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Group well-child care offers unique opportunities for patient education
Patient
Elsevier
Education
and Counseling,
Scientific Publishers
14 (1989) 227-234
Ireland Ltd.
Educational Model of Health Care
Group Well-Child Care Offers Unique Opportunities for Patient Education Lucy M. Osborn Department
of Pediatrics,
University
of Utah Centerfor ft7.S.A.I
Health Sciences, Salt Lake City, UT84132
(Received October 31st, 19891 (Accepted August 22nd, 19891 By using a group process, health educators can greatly increase the cost effectiveness of wellchild care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the author’s 15 years of experience using this model, illustrating with examples the advantages of group well-child care. Key words: well-child care; child health maintenance;
group well-child care; well-baby groups.
Infant well-care: past and present
Well-child care has been an integral part of medical care for children since the late 1800s. High infant mortality rates mandated that the focus of well-care be on physical health and infant feeding practices. Times have changed, and so have the needs of parents and children. American youth are more likely to experience school failure than to have a physical handicap or a chronic illness [l]. Parents are frequently faced with difficult issues regarding the behavior and development of their children, and, with most living away from their immediate families and other relatives, often find themselves at a loss for helpful resources. Because health care providers are among the few professionals families have contact with before their children start school, parents turn to pediatricians, family physicians, nurse practitioners and health educators for information and guidance. The well-child visit provides a unique opportunity to make interventions that can result in a better environment for children [2,3]. Patient education
and the well-child visit
Although it was first suggested almost 40 years ago that “preventive mental health” and “anticipatory guidance” be a part of child health care [4], the Ameri0738.3991/89/$03.50 0 1989 Elsevier Scientific Publishers Published and Printed in Ireland
Ireland Ltd.
227
can Academy of Pediatrics (AAP) did not officially sanction well-child care until 1967 [5]. The AAP has made specific recommendations for the content of health supervision visits, with the most recent edition published in 1988 [6]. Despite recognition that well-child care needs to be oriented toward behavioral and developmental issues, most physicians spend an average of only 1 min per visit discussing such topics [7]. Both the structure and the process of the child health maintenance visit contribute to the problem of providing effective patient education. These visits average lo- 12 min in length. During this short interval, in addition to the general history and physical examination, the health practitioner must establish rapport, give reassurance, teach, and identify obstacles to behavior change [B]. This is a formidable, if not impossible, task during such a brief encounter. Yet, because any effort to provide guidance in this environment must be cost effective for all involved parties, increasing the time spent per visit is not practical
PI* Organizing
group well-child care
The method I have used to address these problems is to provide well-child care using groups [lo - 121. Families are invited to attend educational sessions on the same schedule as recommended by the AAP for well-child care. Infants receive the usual health screening and immunizations, but either before or after a brief physical examination, families are gathered in the waiting room for a l-h discussion of child development, common behavioral problems, safety, nutrition, and other relevant issues. For the past 15 years I have used this technique in a variety of settings, including several university-based resident teaching clinics, a family practice clinic serving the medically indigent, and my private practice. At the e-week visit, after briefly reviewing the well-child visit schedule and describing both the traditional one-to-one visit and well-baby groups, I give families the option of joining a group for their child’s 2-month check-up or returning individually. Over 75% of my patients choose the group option. This paper describes my experience with groups in my part-time, university-based, practice. I currently have 35 active groups that include approximately 175 patients and their parents. I generally conduct between one and three well-baby groups each week. I schedule four to eight families during a 1.5 h time period. Thus, the time I spend per patient is no greater than the usual 15 min encounter. Using the group approach, health care providers can spend an hour with parents, a time period that is usually sufficient to establish trust, answer questions, and cover behavioral topics pertinent to each age group. Since the time required for group visits is equivalent to that required if patients are seen individually, and because the charge is the same, group visits are at least equally cost effective [lo]. A typical group visit is described in Table I. Group well-child care offers many of the same educational opportunities that parenting classes do, but with additional benefits. First, many parents who would not otherwise take the time to attend a parenting class will bring their
228
TABLE I DESCRIPTION OF A TYPICAL GROUP VISIT (ALL PATIENTS APPOINTED AT 4:45 pm1
First patient arrives, is weighed, measured, and taken to examination room 4%~530 Three other patients arrive, each is weighed and measured; one is taken to examination room, the others return to waiting area 5:00--6:oo Two more families arrive at 5:00, just as the group discussion begins
