PEDIATRICS Vol. 102 No. 5 Supplement November 1998, pp. 1317-1326

COMMUNICATING WITH PARENTS AND COMMUNITY INVOLVEMENT:
Talking With Parents About Emotional Development

Matthew E. Melmed

	ABSTRACT

Top Abstract Conclusion References

Parents play a central role in their children's emotional and overall development. To provide the most developmentally sound environment, professionals need to communicate the fine points of research and clinical studies effectively. This article details many strategies for reaching parents; perhaps the most important lessons are to be culturally sensitive, be positive, be relevant, and speak clearly.

Parents play a central, critical role in influencing young children's emotional and overall development. Clearly, researchers and clinicians who wish to promote children's healthy emotional development have a stake in conveying their scientific and practical wisdom to parents. This article addresses how we can do that effectively: how scientists and professional practitioners can talk with parents in ways they can understand, and how to use our knowledge to effect better outcomes for young children.

	SPECIAL SIGNIFICANCE OF PARENT AUDIENCES

For this discussion, let us accept that positive emotional developmental outcomes for young children depend greatly on parents. We know that parents have the motivation and the opportunity, through a continuing, intense emotional relationship and through their influence on the child's environment, to shape children's development. They also are often the first to sense that a problem may exist, and they are key figures in addressing such problems whether through changes in their interactions, through professional intervention, or through both. By changing parents' knowledge and attitudes, building their self-confidence, and guiding their child-rearing behaviors, one can have a major impact on children's emotional and overall developmental outcomes.^1-7

	THE SOCIAL CONTEXT FOR INFANTS AND TODDLERS

We all understand that parenting is an enormously tough job. Today more than ever, parents from all walks of life need educational and emotional support of varying kinds and degrees to do it well. Many professionals have found creative, effective ways to translate their research and clinical knowledge into meaningful educational and emotional support for parentsthrough one-on-one clinical work, community-based services, and print and broadcast media.

Still, the task of successful parenting appears daunting, especially when one thinks about families with infants and toddlers who are confronting multiple risks to their children's healthy development. Over the past generation, there has been a steady rise in conditions that potentially undermine the ability of parents from all walks of life to provide the responsive, nurturing care that is the foundation for healthy emotional development. Today's families are more likely to have less time with their infants and toddlers, to be struggling to make ends meet, or to lack access to trusted sources of personalized support and information for parenting. Confounding these problems are changes in family structure, increased rates of divorce and teenage pregnancy, maternal depression, and the horrors of child abuse and neglect.

Although national statistics tell us something about the emotional environment of infants and toddlers, major aspects of the lives of young children are sparsely sampled or ignored altogether in data- gathering by the government. This is especially true with regard to parental knowledge and attitudes about the early years. That is why my organization, ZERO TO THREE: National Center for Infants, Toddlers and Families, earlier this year commissioned a national research study among parents of children younger than 3 years to determine what parents know and believe about early childhood development, where they go for information and support, and how receptive they are to new information on child development.

	RESULTS OF FIELD RESEARCH ON PARENTS' KNOWLEDGE AND ATTITUDES

Our intent was to obtain information that could help create a strategic communications campaign targeting parents. Experts tell us that to be successful, mass communications must be tailored to the beliefs and concerns of one's target audience.⁸ Consequently, if professionals want to talk to parents of young children, we must first discover how to reach parents "where they are" in terms of their present knowledge and attitudes about early development and child-rearing.

Parents are a comparatively new audience for ZERO TO THREE's communications efforts, which for 20 years have focused primarily on professionals from various disciplines concerned with infant/family health and development. In 1996, our board of directors recognized that with the amount of new knowledge from many fields and growing national attention to the "zero-to-three" age group, there was a tremendous opportunity to capture parents' interest and a clear role for ZERO TO THREE in coordinating, translating, and communicating research and practice-based knowledge to parents in ways that would bolster their child-rearing efforts.

Our research began with a series of eight focus groups held in four cities, with mothers and fathers from a broad range of age, income levels, and educational backgrounds. These focus groups yielded key insights into parents' knowledge and concerns and helped shape the development of a national poll of more than 1000 parents, designed to quantify these findings. ZERO TO THREE hired the market research firm of Peter D. Hart Research Associates to conduct an in-depth telephone survey among a representative nationwide sample of mothers, fathers, and legal guardians of children 3 years and younger. The survey included supplemental "oversample" interviews of African-Americans and Latinos, which then were weighted back into the sample in their proper proportions according to US Census figures. The survey, conducted in the spring of 1997, was funded by the Teresa & H. John Heinz III Foundation and has a margin of error ±3.5%.

Primary Findings

ZERO TO THREE's survey and focus groups confirm that parents of young children today face daunting challenges and pressures and offer us important insights into the nature and extent of their needs for information and support. A review of some of our primary research findings, which suggests barriers and opportunities for effective communication with parents, follows.

