Promoting parental "presence"

February 1, 1999

Article

Why are more parents than ever complaining that their children are out of control? One reason, this authority suggests, is a lack of parental effectiveness or "presence."It follows that strengthening this quality in the parent may be the best way to help the child.

Promoting parental "presence"

By Morris Green, MD

Why are more parents than ever complaining that their childrenare out of control? One reason, this authority suggests, is a lack of parentaleffectiveness or "presence."It follows that strengthening thisquality in the parent may be the best way to help the child.

Toddlers are often brought to the pediatrician when they display "outof control" behaviors like those listed in Table 1. Observation ofthe families of such toddlers at our pediatric consultation clinic suggeststhat deficits in authoritative parental "presence" are an increasinglycommon cause of the youngsters' behavior problems. Although the waning ofparental authority is not limited to families with young children, opportunitiesto intervene are greatest in the early years of life, when pediatricianssee children and their parents most often. This discussion of the diagnosis,management, and prevention of disciplinary ineffectiveness therefore focuseson children younger than 3 years of age. It has direct implications forthe anticipatory guidance offered at periodic health supervision visits.

In this discussion, the term "presence," analogous to whathas been termed "command presence," refers to the ability of parentsto project leadership a bearing and demeanor that evokes a child'strust and respect and a desire to meet the parent's expectations. Characterizedby the attributes listed in Table 2, "presence" or its absence is readily identifiable in the pediatric office.

Although the manner in which mothers and fathers exercise authority hasobvious cultural determinants, parental roles are not necessarily limitedby gender. Indeed, just as fathers currently are encouraged to express morefully their nurturant capacities, mothers are being asked to exercise abroader leadership role in the family.

Deficits in parental presence sometimes are an indirect result of socioculturalchanges, such as an increase in the number of single parents and motherswho work outside the home. More directly, they may result from maternaldepression, chronic parental illness, marital discord, and other familycontingencies listed in Table 3.

Assessing parental "presence"

Most parents rear their children successfully, even in difficult economicor personal circumstances, but some are unable to project the requisiteauthority. Without an adequate understanding of the many reasons for undesirablebehavior, parents usually see the child as its primary cause and as theone toward whom therapeutic efforts should be directed. Understandably,parents may neither anticipate nor understand the need for a contextualapproach to the problem, one that includes themselves as well as the child.

The diagnosis of a deficiency in parental presence is established throughthe pediatric interview and observation of the parent and child, supplementedby reports from child-care workers or early childhood educators. The interviewis the most effective diagnostic and therapeutic tool available to the pediatrician.Diagnosis and treatment must occur concurrently. Both parents should beasked to attend the consultation to elicit their shared observations, assessmentof the child ("How do you see Kevin?"), view of the problem, andideas about possible solutions. Most parents who are asked what they thinkis causing the toddler's behavior ("It would help me to know what youhave considered as possible causes of John's behavior") reply thatthey do not know or "I just think he's 'hyper.'" Other parentspose their own questions, such as "Do you think we are doing somethingwrong?" or "Do you believe he is reacting to all the stress inour family?" In general, parents do not spontaneously report familymatters that put them at risk for diminished parental presence, becausethey either do not recognize them (for example, maternal depression) orthink they are irrelevant to the chief complaint (for example, an ill grandparent).

Accomplished clinicians have highly cultivated abilities to see, hear,and feel more than the obvious during the interview, physical examination,and other parts of the consultation. In addition, they have a repertoireof tested "trigger" questions to elicit the information requiredfor diagnosis and management. They use direct observation to answer questionssuch as these:

Does the parent or the child seem depressed? Overwhelmed? Fatigued?Anxious? Angry? Perplexed? Self-blaming?
Did the parent bring along someone for support?
Are the parents supportive of each other or hypercritical and contradictory? Do they seem familiar with what their spouse is thinking?
Do the parents have authoritative presence with the child?
How does the child relate to them?
Do they include the child in the conversation?
Do they praise or commend him during the consultation?

In the office, the child may demonstrate some of the same behaviors reportedto occur at home, such as hitting, climbing on the window sill, pushing,spitting, and yelling "You liar!" or "You stupid idiot!"at the mother, ignoring the parent's demands, and cursing while the flusteredparents fruitlessly try to ignore or control him. On the other hand, somechildren, much to their parents' surprise, play quietly with toys, lookat books, color, or even sit briefly on the doctor's lap. Similar disparitiesmay be evident in reports from preschool teachers and other caregivers.Once away from home, some of these toddlers may behave in a way that isnormal and acceptable for their age.

