PEDIATRICS Vol. 113 No. 5 May 2004, pp. 1406-1411
Fathers and Pediatricians: Enhancing Men’s Roles in the Care and Development of Their Children
William L. Coleman, MD,
Craig Garfield, MD and
Committee on Psychosocial Aspects of Child and Family Health
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ABSTRACT
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Research substantiates that fathers’ interactions with their children can exert a positive influence on their children’s development. This report suggests ways pediatricians can enhance fathers’ caregiving involvement by offering specific, culturally sensitive advice and how pediatricians might change their office practices to support and increase fathers’ active involvement in their children’s care and development.
Key Words: father’s roles • families • child care • pediatrician’s roles
Over the last 30 years, fathers’ roles in caring for their children have been expanded by rapid and profound socioeconomic changes and by society’s evolving perceptions and expectations of fathers’ roles. "Father" in the United States means more than "wage earner" or "provider" and now can include stay-at-home dad, caregiver of child, and sharer of child care responsibilities. It even may include a grandfather caring for his grandchild. There is increasing recognition of the benefit to the child of the father’s role in providing love and support to the mother or, when the spouse is not the biological mother, the partner. Recent increases in immigration and growing cultural diversity are 2 more sources of change in the roles, expectations, and involvement of fathers. A father may be a biological, foster, or adoptive father; he may be a stepfather, grandfather, adolescent father, father figure, or coparent father in a gay relationship; and he may be custodial or noncustodial, resident or nonresident, near or far. For purposes of this report, father is defined broadly as the male identified as most involved in caregiving and committed to the well-being of the child regardless of living situation or biological relation.
In response to changing expectations, diversity, and changing demographics (ie, more fathers assuming increased child care responsibilities), pediatricians need to broaden their understanding of fathers’ roles and fathers’ own expectations and appropriately modify their clinical style and office practices to accommodate and support fathers’ expanding roles. A substantial proportion of children in America (ie, 30% of white children, 42% of Hispanic children, and 69% of black children) are born to unwed mothers.1 In these cases, pediatricians especially need to remind mothers of fathers’ unique influence on a child’s development, regardless of whether the parents are married, and encourage mothers to include fathers in the next visit(s) and in the care of the child. In addition to the common caregiving tasks, each father makes different and unique contributions to the child-father relationship and to family functioning. Validating, nurturing, and capitalizing on the father’s contributions to the child’s well-being and to the parents’ relationship are major goals for those involved in caring for children.
Despite new expectations, related responsibilities, and evidence-based knowledge (scientific studies) regarding fatherhood, many men still enter fatherhood with little idea of their new role and how it will affect their own lives. They may be unprepared for the challenges of fatherhood yet excited to take up the task. Some may lack role models or previous experience with caregiving responsibilities; others may fail to realize the importance of their involvement to their children and families. Consequently, fathers may or may not be motivated to learn. With appropriate encouragement and specific supports, however, many fathers may become avid, successful learners and providers. Pediatricians are perceived as ideal teachers, role models, moral authorities, and supporters of families in this stage of the family life cycle at which men become fathers.
Pediatricians are necessarily concerned with both the child’s and family’s well-being, knowing full well that families are the single greatest and most enduring influence on children. They are uniquely positioned to enhance the father’s involvement, inform the family about the father’s special influence on his children’s development, and encourage the father to support the other parent. In so doing, pediatricians enhance and support the multiple roles of fathers in their child’s development, the father-child relationship, and healthy family functioning and well-being.
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GOALS
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The goals of this clinical report are to:
- Describe the socioeconomic forces that have changed society’s expectations of fathers’ roles;
- Explain how fathers’ interactions with their children uniquely influence their children’s development; and
- Offer pediatricians specific advice on:
- How to help fathers increase their caregiving and involvement;
- How to help fathers and mothers support each other’s roles as parents; and
- How to change their clinical styles and office practices to promote, support, and increase fathers’ active involvement in their children’s care and development.