Parents' Information Deficit

A primary finding of the survey is that most parents' knowledge of child development is limited. This significant information deficit emerged as a fundamental barrier to better parenting for many. Although parents recognize that they have an important influence on their infants and toddlers' overall development, they do not understand fully how specific parenting practices shape their children's social, emotional, and intellectual development.

Most parents grasp certain fundamental concepts about early child development, for instance, that infants are learning from the moment they are born, that infants are communicating before they use words, and that what a child experiences from birth to age 3 can influence his or her ability to do well in school. Many parents, however, are confused or hold misconceptions about other important concepts. For example, many parents did not know that

• Parent and caregiver interactions with infants and toddlers can influence children's intellectual abilities. One in four parents thought infants are born with set levels of intelligence that cannot be increased or decreased by how parents interact with them. Focus group participants shared this belief that intellect is virtually all nature, rather than nurture, referring to the level of intelligence a child can achieve with such terms as "hard-wired" and "innate ability."
• Stimulation isn't always good for infants. Eighty-seven percent of parents thought that the more stimulation an infant receives, the better off he or she is. This is of particular concern, given that all the attention on early brain development may make some parents feel driven to do more to stimulate their infants' brain development.
• Too many changes in caregivers can have a negative impact on a child's development. Half of all parents surveyed thought that the more caregivers a child has before age 3, the better that child will be at adapting and coping with change. This also held true in focus groups, where we saw that the suggestion that consistency or limited numbers of caregivers was a "hot button" issue that made some parentsparticularly those with multiple child care arrangementsuncomfortable, guilty, or nervous. A mother in a Boston focus group stated plainly, "I hope [having a limited number of caregivers is] not that important, because my child's on her third. Just don't tell me I'm wrong." In fact, we found that differences in how parents perceive children's exposure to multiple caregivers may need to be reframed as a cultural difference rather than lack of knowledge per se.

Although parents believe they have the most influence on a young child's emotional development (which was defined in the survey as "the ways he/she expresses moods and feelings like contentment, happiness, sadness, or fear"), they say they know least about this area of development. Parents also report that they do not understand fully how to tell whether their children's social, emotional, and intellectual development is on track. For example, as shown in Fig 1,

• Only 38% feel totally sure they can tell whether their children's emotional development is healthy and about right for their age.
• Only 37% feel this way about milestones of social development.
• Only 44% feel they can tell whether intellectual development is on track.

View larger version (18K): [in this window] [in a new window]   Fig. 1.   Parents' response to the question, "How do you feel that you know how to tell whether your child's development is healthy and about right for his/her age?" (% who feel totally sure).

Challenges of Parenthood

As these information gaps suggest, new parenthood is a time of learning, self-doubt, and worry, as well as of joy and wonderment. A majority of parents struggle to fulfill conflicting demands and obligations of work and family and to live up to the high expectations they have set for themselves. Although many parents are basically confident in their abilities and view themselves as generally good parents, they also have many questions and concerns about child development and parenting practices (Figs 2 and 3).

• Just 8% rated themselves as "outstanding" and say they do not feel a need to improve; all others indicate that they would like to improve their parenting performance.
• Close to half (45%) said they definitely want to improve in several areas. Foremost among these is the "time crunch" they face in trying to be available for their young children.
• Almost two in five parents (37%) cited not spending enough quality time with their children as a primary reason they feel they may need to improve as parents.
• Fully half of all parents said they end most days feeling that they spent less time than they wanted to with their young childrenwhether a lot (20%) or a little (27%).

View larger version (43K): [in this window] [in a new window]   Fig. 2.   Parents' response to the question, "How would you rate yourself as a parent so far?"

View larger version (45K): [in this window] [in a new window]   Fig. 3.   Areas in which parents feel the need to improve.

Although parents seem well aware of the importance of the love and time they give their infants and toddlers, they feel that they need to do a better job of understanding and responding to their children. For example, parents felt they needed to improve because they

• Find it hard to understand their children's feelings and needs (19%).
• Do not know how to handle difficult situations with their child (19%).
• Lack confidence in their overall parenting skills (10%).

Parents' desires to obtain information on how they can best support their children's development are strongest before their first child is born. A majority (70%) of respondents said they did at least a moderate amount of work to get ready for their first experience as parents, either by reading or by talking to others to get information or advice.

Parents are more likely to seek information very early in their children's lives (from birth to 8 months) than later. This suggests that it is important to get information on child development to new and expectant parents as early as possible. Our focus groups confirmed that parents are more receptive to guidance before they have children or when their infants are very young, because they feel that they are learning about child development "on the job," through their parenting experiences.

By reaching parents early, one avoids provoking guilt or anxiety in parents whose children are older than 2 or 3 years, who may perceive messages that emphasize the critical importance of development in the first 3 years of life as telling them that it is too late to enhance their children's development. As one mother in a Richmond, VA, focus group put it, "I feel that ... when she was born I was just so new at everything, and I'm hoping I get better and better day by day, month by month, and year by year. It scares me to death thinking that in a year, that's it, my time is up."