Managing parents who lack presence

Parents of children who seem out of control come to the pediatricianfrustrated by their child's behavior, baffled as to its cause, and distressedby their own ineffectiveness. Their resignation and sense of helplessnessare implied in the frequent lament, "I've tried everything, and nothingworks!"

To manage this situation successfully, the pediatrician usually needsto use the interview to reframe the presenting problem so the parents cansee the contributing factors more comprehensively. This must be done skillfully,recognizing that parents, especially those under stress or encumbered bya sense of failure, are exquisitely sensitive to what they may misread asblame for their child's behavior. So as not to arouse defensiveness, progressingslowly rather than quickly generally is better in these cases, especiallywhen it comes to explaining the cause of the child's behavior. The needfor changes in the family, though quickly evident to the pediatrician, maynot be apparent to the parents.

Once the parents better understand the many factors contributing to theirchild's behavior, the pediatrician may encourage them to suggest changesand strategies that may be therapeutically effective. ("I know thatyou are here for my suggestions, but first I'd be interested in what youbelieve might help with Jim's behavior.") Parents are more likely toaccept their own ideas as understandable, workable, and useful than theyare an outsider's. This approach also increases their sense of efficacy,autonomy, and ownership.

Ten therapeutic suggestions

The strategies described here can be used selectively to complement andsupplement those worked out on the basis of the parents' own ideas. At theconclusion of the session, summarize the key suggestionsin writing on aprescription or instruction form for the parents to take home. If medicationis not advised (this discussion does not address recommendations for drugtherapy), briefly explain why, in case the parents expected to be givena prescription. An early return appointment helps ensure that the recommendationsare being followed and provides an additional opportunity for the pediatricianto make suggestions.

1. Explore ways to reduce task overload. This goal has a high priority.In the late afternoon, the transition between the demands at work and thoseat home is often hectic, especially for single mothers and their young children.An effective and much-appreciated recommendation, when economically feasible,is that the family employ an adolescent "mother's helper" fromthe neighborhood to help with the children for an hour or so the "children'shour" adapted to today's realities. Flexible or shared work schedulespermit some mothers to spend more time with their children. More participationby the father in domestic matters and fewer elective time commitments areother possibilities.

2. Find ways to give parents some respite. Counsel mothers of young children,especially children with special health needs or demanding, spirited temperaments,to ask the father, another relative, baby-sitter, or friend to care forthe child occasionally so the mother can have a day off to go outwith the father or a friend, or just have some time for herself. Lack ofmoney or a sitter whom the parents trust makes this a difficult option forsome. If anyone in the family criticizes the mother for being away fromthe child, she should reply firmly that "Dr. Smith insists that I mustdo this if I want her to continue as Marcia's pediatrician. I have no choice."A physician's order also helps alleviate guilt in overly conscientious parents.

3. Advise enrolling the child in a developmental child-care program orpreschool. Doing so makes the demands on a mother less constant and at thesame time provides the child with educational and social benefits. Contactwith early childhood educators may also increase the parents' understandingof their child's developmental needs, their ability to meet them, and theirpersonal disciplinary effectiveness.

4. Help parents understand the "gift of time." During the interview,many parents who are confronted by seemingly unending work and other externaldemands may suddenly recognize fully for the first time that they are spendingvery little individual or one-on-one time with their children. Most aretroubled by this realization, having decided some time ago that they wouldmake up the deficit "later" when "I'm not so busy."For these parents, the "gift of time" has proved to be a well-accepted,effective, and rewarding intervention. I introduce the idea with the assurancethat "many parents tell me that this has worked well for them."The parent should regularly sit down with the child and circle on a largewall calendar two or three days in the next week when the two of them willhave a 10- or 15-minute "date" to do something they both enjoy.They may choose to take a walk, read a book, play a board game, toss a ball,tell stories, or just talk.

For parents who travel, a similar practice permits the child to "see"when the father or mother will return. The circled homecoming date providesa concrete answer to the child's repeated question, "When is Daddy(or Mommy) coming home?" Parents may also maintain a virtual presencewhen they are away by sending postcards, calling, or leaving an audiotapedmessage to be played as part of the child's bedtime ritual.

5. Suggest a home visitor. Nurses or other professionals may providetimely support for mothers of low birth-weight infants or children withspecial health-care needs.

6. Encourage parents to take care of their own health needs. The parentwith a chronic physical or emotional illness that limits his or her effectivenessshould have a medical or mental health consultation, if he or she is notalready receiving needed care.