6:00--6:lO Physician examines children who have been weighed, nurse weighs two infants who arrived late 6:10--6:20 Nurse gives immunizations to babies after the examinations, physician completes examinations on last two patients
The children get their “checkadditional time or effort. pay for preventive health care, but do not
children for regular health maintenance ups” and the parents receive counseling
visits. with
little
Many health insurance companies cover the cost of parenting classes. Because children are present, the well-child groups are necessarily smaller than most parenting classes, enabling participants to have more direct involvement with the discussion. They are able to express their opinions, outline the problems they might have in compliance with any advice that is given, and are usually exposed to several different approaches to any problem. Because the same parents meet regularly as a group over an extended period of time, families have the opportunity to form a small support system. They share information regarding child-care, preschools, and other local community services. Recently, a group decided at their l&month visit to get together with their children for a barbeque! An advantage of group well-visits over parenting classes is that the children are present. Because children are the same age, parents can observe both the similarities and the differences in children’s temperaments and behavior. Most are greatly reassured about their child’s development and by the fact that their worries are shared by others. The content of the discussion can be quite agespecific. An added benefit for any health care providers is the time available to observe both the parent-child interaction and the child’s interaction with peers in a relatively unstructured situation. I have found this invaluable. I feel that I am much better acquainted with both the children and the parents who participate in the groups compared to those I see individually. In a busy practice, the educational content of group visits could be presented by others, including nurses, health educators, or psychologists. This would save the physician’s time for acute or chronic health care problems; however, the primary care provider would lose a valuable chance to establish rapport with patients.
229
Content of group well-child care
The content of group visits is similar to that of individual visits, but can be more detailed. I have found, however, that the order in which topics are introduced is important. I begin each session by asking parents to describe their infants, asking them to relate what their child is doing developmentally, and questioning them about their babies’ temperaments. This gives parents the message that the central issues to be discussed are infant behavior and development, rather than “medical” problems. Parents quickly learn that I consider their children’s behavior to be important and that this is a forum for both learning about child development and sharing concerns. This also facilitates the group process, for even the shyest parents will enjoy talking about their children. Later in the discussion, I cover nutritional, safety, and other medical subjects, introducing each topic with a short didactic explanation of the material that is recommended by the AAP and then asking for questions [6]. In directing the content of the groups, I have found the work of Dr. Louis Sander extremely helpful [13,14]. His focus involves the development of the parent-child pair, rather than of the child alone, and provides a theme for each of the group visits. In his papers on issues in early mother-child interaction, Dr. Sander has proposed that there are a series of issues that are negotiated between children and their parents. One of the constant, central issues is the balance in the relationship between indulgence and discipline. This balance is age specific, and will at some times require more indulgence, at others more discipline. For example, the first 2 months of life are considered the “period of initial adaptation.” The primary task of this period is for parents to learn to interpret the cues their infants give and to respond appropriately. At this age, the parent must be indulgent, responding consistently to the baby’s cries, for newborns have no capacities of self-control and discipline is inappropriate. During the 2month group session, I ask each family whether they can interpret their infant’s cries and how they respond. Invariably, this is followed by a discussion of “spoiling” and the pressures that others are putting on parents not to pick up or to hold their infants when they cry. From 2 to 5 months is considered the “period of reciprocal exchange.” The issue at this time is: “to what extent does the interaction between parents and their infants include reciprocal sequences of interchange...that is...active-passive alterations of stimulus and response?” [13]. At the 4-month visit, I ask parents whether they can get their babies to “talk’ to them; many will actually demonstrate an exchange with their infants. This is followed by a discussion of the importance of responding to infants’ cues without overstimulating them. Table II outlines several other examples and how they can be incorporated into the group discussion. Benefits
of group well-child care
Compared to the traditional
230
child health maintenance
visit, group visits offer
TABLE II EXAMPLES
OF SANDERS
ISSUES IN MATERNAL-CHILD
INTERACTION
Age, period
Issue
Question for group
5- 9 months, Early directed activity 6-month group
To what degree will the initiative of the infant be successful in establishing areas of reciprocity in the interchange with mothers?