Parental Socioeconomic Differences

Parental attitudes and actions regarding advance preparations varied greatly according to socioeconomic status, with low-income parents reporting having done less advance preparation than do other parents. Thirty percent of low-income parents said they basically just wanted to "see what it was like" first. This is in striking contrast to 18% of parents overall who chose to "wait and see."

Despite these advance efforts, relatively few parents of young children say they felt totally prepared for parenthood when they had their first children. Those who felt least prepared included younger parents, lower-income parents, and single parents. Low-income and single parents also are more likely than others to have felt that they lacked emotional support.

These data are important, because our survey found that preparation is correlated with a positive parenting experience. Those who begin parenthood thinking they are ill-prepared are far more likely than those who think they are well-prepared to feel

• Stressed and worn out (59% of less prepared vs 31% of well-prepared parents).
• Afraid of doing something wrong (48% vs 27%).
• Afraid of not being good parents (43% vs 23%).
• Unsure about what to do a lot of the time (39% vs 18%).

Sources of Parent Information and Support

Parents of infants and toddlers seem anxious for information and advice on how to understand and respond to their own children's unique needs, changes, and behaviors and to promote their emotional, intellectual, and social development. Parents can be overwhelmed by the sheer volume of questions that arise in their day-to-day lives because, as one mother in a Boston focus group put it, "Babies don't have instructions."

When parents of young children seek information or advice on children and parenting, they tend to rely on informal networks. Even in these days of geographic mobility and long distances between family members, parents turn most frequently to their own families (Figs 4 and 5).

• Two in five say they call their mothers or mothers-in-law, and approximately the same proportion seek another relative's help.
• Friends and neighbors are a source of help for one in five parents of infants and toddlers.
• This underscores the fact that parents place greatest value on information that is provided in the context of a familiar relationship.

View larger version (17K): [in this window] [in a new window]   Fig. 4.   Parental sources of advice on kids and parenting.

View larger version (11K): [in this window] [in a new window]   Fig. 5.   Other sources of parent information.

Beyond the realm of family and friends, pediatricians are the professionals that parents consult most (15%) when they need advice. The news media are also an important source of supplemental information on infants, toddlers, and parenting; nearly half (46%) of all parents indicate that they pay significant attention to newspaper articles and news reports on these topics; 36% look for information in magazines; and 39% pick up literature in their pediatricians' offices on a regular basis.

Indeed, concern for the serious problems facing families has prompted an explosion of information and advice about child-rearing in the media. Child-development and parenting education has become an increasingly prominent topic in print media and for initiatives within electronic mediaincluding public, cable, and network television, as well as the Internet. Today's parents, who are time-pressed, isolated from other information sources, and accustomed to acquiring information via "sound bites," are increasingly likely to look to the media as a parenting resource.⁸

	RELEVANCE OF FINDINGS FOR SCIENTISTS AND PROFESSIONALS

Our data clearly demonstrate that many parents today lack vital information and support for their child-rearing efforts. This heightened need crosses lines of culture, race, ethnicity, and socioeconomic status. Who can know with certainty how to ensure that their children will survive and thrive in the 21st century? Who knows how to give young children a solid foundation in their own family and community values (which, these days, may represent an amalgam of several traditions) while preparing them to function in wider worlds? Although some parents may assert that "the way my parents raised me is good enough for my kids," many other parentsand grandparentswonder what lessons from the past remain useful in an anxious new world.

Role of Mass Media and Experts

In their search for answers, parents turn in part to mass media sources and to "expert opinion." The widespread availability and influence of mass media communications channels present the scientific/professional community with a great opportunity to reach and inform parents as well as a strong imperative to do so in a proactive, strategic way.

First, is the the opportunity. Researchers have found that knowledge of child development can influence parents' interaction with children and children's cognitive development significantly.^9,10 Mass media gives us the ability to reach enormous numbers of parents. A recent study of parenting education and the media found that almost every parent is exposed to printed information about parenting, and many are exposed repeatedly. The ubiquity of television is well-documented. Media experts who track the children's Internet market project that the number of families with Internet access will almost triple by 2002, to 55%.⁸

We also know (from theory, research, and professional opinion) that information conveyed via mass media can and does have a significant impact on parents' attitudes and parenting behaviors and, hence, on child outcomes.⁸ Daniel Stern points out that today, the media provide powerful representations of who the infant and mother are and ideally ought to be, and what constitutes competence, age appropriateness, and so on.¹¹

Second is the imperative. Given that so much information about early childhood development and parenting is being disseminated via various mass media, professionals from all disciplines who work with infants, toddlers, and families have a responsibility to engage with researchers and with the media concerning communications to families and front-line caregivers.

Parents' responses to our survey and focus group questions pose several key challenges that members of the scientific and professional communities must address to be most effective when talking about early childhood development and parenting.

Parents say they want simple, concrete messages but complain that parenting "tips" don't fit their own babies and circumstances.