7. Counsel parents on how to demonstrate greater presence. The successof pediatric intervention depends on a parent's ability to modify his orher behavior. One way to achieve better family interaction and communicationis for parents to "coach" each other. This is how the parentsof Jacob, a 4-year-old boy who was have difficulty separating from his mother,used this technique to tackle their problem. In the interview, Jacob's motherrecalledher son's birth by emergency cesarean section and her fears that both sheand Jacob might die. She recognized her overprotectiveness and wanted helpin mastering her inhibiting behaviors. In response to the pediatrician'squestion as to what coaching recommendation each parent could make to theother, the father offered to take care of Jacob on weekend afternoons sohis wife could engage in activities outside the home. He also suggestedthat they explore enrolling Jacob in a preschool where experienced educatorscould help both Jacob and his mother master this separation experience.Looking farther ahead, the father said he was certain that his mother, wholived nearby, would baby-sit for Jacob so the boy's mother could take acomputer class in community college. Jacob's mother agreed that these suggestionswere realistic and helpful and suggested that in addition she and her husbandalternate handling the nightly bedtime rituals for Jacob and his youngersister. Both parents concurred that further mental health counseling shouldbe arranged.

Family therapy may be useful. When the father does not actively participatein family life, the pediatrician should help the mother identify ways topromote a fuller paternal role. By praising her husband for any effortsand building on them, the mother may become comfortable enough to ask herhusband directly to join in family activities.

8. Encourage parents to develop support outside the immediate family.Family support and service agencies, parent support groups, and mental healthclinics are among the community referral resources available to parents.Parent education programs such as PET (Parent Effectiveness Training), STEP(Systematic Training for Effective Parenting), and Active Parenting maybe identified through community information and referral network informationcenters. Family members, neighbors, and the clergy are additional sourcesof personal support and friendship.

9. Offer encouragement and empathy. The pediatrician's understanding,empathy, and commendation contribute greatly to a parent's self-esteem,optimism, confidence, and motivation. Don't underestimate the effectivenessof this support.

10. If parents are at risk of diminished parental presence, take appropriateaction. Developmental surveillance of the parents as well as the child duringhealth supervision and illness visits permits the timely introduction offamily protection measures or early therapeutic intervention. Counselingto foster authoritative parental presence is a timely addendum to periodicpediatric health-supervision visits.

Table 4 summarizes these management strategies.

How parenting presence develops

In part, parenting presence is acquired through a parent's identificationwith his or her own parents if they have been good role models. Whenthey have not, parents can extend their effectiveness by reading, gettinganticipatory guidance from their pediatrician, and modeling their behavioron that of other mothers and fathers who are especially talented in thecraft of parenting. Effective parental presence is reinforced by many things:enjoying one's children, pride in parenthood, personal maturation, a nourishingmarital relationship, interest in one's personal development as well asthat of the children, educational preparation for family life and parenthood,an optimistic explanatory style, good health, high self-esteem, social skills,a sense of efficacy as a parent, social supports, and the resilience thatpermits positive adaptation to expected and unexpected life changes andstressors.

The contribution of anticipatory guidance

During early childhood, parents are responsible for promoting their child'sgood health and normal development social and emotional as well asphysical. To rear responsive, affectionate, disciplined, and admiring childrenis both a praiseworthy goal and a major parental achievement.

Preparation of expectant parents for parenthood is a developmental processthat begins in the parents' own childhood. The pediatrician can sample recallof those years by asking trigger questions such as "How was it foryou when you were growing up?" or "Do you intend to raise yourchild the way you were raised or somewhat differently?"

The deficits practitioners are seeing suggest that promotion of parentalauthoritative presence deserves more emphasis in health-supervision consultationsthan it is receiving. The following anticipatory guidance suggestions forthe child's first year of life are intended to promote parental leadershipand effectiveness. Exactly how they are stated needs to be fitted to specificpractice populations.

The prenatal consultation. As they prepare for their new role,parents generally appreciate the opportunity to meet the pediatrician. Anintroductory brochure can present the goals of the practice and answer frequentlyasked questions. The practice orientation brochure may also include questionsor concerns that merit a call to the pediatrician's office. By showing aninterest in the prospective father during this and subsequent consultations,the pediatrician validates the major role fathers play in child rearing.Early in this introductory meeting, identify authoritative parental presenceas a joint parent-pediatrician goal and a continuing theme throughout futurehealth-supervision consultations. It may be more difficult to establishthis theme once problems related to parental presence have arisen.

Use a family database questionnaire to obtain information on the courseof the pregnancy, family health, prenatal concerns, and the parent supportplanned after the baby's birth. The parents' answer to the question, "Howdo you expect your new baby will change your lives?" may give the pediatriciana sense of the amount and kind of guidance needed.