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THE INCREASING PRESENCE OF FATHERS IN THE LIVES OF CHILDREN: SOCIOECONOMIC FORCES
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Pediatricians see more fathers today than they have in the past as more fathers in 2-parent families or in shared-custody arrangements are spending more time with their children and beginning to attend more office visits. This national trend has the potential to strengthen the father-child relationship, stimulate the child’s development, ease the mother’s or partner’s workload, and strengthen the overall family functioning. Several factors contribute to this trend.
- The number of father-only households (no wife or partner in the home) increased almost 25% from 1995 to 1998, to 2.1 million households.2 The 2000 US Census revealed father-only households increased to 4.3 million, or 4.2% of US households. In Illinois alone, the number of children living in father-only households increased by 109%, from 47 000 in 1985 to 98 000 in 1995.3 Although the total number is small, the rate of change is significant. Additionally, father-only households seem to be headed by fathers who are highly involved in their children’s lives at home and school.4
- Economic shifts over the past 30 years increasingly place women in the workplace, often in higher paying jobs than their male partners. Subsequently, many men spend more time at home taking care of their children. For example, most mothers prefer the father to be the child care provider if the mother cannot provide the care.5 Additionally, married men are likely to be the primary caregivers of their children during the mother’s working hours if the family is poor, if the father is unemployed or working part-time, or if the children are younger.6
- The average amount of time fathers in 2-parent families spend with their children, directly engaged or accessible, has increased in the last decade to 2.5 hours per weekday and 6.3 hours per weekend.7
- In divorced families, a plan for shared-custody arrangements developed by both parents during divorce proceedings increases opportunities for the father to be more involved in his children’s care.
- Changing technology in the marketplace, telecommuting from home, and making use of flexible work hours provides more opportunities for fathers to spend more time with their children and families.
- The media and popular culture reflect and positively reinforce fathers’ increased involvement in the care and development of their children. Father birthing classes have sprung up in hospitals across the country. General parent magazines, special magazines, Web sites, and newspapers (both paper and Web based) increasingly are targeted at fathers and champion men who have taken to the "daddy track." Many daily and Sunday newspapers feature comic strips based on fathers’ involvement and good-hearted foibles at home. Several celebrities, Paul Reiser, Bill Cosby, and Al Roker included, have written books describing their experiences.8–10 This media emphasis, coupled with cultural image changes and products such as infant-joggers and snugglies that encourage men’s participation, reflect the growing trend of fathers caring for and interacting with their children. Meanwhile, scholarly works continue focusing attention on the role and importance of fathers in their children’s social and emotional well-being.11–19
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FATHERS’ INFLUENCE ON THEIR CHILDREN’S DEVELOPMENT: SCIENTIFIC EVIDENCE
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Fathers’ interactions exert a powerful influence on every domain of their children’s functioning beginning at infancy. Recent research substantiates how fathers impact their children’s social, emotional, and cognitive development. For example, in the first few days of life, many newborn infants turn their heads preferentially to their father’s voices versus the voice of a stranger.20 Premature infants who experience increased visits from their fathers have improved weight gain during hospitalization and score higher during the first 18 months of life on adaptive-behavior and social-development tests, even after controlling for levels of prematurity and hospital stay.21 In a study of premature black infants, the father’s involvement enhanced the child’s cognitive and behavioral outcomes.22
Mothers and fathers influence their children in similar ways with regard to development of morality, competence in social interactions, academic achievement, and mental health. However, father involvement is of a different nature than mother involvement. In terms of relative frequency, fathers devote more time to playing with their children than do mothers. When children are young (0-4 years old), fathers tend to engage in more tactile physical and stimulating activities. As children enter middle childhood (the school-aged years), fathers engage in more recreational activities such as walks and outings as well as private talks. Fathers also have a strong influence on their children’s gender role development and are important role models for both girls and boys.23,24