What kind of information do parents want and need? ZERO TO THREE's research found that parents have many uncertainties about how they can promote healthy emotional, social, and intellectual development. To address this gap, parents first need clear explanations of what scientists understand about typical development in the earliest years of life. Rather than using complex terminology that parents report is an immediate "turn-off," our descriptions must depict the story of development using concrete examples drawn from everyday experiences and behaviors. This story must make clear the interplay between nature and nurtureand particularly help parents understand the powerful influence their own actions and reactions have on their children's growth and development (eg, when you talk with your baby, you help her ... ; when you share in your baby's excitement, she learns that ... ). Such basic, authoritative information provides parents with a context in which to understand and react more appropriately to their own children's individual needs, behaviors, and cues. It also helps them gain a fuller appreciation of the extent to which their shared everyday moments build a strong foundation for healthy development.

We must take this a step further, however, and go beyond providing general information. An often-heard criticism from parents is that suggestions offered in parenting resources often are not meaningful to them and their own infants. Over and over, parents in ZERO TO THREE's research (and those who comment in our website guest book) asked for specific, easy-to-understand guidance on parenting. For example, parents in our focus groups said they would appreciate "tips" on how to understand their infants' unique preverbal communications and behaviors so that they could be more responsive to their needs.

As we know, there are no tips or shortcuts to effective parenting. Learning to read an infant and becoming attuned to him require a great deal of time, careful attention, trial and error, reflection, and so on. Moreover, our field research indicates that parenting advice should not be prescriptive. Effective communication with parents requires a difficult balancing act. On one hand, parents crave specifics on what they can do to promote their children's development. On the other hand, detailed "how-to's" are likely to be rejected by many parents as irrelevant to their children's and family's unique needs.

At ZERO TO THREE, we have struggled with this challenge a great deal, and have devised a promising solution. Guided by our field research, we have developed a communications approach designed to provide parents with valuable empiric, generic knowledge not only about the course of early development but also the role that caregivers and the environment play in shaping development. Of particular importance, our communications also seek to give parents basic tools of careful observation and thoughtful reflection that will enable them to adapt that knowledge to their own children, families, and circumstances, and to translate that wisdom in their everyday lives.

What I am suggesting here is that intermediaries between scientists and front-line caregivers can join with parents as co-investigators. As such, we can encourage them to look at and understand their children and themselves, give them the tools to guide their observations and analyses, and support their efforts to solve the mystery of their children's behaviors and to develop the most appropriate ways to parent their children. For example, in helping parents learn how to read their children's cues, one might use vignettes to illustrate ways of observing and thinking about their children's cues and behaviors (pointing out that similar cues might mean different things for different children) to determine what responses would be most appropriate. Although the scenarios presented in these vignettes may or may not be directly relevant to a given parent and child, our intent is to describe a process of observation, reflection, and response that will have broad meaning. This should help parents work through many other interactions with their children and find optimal solutions for their families.

Parents are most receptive to messages that are positive, not overwhelming or prescriptive. At the same time, communications efforts must acknowledge parents' everyday realities.

Parents are more receptive to information designed to engage and excite them about the great "opportunities of early childhood" than to messages that scare or overwhelm them or make them feel guilty. Similarly, overloading parents who are already feeling anxious, burdened, or inadequate with prescriptive instructions and lists of "shoulds and should nots" can be counterproductive, serving to increase stress and further undermine parents' confidence. This was clear when parents in our focus groups were asked how the following statement made them feel.

"What happens to a baby from birth to its third birthday has enormous, long-lasting, lifetime impact on developmentemotional, social, intellectual, and physical. This is a window of opportunity for parents to have a positive impact on all those areas of a baby's development."

This comment evoked a steady stream of anxious commentary, including

• Complete skepticism, as in, "How can you even prove that's true?"
• Anxious self-doubt, as in, "It makes me paranoid ... even though I'm trying, I do the best I can, like if I do one thing wrong ... I'm an idiot ... So, I think you always question yourself, even though you do the best that you can for them."
• Fear, as in, "I find it overwhelming. My anxiety level is up to here as it is. I think it's scary to think about that. Yes, it's important, but at the same time, it's very intimidating."
• Indignant denial, as in, "I've got to go to work, I just have to live with the fact, have to live life, I can't just ... revolve around my daughter and be paranoid 24 hours a day, 7 days a week."
• Pragmatic: "I think you definitely want to do your best to expose them to things, but all this emphasis on between the ages of 0 and 3 ... You have to do everything you possibly can or you ruin the rest of their livesit's really out of whack ... My parents, they didn't do any of that."