Can your baby, without crying, get you to do something for him? Ask for examples.
9- 15 months Focalization on mother g-month group
To what degree will the child succeed in his demands that the mother alone fulfill his needs?
Doesyourbabyrespond differently to mother than to father? Whom does the baby seek for comfort? Discuss stranger anxiety. Tell fathers there will be a period of focus on them later.
12- 15 months Period of self-assertion 12-month group
To what extent will the child establish self-assertion in the interaction with the mother?
Has your child had a temper tantrum? Discuss power and control in parent-child relationships.
additional possibilities for patient education. Benefits include more time for patient education, greater parental reassurance, the opportunity to model behaviors, and a chance to provide direct teaching and immediate feedback. Children also seem to find comfort during the group visit: they learn that the clinic is not just a place where they are going to get a shot. Below are examples of incidents that illustrate the advantages of group well-child care. 1. Increased
time forpatient
education
The most obvious benefit of the hour discussion time is that a broader range of topics can be covered. Perhaps an even more important factor, however, is that the provider can easily follow the “stepped approach” to patient education: establishment of trust and rapport, teaching about health matters, and identification of obstacles to behavior change [8]. The following anecdote is an example of how the process of group care can facilitate education. Kelly was 9 months old when the families in her group were discussing their infants’ sleeping patterns. As commonly occurs at this age, Kelly was awakening frequently during the night. Her mother was exhausted and frustrated. To her surprise, Kelly’s mother learned that her child was not the only infant who seemed to be having difficulty sleeping. The other parents began to relate advice they had been given and the steps that they had taken attempting to help the infants sleep. One of the mothers talked of letting her baby cry. It had been difficult, but had worked. Simply not responding to an infants cries is the most frequently given advice for this problem [15]. Although this method is the one that works most reliably, this advice is
231
rated by parents as being the least helpful and is the least likely to be attempted [16]. Kelly’s mother, picturing herself lying in bed, trying not to respond to the baby, asked: “How old do they have to be before you don’t feel like an ogre letting them cry?” The others unanimously agreed that no matter how old the child, listening to cries would never be easy. They talked about issues of setting limits for children and the challenge to parental self-esteem that occurs as children struggle against those limits. Each family heard several different ways of addressing sleep disturbances, about the difficulties with each choice, and then had the opportunity to choose the method that best suited both their lifestyle and the temperament of their child. This process is not possible during an individual visit, both because the provider alone cannot relate the varied experiences described and because he cannot easily take the time required. 2. Formation of a support group and parental reassurance Groups begin to meet for their well-child care at the 2 month visit. They meet regularly during their children’s formative years: every 2 months for the first 6 months, at 3-month intervals for the following year, and then every 6 months. By the time Richard was 15 months old, his group had met five times. Although fathers usually attend, none participated in Richard’s group. The mothers had become well acquainted and had established good rapport with one another. Richard’s mother had raised three teenaged step-children, but caring for Richard was her first experience with an infant. During a discussion of limit setting, Richard’s mother suddenly began to cry. Through her tears, she explained: “I feel so guilty and ashamed. The other day he was having a temper tantrum and I spanked him. I’d never done that before. I don’t think people should spank children, but that’s not really what I feel so bad about. What frightened me was that it felt so good to let out my frustrations by spanking him! I had to take him to the crib and leave him to get control of myself! What kind of parent could feel that way ?” Suddenly all the mothers were crying, talking about feelings and issues they had never shared with anyone. Richard’s mother was not alone. 3. Modeling ents
behavior,
providing
instruction
and immediate
feedback
for par-
Keith’s parents had been eager participants in their well-baby group. They had never missed a meeting. When Keith was 2 years old, he picked up a book and threw it across the room during the discussion period. His mother, Sue, yelled: “Keith! Bad boy! Stop that and come over here!” Her hand was raised to swat him. I asked Sue to consider handling the behavior differently, and requested that Keith come to me. Holding Keith by the shoulders, I explained in a quiet voice that throwing books was not acceptable, asked him to pick up the book and put it back. I then explained that if he threw another one, the books would have to be put away. Keith squirmed under my stare, but cooperated by returning the book to the shelf. Of course, that wasn’t the end of it. After 10 min, he looked at his mother, picked up a book, and threw it. I asked
