Abstract
This article provides knowledge translation on up-to-date parenting strategies (pearls of wisdom). These pearls support the development of specific skills in children from birth through 5 years of age. Paediatricians have indicated that they feel inadequately trained in providing parenting guidance. This article could be used by family physicians, community health nurses, nurse practitioners, and paediatricians as an office reference when providing anticipatory parenting guidance and when there are parent or clinician concerns that relate to various developmental stages. Included are general tips for guiding parents and pearls that support self-regulation, attachment, perspective taking, and developing the child’s sense of self. The present review links pearls to specific reference sources in the literature which cite developmental standards and advice. Evidence-based parenting programs are cited for children with more complex presentations due to developmental, regulatory, or behavioural disorders, temperament individual differences, or limited parenting support. Website links for parents are recommended, and Parenting Pearls handouts provided, to solidify understanding and follow through.
Keywords: Child development, Child behavior, Parenting
“We must not blame the child for his behaviour…we must try to understand why the problem has developed [and teach the lacking skill: Difficulty meeting expectations communicates a lacking skill (1–3). Self-regulation and problem-solving are skills the child can apply to numerous situations (2–7). The less skills are used, the more co-regulation and contribution to the collaborative problem-solving the parent provides (5,7–10).] Tolerance and understanding of a child’s developing mind are important…parents need to model respect and sensitivity to emotion…the child needs love and security at all times, love particularly when he is ‘misbehaving’…reprimands must be kept to a minimum…where possible, he should make amends for damage caused” (11). That parenting synopsis, described 60 years ago, during the beginnings of developmental-behavioural paediatrics, is now empirically validated (12–14). The current article builds on updated evidence-based developmental attainments charts by providing pearls of wisdom that support the development of specific skills in children during the first 6 years (15). The impetus for this update comes from feedback from Canadian paediatric residency program graduates regarding the significant gap between the importance of parenting guidance in well-child care and their feeling inadequately prepared during the first 5 years of practice [‘Parent/them/their’ is used to represent the primary caregiver; he/him/his, the child of any gender.] (16).
Many pearls represent components of evidence-based parenting programs, in which attachment relationships of the child toward his caregivers are recognized as essential in shaping brain development (4,5,7,10,13,17–19). Other pearls represent an integration of these components with interpersonal neurobiology (IPNB) literature (1,6,8,19–23) highlighting the critical importance of self-regulation to the structure and function of the developing brain and long-term functional skills across the wide range of adult domains including psychological, social, academic, and health (8,9). Self-regulation is the foundational skill for parents to continually teach and support (9). Including pearls from classic sources fortifies the translation of current standard of practice (24–28).
Parents are critical intervention participants for supporting child development (9). In Canada, 38% of parents have development or behaviour concerns (29). Clinicians who support those families use knowledge of child development to provide parenting guidance for ‘problems’ (such as tantrums, aggression, bedtime stalling, fears) that occur predictably at specific typical developmental stages, thereby preventing developmental, regulatory, or behavioural disorders (12,13). Evidence-based parenting programs are recommended for children with more complex presentations due to disorders, temperament individual differences, or parental interest, stressors, or limited support (https://incredibleyears.com/programs/parent/, https://www.triplep-parenting.ca, https://positivedisciplineeveryday.com).
GENERAL TIPS FOR CLINICIANS GUIDING PARENTS
Address parenting challenges
Acknowledge that parenting young children can be exhausting; validate parent stressors; praise parents for their efforts; refer parents to community parenting programs (13). Follow-up in < 3 months and consider behavioural disorder screening or specialist referral if no improvement (30).
Examine parents’ concerns and needs
Use developmental surveillance tools [such as standardized developmental screening instrument or https://www.rourkebabyrecord.ca/ developmental surveillance checklist] to detect clinical concerns; ask parents about their concerns; share your concerns (13,31). When parents acknowledge concerns, they are more likely to listen to advice (30). Respect parents’ goals for their child and help them problem-solve how to apply strategies within their individual family cultural values (10,13).
Ensure parental expectations match the child’s developmental level
Through surveillance, ‘estimate the age’ of the child’s skills in each developmental sector and provide parenting guidance customized to those levels (13).