In our educational material, we offer parents positive, affirming messages (such as "You can learn to read your baby" or "You can understand your child's temperament") along with specific tools for achieving such goals. Examples of empowering messages include

• "How you are is as important as what you do." The way you act with your child, and the way you interpret and then respond to her behavior, will strongly influence what she learns from those interactions. Understanding who you are as a parent requires self-awareness about your attitudes and expectations and about your own temperament and way of approaching and relating to the world.
• "Don't just do something, stand there." Unless it is an emergency, you do not need to react immediately. Taking a few moments to observe and think about what is happening may lead to a more effective response.
• "Parenting is a lifelong learning process." When something you do does not create the desired or intended effect, it should not be seen as a failure. You are learning something new about your infant that will guide you in trying something different.

Messages such as these are particularly affirming because they connect with parents' everyday lives. ZERO TO THREE's research made clear that communications efforts must acknowledge the realities of parenthood. If they do not, if we present recommended, ideal strategies that seem irrelevant to them, parents are likely to disregard that information. For example, a father with two jobs rejected vehemently the suggestion that he and his wife spend 30 minutes of uninterrupted "floor time" each day watching their infant and letting him explore, and so forth (a suggestion that other parents found quite appealing), saying, "My wife and I are very busy people. Kids can be as well-developed without it. I don't like that statement, it's unrealistic. When you put a child in unrealistic settings, you're not really preparing them for the reality of the world we live in."

One key message from ZERO TO THREE to parents who feel overwhelmed by their responsibilities is that "everyday moments are times of greatest learning for you and your baby." Parents who lack the time or interest to follow a specific infant stimulation routine usually want to learn how they can make the most of interactions during daily activitiesdiapering, feeding, dressingto teach their young children that they are loved, cared for, safe, and secure. Such parents typically are delighted to hear how these common interchanges can actually serve as opportunities to learn important things about their children such as their likes and dislikes and how they respond to different sensory experiences. Thus, by building on what parents already know and do with their children, we can help parents feel affirmed and, in doing so, offer them meaningful strategies to stimulate their children's development.

Communications efforts must acknowledge that parents know their children best and recognize and respect ethnic and cultural differences.

Our research confirmed that many parents mistrust "experts." They are most receptive to information provided by professionals in the context of a trusting relationship that truly honors parents' primary role as chief mediators of their children's development and caregiving environments. As one focus group father put it, "Basically, I don't think someone can tell you about your own kid ... I'm with my child every day. This so-called expert doesn't live with me, doesn't see what's going on ... Their degree is all paperwork."¹¹

Implicit in developing positive, supportive partnerships with parents is the need to understand and respect ethnic and cultural differences. As our focus group of African-American fathers made clear, cultural differences are important. They sometime can put parents in direct opposition to professional views many hold as "proven facts" about what is best for young children. In these cases, professionals must be careful to recognize that such divergent views stem from different cultural experiences rather than from a lack of parental knowledge.

This was evident in the focus group's discussion of social development, in which it became clear that fathers perceived their children's exposure to multiple caregivers, an unavoidable fact of life for all of the group's participants, as a positive experience, which they characterized as putting their children "ahead of white children." As one father bluntly put it, "We're African-Americans ... We're not white or rich, we don't have a nanny, or we don't have a wife who can sit home all day long. We have to go to work, we have to make ends meet, so we have to have that baby with a third or a fourth person. So they have to socialize much earlier than the average white child." This man went on to assert that this was very beneficial for the children, " ... because they're learning to deal with other individuals besides Mommy and Daddy."

Front-line practitioners have reported similar observations concerning class/cultural differences in parents' perspectives on young children's exposure to multiple caregivers. For example, mothers in a focus group of Early Head Start participants in the Grand Boulevard neighborhood of Chicago, IL, said that they believe it is important for their infants and toddlers to learn to relate to many different caregivers.¹²

When they stated that they would completely reject advice from someone who was not African-American, our group of fathers made it clear that cultural sensitivity and shared cultural identity/experiences are essential prerequisites for effective communication about parenting.

Father: "If that person wasn't a brother or a sister, I'd certainly be looking at them from an angle like, `What can you tell me about raising a black child?'"

Moderator: "Right off the bat, if they're not black, they're out of your comfort zone?"

Father: "I'd be more comfortable if they were black, because then at least I'd know that person was raised in a black household. I don't like the fact of being under a magnifying glass with somebody else's set of rules that I don't know."

ZERO TO THREE's field research and one-on-one communications efforts with parents of young children have taught us that a powerful strategy for minimizing obstacles posed by differences of race and class is to begin discussions by finding out parents' own goals for their children and approach interactions with parents as opportunities to join with them in a respectful partnership that helps them find ways to meet their goals.

An example of appropriate communications is that through a new partnership with Kellogg's, ZERO TO THREE has developed educational messages for parents of young children and other caregivers that over the next few months will be featured on the back panels of 22 million boxes of Rice Krispies cereal.