232
Sue to gently remind Keith of the consequence of throwing the book and to help him put all of them away. He played quietly with the other children during the remainder of the session. During the brief individual encounter with me for Keith’s physical examination, Sue explained that both she and her husband had been reared by families that attempted to enforce discipline by yelling and physical punishment. She knew that it didn’t work, she wanted to treat Keith differently, and sadly said: “But I don’t know how. Could you help me?’ The family was subsequently seen for several individual appointments for counseling and referred to a parenting class. 4. Reassurance
for children
John had been ill as an infant. He had been hospitalized for a urinary tract infection and for bladder surgery. He had recurrent ear infections that required placement of tympanostomy tubes. During each office visit a painful procedure was required. He was catheterized for urine specimens, blood was drawn, his ears were cleaned, or he got an immunization. He would fuss from the time he entered the office until he left and would scream as soon as he saw me. When he was a year old, his parents decided to join a well-baby group. Because he was seen so frequently for his medical problems, John’s parents agreed to bring him just for the discussion. He played with the other children while his parents talked with the other families. He wasn’t weighed, measured, examined, or given a shot. At the end of each group session, he simply got to go home. After the second group visit, John was able to look at me without crying! After the third, he was able to come to the office, play in the waiting room, and only cried during procedures. He was able to learn that sometimes the office wasn’t a terrifying place. Barriers to change
These are only a few examples of the possibilities for patient education that group well-child care can provide. Just as with patients, however, there are barriers to changing provider behavior if group care is to be instituted. The most important barrier is probably inertia. Any change in office routine takes effort, energy, and commitment. Not every provider will be comfortable with conducting group visits. Some may prefer the intimacy of individual encounters; others will have difficulty tolerating the relative chaos of group visits. Space is a problem if the provider cannot use the waiting area for the group discussion. Blocking 1.5 h out of a busy schedule can be difficult, particularly if the provider is frequently called away from the office for emergencies. Converting from individual to group well-child care requires the cooperation of the entire office staff: the health care provider, the receptionists, and the nurses. The first visits can be difficult, disorganized and exhausting. But if these barriers can be overcome, those interested in patient education are likely to find that group care is challenging, exciting, fun, interesting, and a wonderful learning experience for patient and physician alike.
233
References 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
234
Werner EE, Burman JM, French FE. The Children of Kauai. University of Hawaii Press, 1971. Thomas KA, Hassanein RS, Christopherson ER. Evaluation of group well-child care for improving burn prevention practice in the home. Pediatrics 1984; 74: 879-882. Chamberlain R, Szumowski EK, Zastowny TR. An evaluation of efforts to educate mothers about child development in pediatric office practices. Am J Public Health 1979; 69: 875-886. Stine OC. Content and method of health supervision by physicians in child health conferences in Baltimore, 1959. Am J Public Health 1962; 52: 1958. Charney E fed). Well-child care. Report of the Seventeenth Ross Roundtable on Critical Approaches to Common Pediatric Problems. Columbus, OH: Ross Laboratories, 1986. Green M fed). Guidelines for Health Supervision II. Elk Grove Village, IL: American Academy of Pediatrics, 1988. Reisinger KS, Bires JA. Anticipatory guidance in pediatric practice. Pediatrics 1980; 66: 889. Bartlett EE. Effective approaches to patient education for the busy pediatrician. Pediatrics 1984; 74(suppl): 920- 923. Fulginiti VA. Role of the pediatrician in patient education. Pediatrics 1984; 74tsuppl): 914-919. Osborn LM, Wooley FR. The use of groups in well-child care. Pediatrics 1981; 67: 701- 706. Osborn LM. Group well-child care: an option for today’s children. Pediatr Nurs 1982; 8: 306308. Osborn LM. Group well-child care. Clin Perinatol1985; 12: 355-365. Sander LW. Issues in early maternal-child interactions. J Am Acad Child Psychiatry 1962: 1: 141-161. Sander LW. Adaptive relationships in early mother-child interactions. J Am Acad Child Psy chiatry 1965; 3: 231- 264. Schmidt B. When baby just won’t sleep. Contemp Pediatr 1985; 2: 38- 52. Kanoy K, Schroeder C. Suggestions to parents about common behavior problems in a pediatric primary care office: Five years of follow-up. J Pediatr Psycho1 1985; 10: 15- 30.