Enhance parenting strategies
Help parents coach one or two skills at a time (13) using model (shows child skill), prompt (tells child what to do), and praise (descriptive commenting on what he did) (18). Give feedback and help them understand their child’s point of view (13). Offer handout or website to solidify understanding and follow through (30) [<https://www.zerotothree.org> <https://incredibleyears.com/parents-teachers/articles-for-parents/> <https://cccf-fcsge.ca/ece-resources/topics/parenting/> <http://raisingchildren.net.au>]. Parenting Pearls handouts are available at Paediatrics & Child Health Online (Supplementary Materials).
FOUNDATIONAL PEARLS—SELF-REGULATION
Calming in infancy
Newborn.
He recovers from distress with sensory help from parent (8). Calming with the same parent over time will bring connection for relationship growth (8). His earliest way to communicate distress is nonverbal (facial expressions, eye gaze, tone of voice, response timing and intensity, body movements) (19). Children primarily feel understood from nonverbal mirroring of their emotions and thoughts (8).
As a parent, you are a ‘baby scientist’ (17). Over the first month, you will learn to interpret different cries for hunger, fatigue, loneliness, or pain. By responding consistently to cries for help, you will build trust. Your responses will vary depending on why he is crying but may include feeding, burping, changing, cuddling, carrying, rocking, and swaddling (17,24,32).
Your baby may become overstimulated (gaze averted, limp arms and hands, frowning face) and may need a break (24).
For colic, when comforting techniques do not work, place your baby in the crib and dim the lights to reduce stimulation and give both of you a break. Stay close. If your baby has not settled, repeat routine of soothing followed by a break until fussing is over (17).
6 months.
He will soon develop object permanence and will therefore know that his parent continues to exist when out of sight (4). However, he will feel separation anxiety because he does not yet know that his parent will come back (25).
To develop separation security, initiate a predictable separation routine: Say goodbye; tell him who will be watching him and when you will be back. His distress will decrease as he gets used to this routine and learns that you always return, setting the stage for healthy separations (18).
Coping with overwhelming emotions
15 months +.
Tantrums are a stress response indicating the child’s window of tolerance has broken (19); they peak at 30 months (4). Helping him recover over time develops self-soothing and widens his window of tolerance (19). Follow Tantrum ‘Prevention → In the moment → After’ Steps (Table 1).
Table 1.
Coping with overwhelming emotions
15 months +. |
---|
Tantrum ‘Prevention’ steps (18): •Keep your relationship with your child strong by being caring and empathetic and by playing with him daily. •Keep predictable routines (ensure your child is well rested and fed). Routines also help him feel secure and reduce stress. •If your child has slept poorly or is not feeling well, reduce expectations. •Understand your child’s triggers (such as sudden transitions, waiting for turn) and be prepared to help him navigate these situations (prepare him in advance to give him time to adjust, “First it is her turn to throw the ball, then your turn.”). •Offer choices when possible (instead of saying no). •When he is calm, mirror his positive emotions (such as curious, excited, proud) to increase their frequency. •Offer specific praise to build confidence and to reinforce the behaviours that you want to see (‘Wow- nice sharing!’). Tantrum ‘In the moment’ and ‘After’ Steps: 1) Ensure safety: Remove him from the situation and stay calm so he feels reassured and connected. Changing location also helps him forget (4,18,20). 2) Soothe: Use strategies that fit your culture. Try cuddling or rocking; reassure him vocally ‘You’re okay; I’m here’; mirror his emotion with facial expression, vocal tone, and naming it with a word (‘You’re so mad’.). Look for your child’s cues to see what helps or hinders his recovery (8,18). 3) Maintain proximity: If soothing does not help or worsens his distress, stop soothing efforts and stay nearby so he feels secure; soothe him once he starts to calm (4,10). 4) Redirect: Distraction and coping statement help him learn to self-soothe; use a calming object such as a toy or a special blanket (“Hold your blankie; then you’ll feel better.”) (8,18). •Praise: As soon as the tantrum is over, praise his calming down (“You’re feeling better now.”) (18). •Avoid missing a ‘teachable moment’ through giving him the object that precipitated the tantrum (18). •When you help your child recover from stress, he will learn to self-soothe in time, and his tolerance for difficult emotions will increase (19). |
