- Email: [email protected]
Incorporating violence prevention into anticipatory guidance for well child visits
Virginia Cynthia
M
McCarthy, Hobbie,
MS, MPH,
uch that has been written about violence prevention starts with early adolescence and the prevention of violent acts during that period. Interventions early in a child’s life that promote positive nonviolent parenting can have an impact to prevent the violence that occurs in school-aged children and adolescents. Violence prevention can be addressed in some way at every well child visit. A good start is to help parents of newborn babies manage their stress and to give them tools for coping with the fussiness and crying of infancy and the conflicts that occur later as their children grow and develop. If parents have problem-solving skills that are peaceful, they model this behavior for their children. Role modeling is the most powerful way to influence a child’s behavior. Hopefully, this will prevent the violent acting out
222
CPNP,
Child Visits
and
CPNP
that seems to occur so often in later childhood and adolescence. There are some important principles for positive nonviolent parenting. 1, Conflict is real, and learning skills to manage conflict helps prevent violence. 2. Anger is a normal response, and helping children to talk about their angry feelings and find safe ways to handle thosefeelings is important. 3. Spanking usually does not work to resolve conflict; it teaches that hitting is okay and models violent behavior. 4. Alternative methods of teaching self discipline such as providing time Virginia McCarthy Cynthia
Hobbie
is a CPNP at Children’s is a CPNP at Children’s
J Pediatr Health Care. (1997). Copyright
Parenting is very difficult, and parents do not always take the time
Health Care in St. Paul, Minnesota. Health Care in St. Paul, Minnesota.
7 7,222-226.
0 1997 by the National
0891.5245/97/$5.00+0
out, redirecting behavior, pointing out natural consequences,providing positive reinforcement, giving quality time, and ignoring aberrant behaviors are usually more efective. 5. Respect within a family helps to keep violent situations from occurring. 6. Positive parenting includes spending time every day with each child doing something fun, such as reading a story, going for a walk, or playing a game; the activity can be a simple and lastfor just a short time. 7. It is important for parents to frequently tell children that they love them.
Association
of Pediatric
Nurse Associates
& Practitioners.
25/l/83181
SeDtembedOctober
1997
PATIENT
MANAGEMENT
to care for themselves. It is important for them to find ways to handle their own stress and anger. They need to nurture their relationships with their partners and other supportive adults. Parents who are experiencing a high degree of stress in their lives are at risk for reacting toward their children in a violent way. It is valuable for health care providers to help parents realize the connection between nonviolent parenting and taking care of themselves. This can include directing parents to resources within institutions and communities where they might find help with their situations. An important component of nonviolent parenting is understanding normal growth and development. When health care providers give parents an understanding of what to expect in the next stage of their child’s development and the tools to deal with normal behavior, parents are more prepared to respond in a nonviolent manner. There are some critical milestones when intervention has a long-term impact. The following guidelines for violence prevention can be incorporated into routine anticipatory guidance for well child visits. l
l
l
McCarthy
EXCHANGE
Newborn visit: Discuss crying, what it means, and specific ways to handle it; discuss shaken baby syndrome; and discuss ways to handle post partum blues and the extreme fatigue that new parents experience from sleep deprivation Two-week visit: Reinforce the things discussed at the newborn visit, especially management of fussiness and parental self care; explain that feelings of frustration are normal for most new parents. TWO- to four-month visit: Emphasize enjoyment of the baby, things parents can do to stimulate and interact with the baby, and management of colic and normal
JOURNAL OF PEDIATRIC HEALTH CARE
l
l
l
l
l
fussiness; discuss different temperaments; check parent support systems and encourage time separate from the baby; again, emphasize the importance of not shaking the baby. Six- to ten-month visit: Discuss issues related to mobility such as accident prevention, poisoning prevention, gun safety, and child proofing the household to prevent potential conflict resulting from a curious mobile child; introduce the concept of redirecting behavior and give parents concrete examples of ways to use it. Twelve- to fifteen-month visit: Continue discussion of discipline by introducing time out, redirecting behavior and providing positive reinforcement, with specific details about how to use these techniques with the child; discuss temper tantrums; reinforce making the home child proof; begin discussing potty training. Two- to four-year visit: Discuss behavior management