The long-term effects of fathers’ direct involvement in the care of their children manifest through childhood and adolescence. For children with a father figure, those who described greater father support had a stronger sense of social competence and fewer depressive symptoms.25 Although time spent with children is usually less for fathers compared with mothers, studies show that shared activities between fathers and their children are independently associated with improved academic performance.7,26 Adolescents who perceive their fathers as encouraging and involved in their lives have higher college entrance examination scores, reach higher economic and educational attainment, show less delinquent behavior, and possess greater psychologic well-being.27,28
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THE FATHER’S ROLE IN FAMILY FUNCTIONING
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Fathers positively influence the behavior and relationships of the mother or other parent, siblings, and other family members. For example, fathers play an important role in the initiation, support, continuation, and ultimate ongoing success of breastfeeding.29–35 Father involvement also stabilizes and promotes healthy family functioning. Fathers, as much as mothers, can and often do provide affection, nurturing, and comfort to their children. As teachers, disciplinarians, and role models, fathers assume some of the responsibility for teaching their children what they need to know for life-survival skills and for school learning. These lessons may come in the form of teaching about letters, numbers, and shapes; helping the school-aged child with homework; coaching the child in an athletic skill or hobby; teaching manners and social skills; and encouraging a healthy lifestyle. Rituals that involve special time with fathers, such as homework, play, sports activities, bathing routines, bedtime rituals, household chores, shopping, or reading together, also help strengthen the father-child bond. Such involvement may even prove to be protective. In families in which even mild levels of maternal depression exist, for example, a nurturing father-child relationship counteracts behavioral and interactional problems often associated with maternal depression.36–38
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THE FATHER’S ROLE IN SUPPORTING THE OTHER PARENT IN THEIR RELATIONSHIP
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The emotional support a father provides to the other parent helps in practical ways with the care of children. Parents who feel loved, appreciated, and supported as spouses or partners tend to parent with more demonstrations of love, approval, and support and communicate better with their children. Maintaining and nourishing the spousal or partner relationship helps improve the marriage and parenthood (eg, remembering special occasions, bestowing compliments, demonstrating affection, and taking time together as partners).39–43 When parents are separated or unmarried, a positive, supportive relationship with the mother or other parent is an important predictor of children’s successful adjustment to their family structure.
In general, mothers’ support and encouragement of fathers is a key predictor of fathers’ involvement with their children.44,45 Mothers may actively oppose or quietly resist involvement or sharing household responsibilities for reasons of efficiency (things are done faster if she does it), quality (she does a better job), sympathy (not wanting to bother the father), admiration (he has done enough), anger (a by-product or after-effect of marital estrangement), or cultural beliefs in gender roles.45 Thus, in some cases, fathers may desire more involvement, but mothers themselves may discourage greater paternal involvement. Mothers who feel supported themselves as mothers are more likely to support and encourage the father’s involvement in the care of the child.
In families experiencing divorce, the relationships between father, mother, and children can become especially strained.46 Divorce affects children’s relationships with their parents and their sense of trust, acceptance, and support, creating feelings of loss and sadness.47 The quality of the parents’ pre- and postdivorce relationship plays a significant role in the child’s emotional and social response and the father’s involvement with his children. The quality of a father’s parenting has been found to be inversely related to sibling conflict, adolescent depression, delinquent behavior, and affiliation with deviant peers.48 Yet, there is a negative relationship between divorce and the quality of father’s parenting; in other words, divorce can lead to less quality parenting by fathers, compounding the aforementioned problems.
There are situations, however, in which divorce can improve paternal involvement. In these situations, positive changes in the father-child bond are a result of increased opportunities to relate to the child in a conflict-free atmosphere.49 Fathers may find themselves in the role of primary caregiver and, for the first time, engaging the health care system. Keeping both parents apprised of the child’s health and involved in the child’s life as well as keeping track of the emerging important adult figures in the child’s life becomes part of the pediatrician’s responsibilities.