24 months +. A 2-year-old might seek help from an adult and might, with adult help, think of solutions to problems (4). At 2, he might express a simple feeling of his and, at 4, define the problem that caused a negative feeling (4). With adult help, at 4 he might choose the best solution to try, to prevent the problem from recurring, and later review what worked (33). |
Tantrum ‘After’ Steps: Process the Event using problem-solving(when calm) 1) Identify how he is feeling and the problem (“You were disappointed. You wanted the orange cup and they are all gone.”) (3,4,8). 2) Invite solutions (ideas) for next time (“Next time it will be your turn to have the orange cup.”) (3,8). 3) Offer choices of best solution to try (“Do you want the blue cup or the green cup today?”) (3). 4) Offer praise and redirect (“Good thinking of ideas! Do you want milk or water?”) (4). 5) Give short consequence that makes sense to coach him what to do (‘Let’s pick up the cup you threw’.). Try to pair this with redirection (‘Then it will be time to go outside to play’.) (7,22). |
15 months +. |
Aggression ‘Prevention’ Steps (18): •Use Tantrum ‘Prevention’ Steps Aggression ‘In the moment’ and ‘After’ Steps (18): 1) Ensure safety: Remove the trigger, separate the children, assess for injury. 2) Remind him of rule: ‘No biting’ said firmly but kindly. 3) Soothe + maintain proximity: Approach and offer a gentle touch; stay nearby until calm. 4) Redirect: Help him to forget by redirecting him to another activity. •Praise his calming down; avoid giving him the object that precipitated the tantrum. |
24 months +. |
Aggression ‘After’ Steps: Process the Event using problem-solving(when calm) •Prevention: Teach your child coping skills to handle stressors (“When you feel frustrated, use your words: truck please.” or “Get your blanket.”) (18,26). •Coach self-assertion to the child who was hurt (“When he pushes, say No! I don’t like that.”) (18). •Teach your child to make amends with an act of kindness or service. This can help him feel relief and pride (26). •Offer praise and redirect your child to another activity (18). |
© Dosman C, Koscielnuk D, Gallagher S 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
3 years +.
He now has the cognitive and language abilities to, with parent help, learn relaxation strategies to prevent tantrums (18) and process the event once he has calmed (4). He begins to self-regulate (18), but only controls his emotions a minority of the time (4). Fears are common (Table 2). Between 3 and 6 years, there will be a dramatic increase in his self-calming abilities (4), using self-talk, distraction, and perspective taking (understanding others’ thoughts and emotions) (34).
Table 2.
Coping with fears
24 months. Fears are common at 2–3 years, because of the child’s imagination and understanding he can get hurt (4). Since he does not yet know the difference between real and pretend, he may fear the dark, monsters, animals, or disappearing down the bath drain or toilet (4). He starts to express emotions (through pretend play or words) (8). |
•Encourage your child to name his fear; reassure, stay with child, or use nightlight. Your child may also lose fear through exploring how a feared object works (playing with toys of the feared situation) (25). |
36 months. |
•Ask your child to tell you about or draw his fear, as these help him understand and lose his fear. Your child will feel comfort when you listen to him (20,25). |
4 years. The 4-year old’s verbal self-talk has changed to internal dialogue to help him through difficult tasks (4) (“Being in the dark at Grandma’s is scary but my invisible superhero cape makes me brave.”). |
•If your child has a slow-to-warm temperament, accept his sensitivity, acknowledge his distress (“I understand how hard it is for you to feel comfortable with…”), and support him in thinking of solutions (“When you are ready, let’s do this together.”). Praise his efforts to reach out to others (“You were really brave.”) and value his caution (“You have a special way of observing and doing things when you are ready.”) (26). |
© Dosman C, Koscielnuk D, Gallagher S 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
Coping with aggressive impulses
15–36 months.
Aggression (especially biting) is the most common reaction to disappointment at this age, used to protest and request due to his limited ability to express his emotions and needs verbally (18); he relies on his parent for regulation (8).
36 months +.
