payments such as insurance payments), the physician’s own advice, or psychologists comprised another category. Books in general, but not AAP books, also accounted for a significant number of responses. The internet – either specific sites or just referring parents to the internet in general,  but not AAP websites – was designated as another category. Finally, the physicians’ own materials such as pamphlets made up the last category.

Results

Seventy-nine pediatricians (8 percent response rate) responded to this survey. Of these, 57 percent reported 15 or more years in practice as a pediatrician, 11 percent reported 11-15 years in practice, 20 percent indicated 6-10 years in practice, 3 percent reported 3-5 years in practice, and 9 percent reported fewer than 3 years in practice. The majority of the participants had at least 6 years in practice, with 87 percent of the respondents reporting six or more years in practice.

What are parents’ primary areas of concern?

Pediatricians reported that parents are primarily (31 percent) concerned with behavior and discipline issues followed by issues related to nutrition (22 percent). The next most frequent response were comments that fell into the category of “other” (16 percent) followed by issues related to children’s sleep patterns (13 percent) and school (9 percent) and toileting (9 percent).

What information do pediatricians want to share with parents?

Pediatricians reported the primary information they wanted to share with parents was related to children’s behavior and discipline (35 percent) and general parenting advice such as the importance of routines (30 percent). Pediatricians reported that parents need advice on nutrition (14 percent) and information about normal child development (14 percent). Finally, five pediatricians, or 7 percent of the sample, reported that anticipatory guidance, or advice on how parents can prevent physical and socio-emotional problems with their child, was important.

What resources are parents referred to?

The final question assessed where pediatricians commonly refer parents with questions related to parenting. Most commonly (38 percent), pediatricians referred parents to American Academy of Pediatrics references such as books or websites. Referrals to professionals such as social workers or psychologists were reported by 33 percent of pediatricians surveyed. Pediatricians also reported often referring parents to their own materials such as pamphlets (27 percent), followed by books (22 percent), and internet resources (21 percent).

Conclusions

Even with this small sample, the results of this online survey support the idea that pediatricians in North Carolina are increasingly called upon by parents to help answer their questions related to a child’s social development and behavior. Besides physical health and development, behavior and discipline are important domains about which pediatricians are asked. However, these are two important areas where pediatricians may not have the training or expertise to appropriately respond to parent questions beyond giving their own personal advice.

Nutrition is another important concern that pediatricians reported hearing from parents. For matters of childhood nutrition, pediatricians have insight about healthy eating, but parents may need to be referred to specialists for additional information about feeding patterns, routine mealtime, or behavior related to eating.

Pediatricians who see more than 40 patients per day may experience extreme demands on their time and, as a result, cannot spend the necessary amount of time with parents addressing all their issues, particularly those related to the child’s socioemotional development. With the demands on pediatricians’ time and lapses of months in between patient visits, pediatricians are left with providing written pamphlets or books for parents for reference when they are not available.

Future directions

To respond to the pediatricians’ reported needs, partnerships at the community level must be forged with medical practitioners to provide parents with important information about their children that is outside of physicians’ area of expertise. Pediatricians may not be aware of the educational and preventative nature of the work of family life educators and Cooperative Extension faculty. Brief fact sheets and other written materials, in addition to special notices of educational sessions or outreach services (toll free numbers, websites), are appropriate passive outreach methods. Further, determining the best way to network and interface with medical professionals is a more critical intervention that can help shape community support for families. Educating physicians and their staff about the supportive parent resources in the community is critical as communities band together to raise healthy children.

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Cite this article

DeBord, Karen, and Rebecca Stelter. 2007.  Family life educators supporting pediatricians with parenting information.  The Forum for Family and Consumer Issues, 12 (2).

On-line:http://ncsu.edu/ffci/publications/2007/v12n2-2007-fall/index-v12n2-nov-2007.php

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