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THE PEDIATRICIAN’S ROLE
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Many fathers want to be more involved in caring for their children. Pediatricians can help fathers learn to play a variety of roles in the family. Expanding on more than the stereotypical roles of the father as financial supporter and offering glimpses into the possibility and benefit of more roles for fathers suggests to the family that these roles are not in competition with those of mothers. In fact, these fathers’ roles enhance and support mothers’ roles. Furthermore, a father’s additional roles serve to support the overall needs of the family and make parenthood more gratifying for both parents. Professionals caring for children need to be aware of these roles and of the greater social and cultural backdrops against which these roles may be played. A father from one family may be expected culturally to meet with the pediatrician and direct most conversations, and another father from a different culture may be expected to meet his child’s pediatrician rarely or never. Given these family, social, and cultural variants, it is still largely true that pediatricians seldom get to know fathers as well as they do mothers.
Pediatricians usually see mothers and children in the office and may not be accustomed to or even comfortable with seeing fathers. Pediatricians can easily adapt their practices to accommodate fathers. The following advice will guide pediatricians in encouraging a father’s involvement and participation in office visits by letting him know he is welcome in the office and the health care system more generally. Pediatricians are encouraged to make special efforts to engage fathers who are separated from the family.
Pediatricians who understand parental expectations and the family’s cultural traditions and values and who respectfully explore and encourage the father-child relationship in pediatric visits are more likely to form a good rapport with fathers and make them feel welcome, which in turn conveys to fathers that they are important to their child’s development and encourages them to be more active in the care and activities of their children. Encouragement from the child’s advocate, the pediatrician, is a powerful message to fathers about their expanded and critical roles in their children’s lives.
In this report we have explained some of the socioeconomic factors that place fathers in a changing, often more prominent position in the care and development of their children and in their support of the spousal or partner relationship. Compelling recent evidence reveals that fathers’ involvement with their children will continue to increase as more women enter the workforce and men seek greater involvement at home. Pediatricians are uniquely qualified and placed to help fathers by encouragement, by practical advice, and by educating men, women, and their families about the benefits of positive father involvement for 1) the care and development of their children, 2) the other parent’s well-being, and 3) healthy family functioning.
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ADVICE FOR PEDIATRICIANS
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Make Your Practice More Father-Friendly
- Offer flexible and extended office hours (eg, late afternoons, evenings, weekends, and early mornings) to accommodate parents and encourage their attendance.
- Actively encourage fathers to come in for at least one of the initial well-infant or acute-illness visits in the infant’s first 2 months of life and more if possible.
- Welcome fathers and express appreciation for their attendance. Speak directly to the father as well as the mother or partner and solicit his opinions. Encourage office staff and nurses to include fathers in the office-visit appointment.
- Introduce yourself to the father and the mother or other parent. Politely explore the father’s relationship to the other parent (eg, married, living together), his cultural traditions, and his own personal beliefs about his role in caring for the child. Assess differences in parenting beliefs and help them negotiate if necessary.
- Learn something about the father’s role and beliefs (eg, how he was parented, expectations and hopes for his children, his previous marriages, other children and how he parented them). Keep the discussions focused on the parenting context and the father’s roles and beliefs; minimize small talk.
- Actively engage the father in the office. For example, tell the father: "As your child’s pediatrician, I want to know you and work with you and your child’s [mother or other parent] to offer the best care for your child."
- If the father is not involved in the dialogue, address him directly, asking him if he has specific questions or concerns. Solicit his opinions about child rearing, sharing responsibilities, and his perceived roles. Ask each parent about his or her transition to parenthood. For example, ask: "How is parenting going for each of you?"
- Ask the parents how they support each other as parents, spouses or partners, and individuals.
- Recognize that mothers and fathers may not always agree on how best to raise a child. For example, parents may disagree on the approach to discipline or issues of firearm safety. Pediatricians can serve as a mediator in such discussions, meeting with both parents or caregivers together to discuss these and other behavior-management issues and should avoid (whenever possible) siding with one parent or the other on important parenting issues.
- Participate in educational opportunities (eg, courses, continuing medical education activities, medical literature) devoted to fathers’ role issues, parental depression, and family functioning to enhance training and education in this area.
Understand the Family
- Explore the family composition, cultural beliefs, overall mental and physical health, and delegation and discussions of child care tasks within the family. If parents are not both in the household, discuss living and custody arrangements as well.