He still needs his parent’s help calming when stressed (4). It is not until 4 to 6 years that using words instead of aggression will increase dramatically (4,18). If he needs solitude to calm, he may tolerate time-out for safe calming, because he has developed object constancy (remembers his parent for long periods of time) (4,18). Feeling remorse and starting to understand what is right and wrong help him make amends (4).
If your child does not soothe from your help or you are unable to stay calm, place your child in a safe place to calm. Stay close so that your child feels secure and not alone in his distress. If he does not calm within a short time, try again to soothe him (21).
Aggression may not resolve immediately, but years of coaching will help him develop the skill of impulse control and, in the meantime, feel less afraid of his aggressive feelings (26).
Self-calming and impulse control
Toddlers and young children need coaching from their parents to recognize their emotions, self-calm, and control their impulses (18) (Table 3). This learning will proceed gradually over time, but it lays the foundation for the 4-year old to show empathy for the feelings of others and at 5 start to initiate helping and other prosocial skills that benefit others (4).
Table 3.
Self-calming and impulse control
15 months. He might have started self-soothing at 2 months (by sucking his finger or thumb, watching light, shadow, and colour, or rocking his head) (24,32). He now starts to self-calm using a comforting object (such as blanket or stuffed animal) (4,28). Now that he increasingly understands words given without gestural cues (32), when parent uses emotion words, he learns to recognize what he is feeling (18). At 18 months, he will start self-comforting when something belonging to his parent evokes in his memory a mental image of his parent (such as seeing picture of parent’s face, hearing their voice, smelling or touching their clothing) (19). If parent teaches him coping statements, he will start using them as self-talk when he is 3 (18). |
•Emotion coaching: Give empathy by mirroring his emotion with your facial expression, vocal tone, and word (‘You are happy to see Dad.’); naming his positive emotions more often than negative ones increases the frequency of the former. Name his unpleasant emotions and what led to them (‘You wanted to play with that truck. You are frustrated because the truck is broken’). Pair this with a coping statement (‘That’s disappointing. I see you are looking at the trains now - do you want me to help you build the tracks?’) (18). |
24 months. Starting to understand if-then statements helps him know the consequence of a behaviour (18). However, he lacks impulse control and might remember his parent’s “no” only after he has done something not allowed (25). Feeling cared about by his parent will motivate him to please them and be receptive to their coaching (25). |
•Mirror your child’s hard-to-achieve emotions to increase their frequency: ‘It was brave to put your face in the water.’ (for fear aversion) or ‘You waited patiently.’ (for impulsivity) (18). •Prevent impulsivity by offering acceptable substitute activities (“If you want to throw the ball, use the soft ball in the house.”) (25). •Teach impulse control by telling him what to do with an impulse each time he needs to manage it (“You’re mad: say help please.” “You want to grab the doll; ask my turn?”) (25). |
4 years. He starts to think about characteristics that make people the same or different (34). As a result, he compares his skills to others’ and may tease or be teased (26). Because of theory of mind and perspective taking, he starts to listen to others’ point of view and respond to their feelings by comforting them the way they would want (4). |
•If your child is teasing others, coach empathy by telling him how the other child might feel, and coach him to give kind comment or action instead (24). •If your child is teased, give empathy and support (“I saw Billy teasing you. How did that make you feel? You look like you’re feeling sad. I’m going to talk to Billy so he knows it is not okay to tease.”); if he looks hurt, coach confidence repair (“I know Billy was making fun of your hair. I really like your hair - I think it is cool that we all have different hair! Look - mine is red and curly, and yours is black and straight! That makes us different and special!”) (24). Coach a response, such as joking back, saying “Stop! I don’t like that,” or ignoring it while walking away and thinking coping self-talk (35). |
© Dosman C, Koscielnuk D, Gallagher S 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
Following directions to learn skills
15 months +.
Toddlers do not follow most directions (4), because they lack impulse control and are easily distracted, slow to process verbal commands, and driven to feel autonomy (18). He needs constant supervision for his safety and pushes limits because he needs parent to help him meet expectations (18). At 2 years, he starts to understand rules; at 3, he might comply to the majority of ‘stop’ commands but rarely to ‘start’ commands (4). At 4–6 years, he starts to develop a conscience of right and wrong and noncompliance becomes infrequent with parent present (4,25,34).