Elsevier
Education
and Counseling,
Scientific Publishers
14 (1989) 227-234
Ireland Ltd.
Educational Model of Health Care
Group Well-Child Care Offers Unique Opportunities for Patient Education Lucy M. Osborn Department
of Pediatrics,
University
of Utah Centerfor ft7.S.A.I
Health Sciences, Salt Lake City, UT84132
(Received October 31st, 19891 (Accepted August 22nd, 19891 By using a group process, health educators can greatly increase the cost effectiveness of wellchild care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the author’s 15 years of experience using this model, illustrating with examples the advantages of group well-child care. Key words: well-child care; child health maintenance;
group well-child care; well-baby groups.
Infant well-care: past and present
Well-child care has been an integral part of medical care for children since the late 1800s. High infant mortality rates mandated that the focus of well-care be on physical health and infant feeding practices. Times have changed, and so have the needs of parents and children. American youth are more likely to experience school failure than to have a physical handicap or a chronic illness [l]. Parents are frequently faced with difficult issues regarding the behavior and development of their children, and, with most living away from their immediate families and other relatives, often find themselves at a loss for helpful resources. Because health care providers are among the few professionals families have contact with before their children start school, parents turn to pediatricians, family physicians, nurse practitioners and health educators for information and guidance. The well-child visit provides a unique opportunity to make interventions that can result in a better environment for children [2,3]. Patient education
and the well-child visit
Although it was first suggested almost 40 years ago that “preventive mental health” and “anticipatory guidance” be a part of child health care [4], the Ameri0738.3991/89/$03.50 0 1989 Elsevier Scientific Publishers Published and Printed in Ireland
Ireland Ltd.
227
can Academy of Pediatrics (AAP) did not officially sanction well-child care until 1967 [5]. The AAP has made specific recommendations for the content of health supervision visits, with the most recent edition published in 1988 [6]. Despite recognition that well-child care needs to be oriented toward behavioral and developmental issues, most physicians spend an average of only 1 min per visit discussing such topics [7]. Both the structure and the process of the child health maintenance visit contribute to the problem of providing effective patient education. These visits average lo- 12 min in length. During this short interval, in addition to the general history and physical examination, the health practitioner must establish rapport, give reassurance, teach, and identify obstacles to behavior change [B]. This is a formidable, if not impossible, task during such a brief encounter. Yet, because any effort to provide guidance in this environment must be cost effective for all involved parties, increasing the time spent per visit is not practical
PI* Organizing
group well-child care
The method I have used to address these problems is to provide well-child care using groups [lo - 121. Families are invited to attend educational sessions on the same schedule as recommended by the AAP for well-child care. Infants receive the usual health screening and immunizations, but either before or after a brief physical examination, families are gathered in the waiting room for a l-h discussion of child development, common behavioral problems, safety, nutrition, and other relevant issues. For the past 15 years I have used this technique in a variety of settings, including several university-based resident teaching clinics, a family practice clinic serving the medically indigent, and my private practice. At the e-week visit, after briefly reviewing the well-child visit schedule and describing both the traditional one-to-one visit and well-baby groups, I give families the option of joining a group for their child’s 2-month check-up or returning individually. Over 75% of my patients choose the group option. This paper describes my experience with groups in my part-time, university-based, practice. I currently have 35 active groups that include approximately 175 patients and their parents. I generally conduct between one and three well-baby groups each week. I schedule four to eight families during a 1.5 h time period. Thus, the time I spend per patient is no greater than the usual 15 min encounter. Using the group approach, health care providers can spend an hour with parents, a time period that is usually sufficient to establish trust, answer questions, and cover behavioral topics pertinent to each age group. Since the time required for group visits is equivalent to that required if patients are seen individually, and because the charge is the same, group visits are at least equally cost effective [lo]. A typical group visit is described in Table I. Group well-child care offers many of the same educational opportunities that parenting classes do, but with additional benefits. First, many parents who would not otherwise take the time to attend a parenting class will bring their
228
TABLE I DESCRIPTION OF A TYPICAL GROUP VISIT (ALL PATIENTS APPOINTED AT 4:45 pm1
First patient arrives, is weighed, measured, and taken to examination room 4%~530 Three other patients arrive, each is weighed and measured; one is taken to examination room, the others return to waiting area 5:00--6:oo Two more families arrive at 5:00, just as the group discussion begins