- In addition to discussing the feelings of joy and fulfillment having a child can bring, also be prepared to discuss issues of the allocation of child and sibling care and the common experiences that siblings and parents encounter with conflict, jealousy, and normal disappointments in connection with the arrival of a new infant.
- Be sensitive to and informed about diverse cultural and ethnic values and customs, especially "traditional" father roles. Pediatricians can determine the extent of the father’s responsibilities and presence at home by respectfully exploring these issues with parents.
- Use a "parenting history" to help parents understand their behaviors by understanding how they themselves were parented. Parents often adopt a parenting style to compensate for their own childhood deficiencies or to emulate childhood experiences depending on their own parenting experiences.
- Discuss how the couple is adapting to parenthood (with each child). Asking questions such as "How is your relationship (or the family) adjusting to the new infant?" or "How is it living with a teenager?" opens the door to reflection and discussion and can remind parents of the importance of their own partner relationship and the need to nurture and maintain it. Encourage parents to continue to dedicate time for adult activities without children.
Empower, Engage, and Inform Fathers of the Importance of Their Involvement
- Remind the family that fathers are not only workers or breadwinners and mothers or partners are not only nurturers or primary providers of child care. They share these roles, complementing one another, often to the benefit of the child.
- As early as in the delivery room or nursery and if culturally appropriate, fathers can be given responsibilities for caring for and making decisions regarding the child.
- Encourage fathers to assume some roles in the care of the child, and encourage the mother to let the father be involved and learn from his own mistakes. Early time alone with the child helps a father gain confidence and develop his own style of interaction and provides a mother or other parent with much-needed time alone.
- Determine how comfortable the father is with his parenting skills and whether he has concerns.
- Explore with the father ways to decrease maternal stress. This might include his helping with meals or household chores, the involvement of other family members with household tasks, or the hiring of household help.
- Identify institutions and policies that facilitate fathers’ involvement and work-family balance. Encourage child care centers, support groups, and schools to involve and include fathers. Promote the use of policies such as the Family Medical Leave Act (codified at 29 CFR
825 [1993]) and flexible work schedules as ways to balance employment and family responsibilities.
Reinforce the Father’s Support of the Mother or Partner
- Inform the family about the normal elation, fatigue, and challenges of being a father. Discuss openly the usual interruptions in sleep for the whole family, the decreases in energy, the alterations in time together as a couple and individual free time, and the changes in intimacy and the sexual relationship. This may be the first time some fathers will have discussed these issues openly.
- Look for signs of maternal depression (postpartum depression in the newborn period) and be able to offer resources to help.
- Explore marital stress and inquire about the marriage or partner relationship. For example, you may ask: "How has the birth of this infant affected your relationship?"; "To whom do you turn for advice and support?"; and/or "Would you like a referral to talk to someone else who can help (individual or couples therapy and/or medication)?"
- Educate fathers about the practicalities of breastfeeding and how to support mothers’ nursing.
- Encourage fathers to provide or protect time for mothers to have time to be alone, exercise, meet friends, or simply relax.
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Committee on Psychosocial Aspects of Child and Family Health, 2001–2002
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Joseph F. Hagan, Jr, MD, Chairperson
William L. Coleman, MD
Jane Meschan Foy, MD
Edward Goldson, MD
Barbara J. Howard, MD
Ana Navarro, MD
Thomas J. Sullivan, MD
J. Lane Tanner, MD
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Invited Contributor
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Craig F. Garfield, MD
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Liaisons
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F. Daniel Armstrong, PhD
Society of Pediatric Psychology
Peggy Gilbertson, RN, MPH, CPNP
National Association of Pediatric Nurse Practitioners
Sally E. A. Longstaffe, MD
Canadian Paediatric Society
Frances J. Wren, MD
American Academy of Child and Adolescent Psychiatry
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Consultants
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George J. Cohen, MD
National Consortium for Child and Adolescent Mental Health Services
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Staff
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Karen Smith
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FOOTNOTES
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The recommendations in this report do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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TOP
ABSTRACT
GOALS