The newborn consultation. When feasible,examine the baby in frontof the parents so as to observe the three of them together as a family.Such a happy occasion also offers a great photo-op a chance to documentthe new parent-pediatrician partnership. In addition to inquiring aboutthe amount of help the mother expects to have at home, specifically underlinethe importance of the father's support. Remember that some mothers feellet down after the excitement of giving birth. Calling the parents a dayor two after discharge helps establish a supportive relationship.

One-week consultation. In addition to inquiring about how thefamily is doing and the kind of support they are receiving,consider introducingthe concept of infant temperament, especially if the baby feeds and sleepsirregularly or is difficult to console.

One-month consultation. Note and commend any parent-infant attachmentbehaviors, such as soothing and gentle cuddling, eye contact, rocking, kissing,smiling, singing, and talking to the baby. Questions about crying, sleeping,support, maternal mood, and the mother's thoughts about returning to workare timely.

Two-month consultation. Are the parents enjoying the baby? Arefamily interactions progressing satisfactorily? Other questions may relateto how the mother is feeling, the extent of the father's involvement, maternalsupport, and the infant's temperament. Has the baby begun to demonstrateself-comforting behaviors? Do the parents have time for themselves? Is themother making plans to return to work?

Four-month consultation. How is the mother balancing time andenergy demands for baby care, housework, homework if she is a student, theneeds of siblings, and work outside the home? Does she ever have time forherself? How are the parents getting along? How does the infant spend theday? Has he begun to play by himself? What do the baby and parents do together?Does the baby have a chance to fall asleep on his own by being put downwhile drowsy?

Six-month consultation. How is the mother feeling? How are interactionsin the family? What do the parents enjoy most about their baby? How is thebaby sleeping? How much do the parents play with her? Do they use baby-sittersso they can go out occasionally?

Nine-month consultation. This is a good time to inquire aboutdiscipline. Do the parents agree in general on their behavioral expectations?How do they plan to teach them to the baby? Emphasize the importance ofconsistency and a firm "No" in response to an undesired behavior,and the value of praise when the child does well: "Good job!""Thanks for helping Mommy." "I like the way you behaved inthe store!" Ignoring minor misbehavior or distracting the child shouldalso be suggested. The occasional use of baby-sitters at this time helpsthe child adapt to separation experiences. Establishing structured bedtimeroutines tends to avert sleep resistance.

Twelve-month consultation. At this age of developing autonomy,children should be learning the rules set by the parents. Theserules shouldbe limited in number and clearly communicated. Offering simple choices mayhelp gain the baby's cooperation. This is an appropriate time to discussin some detail how to use time out as a disciplinary measure.

Similar anticipatory guidance needs to be incorporated into the secondand third years around toilet training, separation experiences, fulfillingparental expectations, temper tantrums, beginning preschool, and other developmentalevents. Addressing these issues will reinforce the basic principles discussedduring the first year as they apply to increasingly independent youngsters.

Looking ahead

One of the notable but understated achievements of pediatrics has beenthe institutionalization of periodic health supervision and anticipatoryguidance. The content, relevance, and vitality of this longitudinal arrangementfor preventive and health-promotion services has been renewed periodicallyin Bright Futures: Guidelines for Health Supervision of Infants, Children,and Adolescents (from the Maternal and Child Health Bureau and the MedicaidBureau), Guidelines to Health Supervision III (from the American Academyof Pediatrics), and Guidelines for Adolescent Preventive Services, or GAPS(from the American Medical Association), as well as other sources. Althoughindividual health-supervision visits may be brief, cumulatively they representconsiderable time spent on health maintenance and promotion, developmentalenhancement, anticipatory guidance, and prevention of problems. Increasingly,parents look to pediatricians for authoritative advice in these areas.

Emphasis on parent effectiveness and authoritative presence is consonantwith integration of child development science into daily pediatric practiceand the use of clinical observations to advance research. The developmentof screening questionnaires to assess authoritative parental presence maybe useful in targeting anticipatory guidance needs or protective factors.Just as child-focused issues such as safety, growth, nutrition, and developmentare regularly addressed in anticipatory advice, parent-centered topics suchas parental presence warrant inclusion. They are an integral part of contextualpediatrics, which views children in the context of their families and communities.The extent to which such augmentation of developmental surveillance willpromote parental authoritative presence and make a real difference is aquestion for further pediatric research.

THE AUTHOR is Perry W. Lesh Professor of Pediatrics, IndianaUniversity School of Medicine, Indianapolis, and a member of the EditorialBoard of Contemporary Pediatrics.