Following directions can take years to develop. Your child needs many opportunities to practice and learn from mistakes (3). Model respect because your child’s feelings about himself are as important as learning skills (18,19) (Table 4).
Table 4.
Following directions to learn skills
15 months +. |
---|
Ten Tips Toward Creating Structure and Setting Limits •Stay connected with your child so he will more easily stay calm and want to please you (pay attention to his needs, communicate empathy, give relationship time) (8,26). •Predictable daily routines (such as same times for meal, snack, play, chores, sleep) reduce stress, allowing him to learn what to expect in daily activities, and consistent sequence of elements within routines (such as shirt → pants → socks for dressing or bath → pyjamas → reading in bedroom for bedtime routine (last step in bed after transition from crib)) build implicit memory and help him feel safe for self-soothing (10). •Decide what rules are most important (safety, bedtime routine, leaving house on time) so that you reduce directions (commands) to giving only the necessary ones. Follow through on these expectations so he learns this is a reliable rule, not just a one-time direction (18,26). •Provide transition warnings to support your child through a change in routine or a transition between activities. This is especially important when transitioning from a preferred to a non-preferred activity. Talk about the upcoming change, represent it in a visual way such as a picture, and allow for a long transition time (to disengage from one and refocus on the next) (“Two more turns then it is time to go home.”) (12-36m) (10,18). •Get his attention before giving a direction (10). •Give ‘do’ instructions instead of ‘don’t’ instructions; show and tell the expected skill (‘sit down,’ ‘gentle touch,’ ‘no thank you’ to decline food) (18,27). •Distract – During less preferred activities, distract him with talking or toys he likes (be playful while buckling his seatbelt) (18). •Redirect – Instead of saying ‘no’ or ‘stop,’ redirect him to an appropriate activity or use an action to say no (take away object; hold hand to prevent running in street; when he throws his meal (a sign he has finished eating) or complains about the food, say ‘You may be excused.’ and have him leave the table until snack time) (18,24,27). •Praise – Give descriptive comment when he uses a skill that is difficult for him to learn or say the positive effect it has on the other person. Break difficult task into smaller steps and praise effort (‘Thank you for bringing your spoon.’) (10). •Protests/whining/complaints – If he responds to direction with protests, whining, or complaints, stay calm to help him calm, communicate understanding of his distress (‘You want to play with the remote.’) to coach expressing himself calmly, and redirect (‘Let’s see if the cookies are done baking.’) if ‘stop’ direction or help him do the task if ‘start’ direction. Praise his effort to do the task or any other positive action he shows. If protests continue, help him calm in other ways and if this does not help his distress, stay nearby. Help him recognize his calming (‘You’re starting to feel better.’). |
18 months +. Bedtime stalling is common due to drive for autonomy. |
Bedtime Acceptance •Prevent bedtime protests by keeping set sleep times, using a picture schedule to help him understand the steps of the calming bedtime routine, and using a predictable separation routine for security (18). •Ensure needs are met before bedtime (snack, drink, voiding). Reassure your child that you will check in on him; praise him in the morning for staying in his bed (18). •At 3+ years, offer a ‘bedtime pass’, which the child can turn in for one request per night. Other times, return him to bed with minimal interaction and do not give him what he is seeking (36). |
24 months +. At 2 years, he might understand if-then statements for logical consequence of his behaviour (18). With many capable skills, he needs the opportunity to make decisions (be offered choices); he gains self-esteem when his opinion is valued (4). He understands first-then concept because of sequential time memory (19), especially from predictable sequence of routines in the day and predictable sequence within routines (32). |
If-Then Statements (18) •Provide warnings when transitioning from a preferred activity (playing at a friend’s house) to a non-preferred (going home) (“Two more turns then…;” try a visual timer). •Provide choices (“Time to put toys away – do you want to take the tower apart or save it for next time?”). •Follow through with “if-then” consequences (“If you don’t sit, then you will need to leave the table.”). •Try using “first-then” commands (“First, clean up toys. Then, we will go to the park.”). This will help him look forward to something during a difficult task. |
3 years +. He now understands if-then statements (18) and rules (4). He might use self-talk to help himself through tasks (“If I be quiet, Mom will give me a high-five.” (at end of store aisle)) and loves to please and be noticed for “good behaviour” (4). |