and parents’ management of their own anger; discuss helping the child learn conflict resolution in relationships with siblings and peers; discuss television viewing and media violence; discuss Early Childhood Family Education (ECFE) and Head Start programs; continue the discussion of potty training. Kindergarten visit: Discuss relationships with friends and school peers, including how to manage bullying, and specific measures the, child can use to manage anger; reinforce the importance of positive parenting that promotes positive self esteem in the child; discuss participation in sports and healthy attitudes about competition; review gun safety again. Seventh grade visit: Continue to assess for bullying in relationships; assess the child’s ability to manage anger and provide appropriate education on managing anger for the child and
l
& Hobbie
the parents; encourage exercise and sports participation and a healthy attitude toward competition; explain that positive parenting now needs to include promoting autonomy; find out whether the child has access to alcohol, tobacco, and guns; discuss how school is going and whether the child feels connected to peers and to teachers. Adolescent visits: Discuss preventive measures such as stress and anger management and problem-solving skills to deal with family, school, and relationship difficulties; discuss specific experiences of violence that can occur during adolescence, such as gang activity, date rape, and loss of self control as the result of drug use; again, discuss whether the child has friends and whether the child feels connected to some adult in a meaningful way.
It is difficult to fit all of these things into an anticipatory guidance visit. If there seems to be more to talk about and the time has run out, schedule the child and parents or the adolescent back for another visit. If things seems to be more than can be handled in the time available, arrange for a social worker or other resource person to talk with families or individuals. Try to refer the parents and child to community resources whenever that is appropriate. There are always the problems that arise when working with parents who have never had a positive-parenting role model or have definite ideas about disciplining children in a negative way instead of teaching the child self-discipline in a positive way. It is much easier to address these problems when a relationship of trust has been established between the parents and the provider. Care must be taken to explore these parents’ experiences and not be critical of their methods while helping them change to a
September/October 1997
223
PATIENT MANAGEMENT
EXCHANGE
more positive philosophy about discipline. It is helpful to reinforce the positive things that they are doing and engage them in finding alternatives to the negative methods they are using to manage behavior. All families have strengths and should build on those strengths. Educational materials that are at a simple reading level, are concisely presented, and include specific suggestions are often appreciated. The Violence Prevention Tip sheets (see pages 224-226) were developed by the authors and are available in the clinic in a rack by the appointment desk where people can help themselves or are given when it seems appropriate. Whenever possible, review the handouts in person to make sure that the parents understood the material.
Violence
in the
McCarthy & Hobbie
1T
Preventing
gun violence
Get rid of guns in your home. If this is not possible, keep guns unloaded in a locked area. Store the ammunition in a different, safe spot. Limit how much your child watchesTV or plays with video gamesthat involve gun violence. Don’t give your children toy guns for play. Encourage nonviolent play Know the gun situation in the homes where your children go to visit. Support gun control laws.
*CMdremi5 HEAL,”
*
CARE
home
Children often feel responsiblefor the violence in their homes. This may be becauseconflict and violence often are related to how women function asmothers and homemakers,and their beliefs on raising children. Children who are exposedto conflict and violence in their homes may have:
Girls may have more stomachachesand headaches,and are more withdrawn. Preschoolersoften act frightened a lot and are irritable. If violence and conflict have become a part of your home do something to stop it. Talk with us. Call a help line. Each of us deserves the best of life.
. Sleeping and eating routines disrupted . Few friends l
*
+
Complaints of stomachaches and headaches
St. Paul Domestic Abuse Intervention
Project . . . . . . . . . .. . .. . . . . . . . . 6452824
Wilder Community Assistance Program.,.....................,....,...........221-0048
. Lessparticipation in activities Family Service.... . . . . . ,.......... ..*......222-03
11
. Wetting accidents and increased thumb sucking
Women’s Advocates . . . . . . . . . . .. . .. .. . . . . 227-8284
. Poor self-confidence
Minnesota Coalition for Battered Women.................... .....................646-0994
. Poor school performance and attendance Boys who are exposedto violence in the home are often more aggressive and
disruptive.