At first glance, the language on these cereal boxes might seem like something a competent copywriter could turn out in an hour or so. In fact, a group of ZERO TO THREE board members, our Director of Communications, and a copywriter debated for several weeks about just which words to choose for this very limited but very visible space. No, "Snap, Crackle and Pop" have not been renamed "Watch, Wait, and Wonder," or even "Snap, Crackle, and Attune." The text "speaks through the baby," for example,

• We say, "Talk with me," not "Talk to me";
• We say, "Share a book with me," not "Read to me for 15 minutes a day";
• We say, "Share in my excitement," not "Praise my achievements"; and
• We talk about the process of building a loving relationship: " ... Sharing pictures and stories ... makes me feel close to you." " ... I learn that you'll take care of me. This helps me feel secure."

We encourage the parent to observe, and we offer clues rather than tipsfor example, "Watch and listen to me. Give me time to respond. My eyes, expressions, and body language tell you things even before I say my first word. When I turn away, I may be telling you, `I've had enough.' A big smile may mean, `Let's talk more,' or `I like what you are doing, keep it up!' The pleasure of our give-and-take encourages me to communicate, speak, and learn words."

	TALKING WITH PARENTS ONE-ON-ONE: INNOVATIVE STRATEGIES IN PRIMARY PEDIATRICS

As ZERO TO THREE's market research makes clear, parents are heavily invested in learning how they can contribute to their children's growth and development. Although today's parents are interested in the latest research findings and recommendations from "expert" sources and, as we've discussed, mass communications vehicles can address these needs to some degree, our research confirms that parents want information and guidance specific to their own children and families, provided by authoritative sources in the context of a trusting relationship. How, then, can child health and development professionals partner with parents of young children to address this need?

Creating Bright Futures: A New Movement in Pediatric Practice to Expand Support for Child/Family Development

One compelling answer is the pediatric primary health care setting, the most universally available and often used source of professional support for families with children under age 3.^3,13 This cutting-edge vision, described in Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, calls for an expansion of pediatric practice beyond its present focus on physical health to fulfill a vital prevention and health-promotion role by monitoring child development; promoting positive parent-child relationships; and boosting parents' knowledge, confidence, and competence.³

We have strong evidence that such child health and development services would find a ready and willing clientele among parents of infants and toddlers. Indeed, parents surveyed by ZERO TO THREE say that their pediatricians are the professionals they rely on most for advice on child development and child-rearing. These parents, however, are not fully satisfied with the quantity or quality of information they presently receive from this source. Forty percent of parents reported that their pediatricians never (or only occasionally) talk to them about their children's social, emotional, and intellectual development, the areas about which parents have the least information and the most questions. When asked whether they would be interested in having their pediatricians facilitate helping them to understand their children, answer questions, and provide guidance on their children's development, two thirds (65%) felt such services would be very important, and another 19% saw them as fairly important.

This confirms a similar desire expressed by parents polled in The Commonwealth Fund's 1996 Survey of Parents with Young Children, which found that parents want more information, services, and attention from physicians on how to help their children thrive during their first years. A majority of parents said they would be willing to pay a modest fee for supplemental pediatric services such as home visits and a telephone advice line.¹⁴

In fact, such services have become available for selected families with young children in demonstration sites across the country. Through a range of initiatives launched in the past few years, model approaches are being tested to promote all domains of children's development and to build positive relationships with parents. Model initiatives include

• The dissemination of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, developed by leading national pediatric experts and supported by the federal Maternal and Child Health Bureau of the Department of Health and Human Services.
• The Healthy Steps for Young Children initiative, currently operating in 15 evaluation and 6 affiliate sites across the country, which offers a core set of services, including developmental screening, home visiting, and parent groups that together restructure the way pediatric care is offered to children from birth to age 3 years.
• ZERO TO THREE's Developmental Specialist in Pediatric Practice (DSPP) Project, which provided for children with developmental or emotional problems, that includes developmental screening, early identification, short-term intervention, timely referral and follow-up, and, for their parents, anticipatory guidance and support.
• The Pediatric Pathways to Success model of enhanced pediatric primary care for low-income families at Boston Medical Center.
• T. Berry Brazelton's Touchpoints Project, which emphasizes developmental and relational aspects of well-baby/child care and local service-delivery organizations.

Although data from formal evaluations will not be available for some time, early evidence from these initiatives suggests strongly that enhanced pediatric services give parents meaningful guidance and support and advance healthy infant/toddler development in cost-effective ways. For example,

• A stable, trusting relationship with a child-development specialist provides a context for identification and remediation of emerging problems in parent-child relationships. The specialist also offers personalized, relevant, meaningful information and support, which can strengthen parents' knowledge, confidence, and competence in stimulating their young children's social, emotional, and intellectual development.
• Regular developmental monitoring in the context of well-baby/child care leads to prompt identification of health and developmental problems. This permits appropriate early intervention and eliminates or reduces the need for more costly rehabilitative efforts later in life.
• Low-income families who feel connected to a dedicated advocate are better able to make appropriate use of primary pediatric care. This makes them less likely to use costly services such as emergency room and inpatient hospital care inappropriately.