Reward System •Try using a reward system (sticker, stamp) when your child demonstrates prosocial behaviour that is difficult for him (“It’s almost time to tidy up before snack. If you put all your toys away when I ask, you can choose a sticker.”) (10). |
<6 years. |
Hand-Over-Hand Assistance •An 18 month old can help with daily chores (with constant help). State the direction. If child follows it, offer immediate descriptive praise (‘Thank you for putting your toys away.’). If child does not follow it, pause to wait 5 seconds to give him time to respond. Repeat the direction if necessary, pause, and then if he again does not try to follow the direction, say ‘Put your toys away; I will help you.’ and provide gentle hand-over-hand guidance (10,18). |
© Dosman C, Koscielnuk D, Gallagher S 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
FOUNDATIONAL PEARLS—ATTACHMENT
Attachment-focused parenting should begin with the newborn and be fostered throughout childhood (20). Spending time with their child and being in tune with his thoughts and feelings and responsive to them strengthens the parent–child relationship and brain growth (19). Parents need to be mentally present, minimizing their screen use to prioritize giving interaction without distractions (37) [Child screen use is ineffective for skill development in the first 2 years and less effective than parental interaction and free play for preschoolers; parents are recommended to disallow screen use for children under 2 (37)].
Attachment building strategies
Newborn.
When his parent reflects baby’s emotional state to him (20) (such as smiling at him when he is calm and happy (10)), he ‘feels felt’ and connected to them (20); this helps him develop interaction skills (32). Calming him and interacting with him during daily routines builds their relationship (8,17).
Spend time enjoying your baby. This will build your relationship and foster his sense of trust in the world. Try interacting with your baby during feeding, diapering, bathing. Be calm, offer face-to-face contact, look him in the eyes according to culture, cuddle closely, talk to him, and smile at him when he is calm and happy. Talking to him throughout the day (descriptive commenting), as if he understands you, will also help his language develop; describe what he is seeing and doing. Speak your home languages to him, so that your interactions feel comfortable. Pause and converse when he responds with movement or pleasure. Prioritize your child’s needs over household chores and visits (10,17,20,24).
4 months.
Comforting contact from his parent brings “falling in love” (8); he starts to play back and forth with them (smiles, eye contact, facial expression, movement) (8,32) which will eventually help him understand theory of mind and perspective taking (20,23). He will signal when he needs ceasing of interaction (loses attention, looks upset, acts too excited) (23,32).
Have fun with this delightful, engaging baby. Pay attention to him through talking, playing, and being responsive to his needs. Respond by imitating his attempts to coo to you (reply when he stops, stop when he replies). When he tries to interact with you by moving or changing his facial expression, respond with playful social games (songs, lifting high in the air) (17).
6 months.
Predictable reunion routines increase security to foster attachment (18,24). He needs parent to prioritize time enjoying him (17) and shows discomfort during interactive play if parent is distracted (8).
After naps or brief separation, use a predictable reunion routine showing your joy and love. Spend time together until you have reconnected, by rocking, singing, talking to him (ask him about his day, tell him how much you missed him) – he will understand the spirit of it if not yet the words (18,24).
When your baby tries to interact with you with vocalization and laughing, respond with playful social games (as above). This will strengthen your bond (17).
12 months.
Children need their parent to be in love with them (26). Relationship time helps him feel valued by them, strengthens their feelings of bond with each other (18), helps self-regulation when parent communicates warmth (8), and models social skills (18). Toddlers start showing the oscillating needs of childhood, between autonomy (needs separation) and security (needs connection); parent watches on ‘standby’ to see his need (20,28).
Build relationship time by scheduling several short (10 + minutes) play times daily. This will help your child understand that you will have more time together soon while also giving each other needed time apart (18).
Relationship building activities include watching him, descriptive commenting on his actions or interests (‘You’re putting the block on the book’.), giving empathy by mirroring (‘You look surprised with…’ or ‘You’re curious’.), imitating his actions, following his lead, and playing with him on topics in which he is interested (3,4,10,18).
Be sensitive to when he needs solitude instead (20).
4 years +.