224
Volume 11 Number
5
Ctiag HEALlH CARE
JOURNAL OF PEDIATRIC HEALTH CARE
!‘?f’PATlENT !
MANAGEMENT
McCarthy & Hobbie
EXCHANGE
Bullying *
If a bully is bothering your child: *
Let your child know that she or he is not to blame. Listen and take seriously what is said about the bully.
l
Review the choiceswith your child. Often the children who are bullied are shy and nonaggressiveand it is not realistic to expect their personalities to change. Suggestthat she or he look the bully in the eye, say, “I don’t like your teasing,” and then walk away.
l
Talk with the school principal, teachers, and with other parents. Call the Parent Warmline at 813-6336 for free advice over the telephone.
l
Tell your child to stay close to the adult who is supervising the playground.
l
* Have your child go inside as soon as the bully appears in the neighborhood. Transfer your child to another school.
l
l
*
l
Encourage other friendships. There is safety in being with others and your child will want to have friends, anyway. Invite friends over and encourage your child to join clubs or teams.
If all else fails, parents can file a complaint with the police. Many times the police can offer other suggestionsto help deal with a bully.
l
Praiseyour child for facing up to his or her fears of the bully. Remember that going to school knowing that one may be bullied is an act of bravery.
HEALTH CARE
Keep the TV but . . .
1 l
l
Help me, I’m angry
Pay attention to what your child watches.
Anger is a feeling. It isn’t a bad thing, but all of us have to be careful about what we do and say when we feel angry. Here are some safe things to do:
Put a TV in a general area, not in a child’s bedroom.
l l
Limit TV watching to two hours or less each day (help your child make choices of what to watch).
l
Watch TV with your children
l
Ask questions
l
l
like:
-
Do you think this is real or pretend?
-
Is this how we do things at our house?
-
What do you think would happen if you did that?
l
Share your feelings violent activity.
of disapproval
Close your eyes and imagine you are hearing what your child is about to hear. If someone else can watch your child, go outside and take a walk.
l
Remember
l
Call a friend who knows how to listen
l
9
Take a deep breath and let it out. Do this a second time. Do it again.
that you are the adult.
*
If you really feel out of control, then call the crisis intervention center at347-3161.
about
Interpret the TV news for your child. Talk about the consequences for actions.
HEALTH CARE
HEALTH CARE
JOURNAL
OF PEDIATRIC
HEALTH
CAKE
September/October
1997
2 2 5
PATIENT MANAGEMENT
Smart
EXCHANGE
McCarthy & Hobbie
discipline
. Tell your children you are pleased when
l
they behave well and cooperate.
. Avoid only pointing out mistakes. Children learn how to behave by watching the adults who care for them. Avoid power struggles by using distraction or by giving choices.
Talk about angry feelings with your children.
l
l
Spend time every day giving each child your complete attention. Do something fnn: read a book together, take a walk, play catch, or do some other simple
When a behavior can’t be ignored, use a time-out in a firm but gentle way. (We suggest one minute for each year of age. So, a 3-year-old would have a 3-minute time-out.)
l
Try to sort out the reasons for these feelings in yourself, and in your child. Say “I love you” to your children Say it a lot.
Remember: Parenting is hard work! Spanking is not recommended because it . . doesn’t work and it teaches that hitting is okay. *
HEALTH
Availability
CARE
of-JOURNAL Back Issues
As a service to our subscribers, copies of back issues of Journal of Pediatric Health Cave for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $10.50 per issue. The following quantity discounts are available: 25% on quantities of 12 to 23, and 33% on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106 (313) 761-4700.