ZERO TO THREE's DSPP Project

ZERO TO THREE's DSPP Project (funded by the Bureau of Maternal and Child Health and by private donors) was designed to explore the feasibility of broadening the scope of primary pediatric care by adding a nonmedical Developmental Specialist (DS), who could provide a range of services to support the development of infants, toddlers, and their mothers and fathers.

For 2 years beginning in July 1995, two masters' level infant/family professionalsan early childhood educator and a clinical social workerserved as DSs in two pediatric sites in the metropolitan Washington, DC, area. They provided developmental screening, early identification, short-term intervention, and timely referral and follow-up for children with emotional or developmental problems. They also provided parents with anticipatory guidance and support to strengthen their effectiveness in nurturing their children. The part-time DSs saw a total of 636 children; the majority (65%) were younger than 12 months of age, 19% were between 12 and 24 months, 11% were between 24 and 36 months, and 5% were 36 months and older.

Key Outcomes/Lessons Learned The DSPP Project evaluation included detailed documentation of key decision points and activities related to the services of the DSs, periodic interviews with pediatric staff, and a survey of parents who used the DS services.

• Strengthen parents' understanding and responsiveness to their children's developmental needs.
• Assuage parents' anxieties about normal parenting challenges, build confidence, and develop parenting skills.
• Identify children's developmental difficulties and begin early treatment.
• Provide short-term interventions that enabled parents to address specific crises or behavioral, emotional, or relational problems.
• Promote access to specialized services for families with special challenges.
• Increase the capacity of the primary care setting to provide comprehensive support for infant/family development.

• Commitment to approaching each parent as an individual. Just as they talked about each infant as unique, the DSs respected each family as unique and joined them "where they were." The DS often spent the first visit asking how parents were doing, how they were feeling about their new roles, and what support they felt they needed. By attending to parents first, the DS let them know that she was interested in them as well as in their child. This was particularly important when dealing with teen mothers, many of whom stated that one of the most painful parenting experiences was seeing the infant "get all the attention" and feeling ignored.
• Attention to "professional use of self." A trusting open relationship between the DS and parents was essential to mutually understanding the infant's unique profile and discovering meaningful ways to foster the infant's development. The DSs found that talking about their own struggles as parents helped build connections and overcome potential obstacles posed by differences in professional status, race, or ethnicity.
• Reframing. Helping families give new meaning to their children's behavior was a simple but powerful tool to strengthen parent-child relationships. On many occasions, after empathizing with parents' exhaustion in dealing with their very mobile, energetic infant, the DSs introduced the idea that the child was in fact very smart and developing well, rather than being "bad" or "hyperactive" or "out to drive them crazy." Reframing also provided the basis for helping many parents understand and provide appropriate nurturing for their children in areas of vulnerability. For example, one mother was troubled by her boisterous 2-year-old's tendency to give his peers "hard hugs" and to "lose it" around tactile activities such as brushing the teeth or dressing. The DS helped her understand these incidents as self-protective maneuvers against tactile intrusions rather than as "bad" behavior, which she and her husband had been punishing. This mother was extremely grateful for what she called a "gift"an invaluable insight about her son and strategies to help him cope with this sensitivitythat she received in less than 30 minutes during a routine visit to her pediatrician.
• Empathy for parents' feelings and experience. There was often a parallel process between DS and parent, and between parent and infant. As the DSs became more engaged and understanding with parents, parents became more engaged, patient, and accepting of their own children. For example, by empathizing with one mother's feelings of rejection and personal inadequacy at her infant's excessive crying and avoidance, the DS was able to help her understand that her child was not being "fussy" or manipulative, but was oversensitive to sound and touch. Engaging this mother in this way helped end a pattern of misunderstanding and misattuned caregiving that would have surely caused this mother-child relationship to deteriorate over time.

[The DS] provides immeasurable good will and a necessary service for Kaiser through her ability to delve into areas and problems the providers don't have the time for, may not know how to handle, and would almost certainly refer out. If she didn't do these things, the patients would be asking the providers, and probably getting "no" or "I don't know" for an answer, taking valuable provider time, and making members dissatisfied. She has been with us about 18 months, and we have found her services invaluable.

	CHALLENGES TO SUSTAINING/EXPANDING DEVELOPMENTALLY ORIENTED PEDIATRIC SERVICES

Given the considerable benefits associated with integrating DS services into primary pediatric care settings, how do we "scale up" this model and make this vital support available to more families with young children? The principal challenge to achieving this goal is developing stable financing that can sustain these services beyond finite periods of public and private grant support. In ZERO TO THREE's DSPP Project, notwithstanding strong commitment from leaders in both pilot sites, efforts to move financial responsibility to the practices themselves proved unsuccessful. Medical staff already besieged by a barrage of cost-containment measures were unwilling to increase practice costs by adding a DS whose services were not likely to be reimbursed by insurers. An attempt to fund her services through a parent-paid fee-for-service arrangement did not generate sufficient revenue to cover her full salary. Finding strategies to finance enhanced pediatric services independent of short-term grant funding also is a concern of the Healthy Steps for Young Children Initiative.¹⁵

Here again, effective communication by leaders in the professional and scientific communities can play a key role in helping realize this important goal. By working to communicate our knowledge of the lifelong consequences of early emotional development and healthy parent-child interactions, we can help convince insurers, managed care providers, health care purchasers, providers, and other stakeholders to invest in this model of expanded pediatric care.