6:00--6:lO Physician examines children who have been weighed, nurse weighs two infants who arrived late 6:10--6:20 Nurse gives immunizations to babies after the examinations, physician completes examinations on last two patients
The children get their “checkadditional time or effort. pay for preventive health care, but do not
children for regular health maintenance ups” and the parents receive counseling
visits. with
little
Many health insurance companies cover the cost of parenting classes. Because children are present, the well-child groups are necessarily smaller than most parenting classes, enabling participants to have more direct involvement with the discussion. They are able to express their opinions, outline the problems they might have in compliance with any advice that is given, and are usually exposed to several different approaches to any problem. Because the same parents meet regularly as a group over an extended period of time, families have the opportunity to form a small support system. They share information regarding child-care, preschools, and other local community services. Recently, a group decided at their l&month visit to get together with their children for a barbeque! An advantage of group well-visits over parenting classes is that the children are present. Because children are the same age, parents can observe both the similarities and the differences in children’s temperaments and behavior. Most are greatly reassured about their child’s development and by the fact that their worries are shared by others. The content of the discussion can be quite agespecific. An added benefit for any health care providers is the time available to observe both the parent-child interaction and the child’s interaction with peers in a relatively unstructured situation. I have found this invaluable. I feel that I am much better acquainted with both the children and the parents who participate in the groups compared to those I see individually. In a busy practice, the educational content of group visits could be presented by others, including nurses, health educators, or psychologists. This would save the physician’s time for acute or chronic health care problems; however, the primary care provider would lose a valuable chance to establish rapport with patients.
229
Content of group well-child care
The content of group visits is similar to that of individual visits, but can be more detailed. I have found, however, that the order in which topics are introduced is important. I begin each session by asking parents to describe their infants, asking them to relate what their child is doing developmentally, and questioning them about their babies’ temperaments. This gives parents the message that the central issues to be discussed are infant behavior and development, rather than “medical” problems. Parents quickly learn that I consider their children’s behavior to be important and that this is a forum for both learning about child development and sharing concerns. This also facilitates the group process, for even the shyest parents will enjoy talking about their children. Later in the discussion, I cover nutritional, safety, and other medical subjects, introducing each topic with a short didactic explanation of the material that is recommended by the AAP and then asking for questions [6]. In directing the content of the groups, I have found the work of Dr. Louis Sander extremely helpful [13,14]. His focus involves the development of the parent-child pair, rather than of the child alone, and provides a theme for each of the group visits. In his papers on issues in early mother-child interaction, Dr. Sander has proposed that there are a series of issues that are negotiated between children and their parents. One of the constant, central issues is the balance in the relationship between indulgence and discipline. This balance is age specific, and will at some times require more indulgence, at others more discipline. For example, the first 2 months of life are considered the “period of initial adaptation.” The primary task of this period is for parents to learn to interpret the cues their infants give and to respond appropriately. At this age, the parent must be indulgent, responding consistently to the baby’s cries, for newborns have no capacities of self-control and discipline is inappropriate. During the 2month group session, I ask each family whether they can interpret their infant’s cries and how they respond. Invariably, this is followed by a discussion of “spoiling” and the pressures that others are putting on parents not to pick up or to hold their infants when they cry. From 2 to 5 months is considered the “period of reciprocal exchange.” The issue at this time is: “to what extent does the interaction between parents and their infants include reciprocal sequences of interchange...that is...active-passive alterations of stimulus and response?” [13]. At the 4-month visit, I ask parents whether they can get their babies to “talk’ to them; many will actually demonstrate an exchange with their infants. This is followed by a discussion of the importance of responding to infants’ cues without overstimulating them. Table II outlines several other examples and how they can be incorporated into the group discussion. Benefits
of group well-child care
Compared to the traditional
230
child health maintenance
visit, group visits offer
TABLE II EXAMPLES
OF SANDERS
ISSUES IN MATERNAL-CHILD
INTERACTION
Age, period
Issue
Question for group
5- 9 months, Early directed activity 6-month group
To what degree will the initiative of the infant be successful in establishing areas of reciprocity in the interchange with mothers?
Can your baby, without crying, get you to do something for him? Ask for examples.