22 6
Volume 11 Number 5
JOURNAL OF PEDIATRIC HEALTH CARE
M
McCarthy, Hobbie,
MS, MPH,
uch that has been written about violence prevention starts with early adolescence and the prevention of violent acts during that period. Interventions early in a child’s life that promote positive nonviolent parenting can have an impact to prevent the violence that occurs in school-aged children and adolescents. Violence prevention can be addressed in some way at every well child visit. A good start is to help parents of newborn babies manage their stress and to give them tools for coping with the fussiness and crying of infancy and the conflicts that occur later as their children grow and develop. If parents have problem-solving skills that are peaceful, they model this behavior for their children. Role modeling is the most powerful way to influence a child’s behavior. Hopefully, this will prevent the violent acting out
222
CPNP,
Child Visits
and
CPNP
that seems to occur so often in later childhood and adolescence. There are some important principles for positive nonviolent parenting. 1, Conflict is real, and learning skills to manage conflict helps prevent violence. 2. Anger is a normal response, and helping children to talk about their angry feelings and find safe ways to handle thosefeelings is important. 3. Spanking usually does not work to resolve conflict; it teaches that hitting is okay and models violent behavior. 4. Alternative methods of teaching self discipline such as providing time Virginia McCarthy Cynthia
Hobbie
is a CPNP at Children’s is a CPNP at Children’s
J Pediatr Health Care. (1997). Copyright
Parenting is very difficult, and parents do not always take the time
Health Care in St. Paul, Minnesota. Health Care in St. Paul, Minnesota.
7 7,222-226.
0 1997 by the National
0891.5245/97/$5.00+0
out, redirecting behavior, pointing out natural consequences,providing positive reinforcement, giving quality time, and ignoring aberrant behaviors are usually more efective. 5. Respect within a family helps to keep violent situations from occurring. 6. Positive parenting includes spending time every day with each child doing something fun, such as reading a story, going for a walk, or playing a game; the activity can be a simple and lastfor just a short time. 7. It is important for parents to frequently tell children that they love them.
Association
of Pediatric
Nurse Associates
& Practitioners.
25/l/83181
SeDtembedOctober
1997
PATIENT
MANAGEMENT
to care for themselves. It is important for them to find ways to handle their own stress and anger. They need to nurture their relationships with their partners and other supportive adults. Parents who are experiencing a high degree of stress in their lives are at risk for reacting toward their children in a violent way. It is valuable for health care providers to help parents realize the connection between nonviolent parenting and taking care of themselves. This can include directing parents to resources within institutions and communities where they might find help with their situations. An important component of nonviolent parenting is understanding normal growth and development. When health care providers give parents an understanding of what to expect in the next stage of their child’s development and the tools to deal with normal behavior, parents are more prepared to respond in a nonviolent manner. There are some critical milestones when intervention has a long-term impact. The following guidelines for violence prevention can be incorporated into routine anticipatory guidance for well child visits. l
l
l
McCarthy
EXCHANGE
Newborn visit: Discuss crying, what it means, and specific ways to handle it; discuss shaken baby syndrome; and discuss ways to handle post partum blues and the extreme fatigue that new parents experience from sleep deprivation Two-week visit: Reinforce the things discussed at the newborn visit, especially management of fussiness and parental self care; explain that feelings of frustration are normal for most new parents. TWO- to four-month visit: Emphasize enjoyment of the baby, things parents can do to stimulate and interact with the baby, and management of colic and normal
JOURNAL OF PEDIATRIC HEALTH CARE
l
l
l
l
l
fussiness; discuss different temperaments; check parent support systems and encourage time separate from the baby; again, emphasize the importance of not shaking the baby. Six- to ten-month visit: Discuss issues related to mobility such as accident prevention, poisoning prevention, gun safety, and child proofing the household to prevent potential conflict resulting from a curious mobile child; introduce the concept of redirecting behavior and give parents concrete examples of ways to use it. Twelve- to fifteen-month visit: Continue discussion of discipline by introducing time out, redirecting behavior and providing positive reinforcement, with specific details about how to use these techniques with the child; discuss temper tantrums; reinforce making the home child proof; begin discussing potty training. Two- to four-year visit: Discuss behavior management and parents’ management of their