	CONCLUSIONS

Top Abstract Conclusion References

Although we know that parents and caregivers who provide strong positive emotional relationships and appropriate stimulation create the foundation for proper intellectual, social, emotional, and physical development, many parents lack the time, resources, and information to provide appropriate nurturing to their young children. These parents are hungry for specific information about their children and their lives to help them do a better job of parenting. The scientific/professional community has a clear responsibility to play an active role in addressing this need.

Primary pediatrics offers a unique opportunity for medical and nonmedical professionals to form partnerships with parents on behalf of infant/toddler health and development. As the DSPP Project, Healthy Steps, and other initiatives show, such alliances can be effective in boosting parental confidence, knowledge, and competence; promoting positive parent-child relationships; and closely monitoring infant/toddler development.

The confluence of several factors, including growing public and political interest in the years from birth to age 3, the steady rise of barriers to effective parenting, the burgeoning of scientific knowledge about early development, and the emergence of successful models for outreach and support to parents, makes this an ideal time for professionals to reach out and offer support to mothers and fathers as they struggle to promote their young children's healthy emotional development. Such support might take the form of enhanced pediatric services, coordinated mass communications efforts, or other strategies to provide families with vital knowledge and resources to support effective child-rearing. I suggest that it is the responsibility of professionals from all disciplines who work with infants and toddlers to

• Read and understand child development research.
• Put research findings into a meaningful context for families and front-line caregivers.
• Enlist parents as "co-investigators" of their infants and toddlers' development, using the same basic tools of careful observation, rigorous data analysis, and thoughtful reflection, as would any researcher.

We all must play a part in these efforts. I encourage you to consider how you and your colleagues can contribute to this exciting national movement.

	FOOTNOTES

Received for publication Aug 2, 1998; accepted Sep 29, 1998.

Address correspondence to John G. Warhol, PhD, The Warhol Institute, 225 First Ave, Atlantic Highlands, NJ 07716.

	ABBREVIATIONS

DSPP, Developmental Specialists in Pediatric Practice.

	REFERENCES

Top Abstract Conclusion References

1. Schor E Measurable development in parents: a goal in effective primary care. ZERO TO THREE. 1997; 17:41-43
2. Olds D, Kitzman H, Cole R, Robinson J Theoretical foundations of a program of home visitation for pregnant women and parents of young children. J Commun Psychol. 1997; 25:9-25
3. Green M, ed. Bright Futures. Guidelines for Health Supervision of Infants, Children and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health; 1994
4. Erickson MF, Korfmacher J, Egeland BR Attachments past and present: implications for therapeutic intervention with mother-infant dyads. Dev Psychol. 1992; 4:495-507
5. Lally JR, Mangione PL, Honig AS, Wittmer DS More pride, less delinquency: findings from the ten-year follow-up study of the Syracuse University Family Development Research Program. ZERO TO THREE. 1988; 4:13-18
6. Werner E Individual differences, universal needs: a 30-year study of resilient high risk infants. ZERO TO THREE. 1988; 8:1-5
7. Seitz V, Rosenbaum LK, Apfel NH Effects of family support intervention: a ten-year follow-up. Child Dev. 1985; 56:376-391 [Medline]
8. Simpson R. The Role of the Mass Media in Parenting Education. Boston, MA: Center for Health Communication, Harvard School of Public Health; 1997
9. Tinsley B, Lees N. Health promotion for parents. In: Bornstein MH, ed. Handbook of Parenting. IV. Applied and Practical Parenting. Mahwah, NJ: Lawrence Erlbaum; 1995:187-204
10. Okagaki L, Divecha D. Development of parental beliefs. In: Luster T, Okagaki L, eds. Parenting: An Ecological Perspective. Hillsdale, NJ: Lawrence Erlbaum; 1993:35-67
11. Stern D. The Motherhood Constellation. New York, NY: Basic Books; 1997
12. Gilkerson L, Stott F Listening to the voices of families: learning through caregiving consensus groups. ZERO TO THREE. 1997; 18:9-16
13. Kaplan-Sanoff M, Brown T, Zuckerman B Enhancing pediatric primary care for low-income families: cost lessons learned from pediatric pathways to success. ZERO TO THREE. 1997; 17:34-36
14. Young K, Davis K, Shoen C. The Commonwealth Fund Survey of Parents with Young Children. New York, NY: Commonwealth Fund; 1996
15. Zuckerman B, Kaplan-Sanoff M, Parker S, Young K The healthy steps for young children program. ZERO TO THREE. 1997; 17:20-25