9- 15 months Focalization on mother g-month group
To what degree will the child succeed in his demands that the mother alone fulfill his needs?
Doesyourbabyrespond differently to mother than to father? Whom does the baby seek for comfort? Discuss stranger anxiety. Tell fathers there will be a period of focus on them later.
12- 15 months Period of self-assertion 12-month group
To what extent will the child establish self-assertion in the interaction with the mother?
Has your child had a temper tantrum? Discuss power and control in parent-child relationships.
additional possibilities for patient education. Benefits include more time for patient education, greater parental reassurance, the opportunity to model behaviors, and a chance to provide direct teaching and immediate feedback. Children also seem to find comfort during the group visit: they learn that the clinic is not just a place where they are going to get a shot. Below are examples of incidents that illustrate the advantages of group well-child care. 1. Increased
time forpatient
education
The most obvious benefit of the hour discussion time is that a broader range of topics can be covered. Perhaps an even more important factor, however, is that the provider can easily follow the “stepped approach” to patient education: establishment of trust and rapport, teaching about health matters, and identification of obstacles to behavior change [8]. The following anecdote is an example of how the process of group care can facilitate education. Kelly was 9 months old when the families in her group were discussing their infants’ sleeping patterns. As commonly occurs at this age, Kelly was awakening frequently during the night. Her mother was exhausted and frustrated. To her surprise, Kelly’s mother learned that her child was not the only infant who seemed to be having difficulty sleeping. The other parents began to relate advice they had been given and the steps that they had taken attempting to help the infants sleep. One of the mothers talked of letting her baby cry. It had been difficult, but had worked. Simply not responding to an infants cries is the most frequently given advice for this problem [15]. Although this method is the one that works most reliably, this advice is
231
rated by parents as being the least helpful and is the least likely to be attempted [16]. Kelly’s mother, picturing herself lying in bed, trying not to respond to the baby, asked: “How old do they have to be before you don’t feel like an ogre letting them cry?” The others unanimously agreed that no matter how old the child, listening to cries would never be easy. They talked about issues of setting limits for children and the challenge to parental self-esteem that occurs as children struggle against those limits. Each family heard several different ways of addressing sleep disturbances, about the difficulties with each choice, and then had the opportunity to choose the method that best suited both their lifestyle and the temperament of their child. This process is not possible during an individual visit, both because the provider alone cannot relate the varied experiences described and because he cannot easily take the time required. 2. Formation of a support group and parental reassurance Groups begin to meet for their well-child care at the 2 month visit. They meet regularly during their children’s formative years: every 2 months for the first 6 months, at 3-month intervals for the following year, and then every 6 months. By the time Richard was 15 months old, his group had met five times. Although fathers usually attend, none participated in Richard’s group. The mothers had become well acquainted and had established good rapport with one another. Richard’s mother had raised three teenaged step-children, but caring for Richard was her first experience with an infant. During a discussion of limit setting, Richard’s mother suddenly began to cry. Through her tears, she explained: “I feel so guilty and ashamed. The other day he was having a temper tantrum and I spanked him. I’d never done that before. I don’t think people should spank children, but that’s not really what I feel so bad about. What frightened me was that it felt so good to let out my frustrations by spanking him! I had to take him to the crib and leave him to get control of myself! What kind of parent could feel that way ?” Suddenly all the mothers were crying, talking about feelings and issues they had never shared with anyone. Richard’s mother was not alone. 3. Modeling ents
behavior,
providing
instruction
and immediate
feedback
for par-
Keith’s parents had been eager participants in their well-baby group. They had never missed a meeting. When Keith was 2 years old, he picked up a book and threw it across the room during the discussion period. His mother, Sue, yelled: “Keith! Bad boy! Stop that and come over here!” Her hand was raised to swat him. I asked Sue to consider handling the behavior differently, and requested that Keith come to me. Holding Keith by the shoulders, I explained in a quiet voice that throwing books was not acceptable, asked him to pick up the book and put it back. I then explained that if he threw another one, the books would have to be put away. Keith squirmed under my stare, but cooperated by returning the book to the shelf. Of course, that wasn’t the end of it. After 10 min, he looked at his mother, picked up a book, and threw it. I asked