own anger; discuss helping the child learn conflict resolution in relationships with siblings and peers; discuss television viewing and media violence; discuss Early Childhood Family Education (ECFE) and Head Start programs; continue the discussion of potty training. Kindergarten visit: Discuss relationships with friends and school peers, including how to manage bullying, and specific measures the, child can use to manage anger; reinforce the importance of positive parenting that promotes positive self esteem in the child; discuss participation in sports and healthy attitudes about competition; review gun safety again. Seventh grade visit: Continue to assess for bullying in relationships; assess the child’s ability to manage anger and provide appropriate education on managing anger for the child and
l
& Hobbie
the parents; encourage exercise and sports participation and a healthy attitude toward competition; explain that positive parenting now needs to include promoting autonomy; find out whether the child has access to alcohol, tobacco, and guns; discuss how school is going and whether the child feels connected to peers and to teachers. Adolescent visits: Discuss preventive measures such as stress and anger management and problem-solving skills to deal with family, school, and relationship difficulties; discuss specific experiences of violence that can occur during adolescence, such as gang activity, date rape, and loss of self control as the result of drug use; again, discuss whether the child has friends and whether the child feels connected to some adult in a meaningful way.
It is difficult to fit all of these things into an anticipatory guidance visit. If there seems to be more to talk about and the time has run out, schedule the child and parents or the adolescent back for another visit. If things seems to be more than can be handled in the time available, arrange for a social worker or other resource person to talk with families or individuals. Try to refer the parents and child to community resources whenever that is appropriate. There are always the problems that arise when working with parents who have never had a positive-parenting role model or have definite ideas about disciplining children in a negative way instead of teaching the child self-discipline in a positive way. It is much easier to address these problems when a relationship of trust has been established between the parents and the provider. Care must be taken to explore these parents’ experiences and not be critical of their methods while helping them change to a
September/October 1997
223
PATIENT MANAGEMENT
EXCHANGE
more positive philosophy about discipline. It is helpful to reinforce the positive things that they are doing and engage them in finding alternatives to the negative methods they are using to manage behavior. All families have strengths and should build on those strengths. Educational materials that are at a simple reading level, are concisely presented, and include specific suggestions are often appreciated. The Violence Prevention Tip sheets (see pages 224-226) were developed by the authors and are available in the clinic in a rack by the appointment desk where people can help themselves or are given when it seems appropriate. Whenever possible, review the handouts in person to make sure that the parents understood the material.
Violence
in the
McCarthy & Hobbie
1T
Preventing
gun violence
Get rid of guns in your home. If this is not possible, keep guns unloaded in a locked area. Store the ammunition in a different, safe spot. Limit how much your child watchesTV or plays with video gamesthat involve gun violence. Don’t give your children toy guns for play. Encourage nonviolent play Know the gun situation in the homes where your children go to visit. Support gun control laws.
*CMdremi5 HEAL,”
*
CARE
home
Children often feel responsiblefor the violence in their homes. This may be becauseconflict and violence often are related to how women function asmothers and homemakers,and their beliefs on raising children. Children who are exposedto conflict and violence in their homes may have:
Girls may have more stomachachesand headaches,and are more withdrawn. Preschoolersoften act frightened a lot and are irritable. If violence and conflict have become a part of your home do something to stop it. Talk with us. Call a help line. Each of us deserves the best of life.
. Sleeping and eating routines disrupted . Few friends l
*
+
Complaints of stomachaches and headaches
St. Paul Domestic Abuse Intervention
Project . . . . . . . . . .. . .. . . . . . . . . 6452824
Wilder Community Assistance Program.,.....................,....,...........221-0048
. Lessparticipation in activities Family Service.... . . . . . ,.......... ..*......222-03
11
. Wetting accidents and increased thumb sucking
Women’s Advocates . . . . . . . . . . .. . .. .. . . . . 227-8284
. Poor self-confidence
Minnesota Coalition for Battered Women.................... .....................646-0994
. Poor school performance and attendance Boys who are exposedto violence in the home are often more aggressive and
disruptive.
224
Volume 11 Number
5
Ctiag HEALlH CARE
JOURNAL OF PEDIATRIC HEALTH CARE
!‘?f’PATlENT !
MANAGEMENT
McCarthy & Hobbie
EXCHANGE
Bullying *
If a bully is bothering your child: *
Let your child know that she or he is not to blame. Listen and take seriously what is said about the bully.
l
Review the choiceswith your child. Often the children who are bullied are shy and nonaggressiveand it is not realistic to expect their personalities to change. Suggestthat she or he look the bully in the eye, say, “I don’t like your teasing,” and then walk away.
l
Talk with the school principal, teachers, and with other parents. Call the Parent Warmline at 813-6336 for free advice over the telephone.
l
Tell your child to stay close to the adult who is supervising the playground.
l
* Have your child go inside as soon as the bully appears in the neighborhood. Transfer your child to another school.
l
l
*
l
Encourage other friendships. There is safety in being with others and your child will want to have friends, anyway. Invite friends over and encourage your child to join clubs or teams.
If all else fails, parents can file a complaint with the police. Many times the police can offer other suggestionsto help deal with a bully.
l
Praiseyour child for facing up to his or her fears of the bully. Remember that going to school knowing that one may be bullied is an act of bravery.
HEALTH CARE
Keep the TV but . . .
1 l
l
Help me, I’m angry
Pay attention to what your child watches.
Anger is a feeling. It isn’t a bad thing, but all of us have to be careful about what we do and say when we feel angry. Here are some safe things to do:
Put a TV in a general area, not in a child’s bedroom.
l l
Limit TV watching to two hours or less each day (help your child make choices of what to watch).
l
Watch TV with your children
l
Ask questions
l
l
like:
-
Do you think this is real or pretend?
-
Is this how we do things at our house?
-
What do you think would happen if you did that?
l
Share your feelings violent activity.
of disapproval
Close your eyes and imagine you are hearing what your child is about to hear. If someone else can watch your child, go outside and take a walk.
l
Remember
l
Call a friend who knows how to listen
l
9
Take a deep breath and let it out. Do this a second time. Do it again.
that you are the adult.
*
If you really feel out of control, then call the crisis intervention center at347-3161.
about
Interpret the TV news for your child. Talk about the consequences for actions.
HEALTH CARE
HEALTH CARE
JOURNAL
OF PEDIATRIC
HEALTH
CAKE
September/October
1997
2 2 5
PATIENT MANAGEMENT
Smart
EXCHANGE
McCarthy & Hobbie
discipline
. Tell your children you are pleased when
l
they behave well and cooperate.
. Avoid only pointing out mistakes. Children learn how to behave by watching the adults who care for them. Avoid power struggles by using distraction or by giving choices.
Talk about angry feelings with your children.
l
l
Spend time every day giving each child your complete attention. Do something fnn: read a book together, take a walk, play catch, or do some other simple
When a behavior can’t be ignored, use a time-out in a firm but gentle way. (We suggest one minute for each year of age. So, a 3-year-old would have a 3-minute time-out.)
l
Try to sort out the reasons for these feelings in yourself, and in your child. Say “I love you” to your children Say it a lot.
Remember: Parenting is hard work! Spanking is not recommended because it . . doesn’t work and it teaches that hitting is okay. *
HEALTH
Availability
CARE
of-JOURNAL Back Issues
As a service to our subscribers, copies of back issues of Journal of Pediatric Health Cave for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $10.50 per issue. The following quantity discounts are available: 25% on quantities of 12 to 23, and 33% on quantities of 24 or more. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, or call (800) 453-4351 or (314) 453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues are available from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106 (313) 761-4700.
22 6
Volume 11 Number 5
JOURNAL OF PEDIATRIC HEALTH CARE