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Sue to gently remind Keith of the consequence of throwing the book and to help him put all of them away. He played quietly with the other children during the remainder of the session. During the brief individual encounter with me for Keith’s physical examination, Sue explained that both she and her husband had been reared by families that attempted to enforce discipline by yelling and physical punishment. She knew that it didn’t work, she wanted to treat Keith differently, and sadly said: “But I don’t know how. Could you help me?’ The family was subsequently seen for several individual appointments for counseling and referred to a parenting class. 4. Reassurance
for children
John had been ill as an infant. He had been hospitalized for a urinary tract infection and for bladder surgery. He had recurrent ear infections that required placement of tympanostomy tubes. During each office visit a painful procedure was required. He was catheterized for urine specimens, blood was drawn, his ears were cleaned, or he got an immunization. He would fuss from the time he entered the office until he left and would scream as soon as he saw me. When he was a year old, his parents decided to join a well-baby group. Because he was seen so frequently for his medical problems, John’s parents agreed to bring him just for the discussion. He played with the other children while his parents talked with the other families. He wasn’t weighed, measured, examined, or given a shot. At the end of each group session, he simply got to go home. After the second group visit, John was able to look at me without crying! After the third, he was able to come to the office, play in the waiting room, and only cried during procedures. He was able to learn that sometimes the office wasn’t a terrifying place. Barriers to change
These are only a few examples of the possibilities for patient education that group well-child care can provide. Just as with patients, however, there are barriers to changing provider behavior if group care is to be instituted. The most important barrier is probably inertia. Any change in office routine takes effort, energy, and commitment. Not every provider will be comfortable with conducting group visits. Some may prefer the intimacy of individual encounters; others will have difficulty tolerating the relative chaos of group visits. Space is a problem if the provider cannot use the waiting area for the group discussion. Blocking 1.5 h out of a busy schedule can be difficult, particularly if the provider is frequently called away from the office for emergencies. Converting from individual to group well-child care requires the cooperation of the entire office staff: the health care provider, the receptionists, and the nurses. The first visits can be difficult, disorganized and exhausting. But if these barriers can be overcome, those interested in patient education are likely to find that group care is challenging, exciting, fun, interesting, and a wonderful learning experience for patient and physician alike.
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References 1
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Werner EE, Burman JM, French FE. The Children of Kauai. University of Hawaii Press, 1971. Thomas KA, Hassanein RS, Christopherson ER. Evaluation of group well-child care for improving burn prevention practice in the home. Pediatrics 1984; 74: 879-882. Chamberlain R, Szumowski EK, Zastowny TR. An evaluation of efforts to educate mothers about child development in pediatric office practices. Am J Public Health 1979; 69: 875-886. Stine OC. Content and method of health supervision by physicians in child health conferences in Baltimore, 1959. Am J Public Health 1962; 52: 1958. Charney E fed). Well-child care. Report of the Seventeenth Ross Roundtable on Critical Approaches to Common Pediatric Problems. Columbus, OH: Ross Laboratories, 1986. Green M fed). Guidelines for Health Supervision II. Elk Grove Village, IL: American Academy of Pediatrics, 1988. Reisinger KS, Bires JA. Anticipatory guidance in pediatric practice. Pediatrics 1980; 66: 889. Bartlett EE. Effective approaches to patient education for the busy pediatrician. Pediatrics 1984; 74(suppl): 920- 923. Fulginiti VA. Role of the pediatrician in patient education. Pediatrics 1984; 74tsuppl): 914-919. Osborn LM, Wooley FR. The use of groups in well-child care. Pediatrics 1981; 67: 701- 706. Osborn LM. Group well-child care: an option for today’s children. Pediatr Nurs 1982; 8: 306308. Osborn LM. Group well-child care. Clin Perinatol1985; 12: 355-365. Sander LW. Issues in early maternal-child interactions. J Am Acad Child Psychiatry 1962: 1: 141-161. Sander LW. Adaptive relationships in early mother-child interactions. J Am Acad Child Psy chiatry 1965; 3: 231- 264. Schmidt B. When baby just won’t sleep. Contemp Pediatr 1985; 2: 38- 52. Kanoy K, Schroeder C. Suggestions to parents about common behavior problems in a pediatric primary care office: Five years of follow-up. J Pediatr Psycho1 1985; 10: 15- 30.