Relationship time, wherein parent concentrates solely on their child, showing interest in his interests and following his lead in play, continues to strengthen the relationship while modelling social-emotional skills (18).
Foster your relationship by playing with your child for at least 10 minutes daily doing something your child wants to do (3,10).
During play, accept the rules he makes up and let him win; he often has to obey rules throughout the day that he may not like. Try not to ask questions that test his performance; you may occasionally prompt social skills; stop if he ignores the prompt (18).
Continue to give empathy by mirroring (‘You look puzzled’.) and help him see the connection between his behaviour and another’s feelings (‘She is happy because you shared your snack with her’.) (18).
Model social interaction skills by doing what your child asks, joining his imaginary play, listening when he talks, thinking of his point of view, sharing, helping, waiting, taking turns, using a quiet voice, asking politely, thanking him (18).
Consider scheduling a weekly special time (up to 2 hours, child decides what to do) that you and your child look forward to. Multigenerational rituals foster relationships with extended family, such as weekly dinners or annual holiday celebrations (26).
INSIGHT PEARLS—SENSE OF SELF AND OTHERS
He interacts with his mirror image at 4 to 8 months; at 16 months, self-recognition occurs, an early stage of self-awareness (38). The attachment relationship builds the child’s sense of self through feeling understood and having his emotion reflected to him by his parent (20). Gaining insight into himself leads him to understand others’ perspectives, communicate empathy, and, eventually into adulthood, provide co-regulation and secure attachment to others (Table 5) (20).
Table 5.
Insight into self and others
Sense of Self Beginning |
---|
4 months. Having discovered how his hands work by watching them move at 2 months, now through sucking his hand he becomes aware of his own body as separate from his parent’s (17,25). Through back-and-forth play, he delights in learning that his actions result in a response (17). |
•Say your baby’s name when talking. It helps him discover he is a separate and unique person. Help him become aware of his body by playing with you: move his legs like a bicycle, raise your hands for him to kick against, let him stand on your lap, stretch his arms above his head, sing songs with actions such as patty cake. Provide lots of opportunity for free play as he learns to move and discovers its results: kicking at mobile, time in prone, shaking ankle rattles, batting at toys; avoid wearing mittens (17). |
Reflective Dialogue Sequence |
24 months. He starts to recall events and memories of himself, due to speaking in phrases, sequential time memory, and explicit factual memory (19). When his parents engage him in reflective dialogue, they help him verbalize his thoughts and feelings to learn from events (4). It is hard to understand the meaning of a 2-year old’s narrative, because he does not yet sequence his ideas (32). |
•Talk to your child about events (before, during, and after) and what he remembers after experiences (his thoughts and feelings). You can do this after real life experiences or when reading together (19). •Parents can support narrative development by frequently talking about past events (ask him what, where, who, why; add information; respond to what he says); giving explanations; talking about future plans; describing things, people, and events (32). •Reflective dialogue also includes problem-solving. After a ‘problem’ behaviour, he might be able to think about some solutions with your support. However, since he is still driven to explore and can be easily distracted, he will still learn best by being redirected to an appropriate activity and praised for doing it (such as ‘Good drawing on the paper’ if the problem was drawing on the wall) (3,4,18). |
3 years. He might discover his self as a unique identity inside his body, separate from other people’s identity (25). He might talk about his emotions and answer questions by making cause-effect links between events and positive emotions (8,32,34). This helps him self-regulate (4,19,32). |
•Talk to him about what he imagines and feels, and about his thoughts and memories (“Are you sad because you dropped your ice cream?” “How do you feel about Grandma coming to visit?”) (19,32). •A child’s statement “I feel bad” or “I feel good” is likely an accurate appraisal of his primary emotions; he does not always have to differentiate his emotions more specifically (surprise, fear, etc) (19). |
4 years. His narrative now has accurate sequence of events (32), but he relies on adult to keep him focused on the topic without suggesting answers (39). He might talk about negative feelings and recognize situations that elicit them (32,34). Reflective dialogue shapes his autobiographical memories, which he will retrieve in adulthood (especially those experienced with more emotional intensity) and which will help him understand his own life experiences, other people’s thoughts and feelings, and his own cultural identity (19). |
•Ask your child to tell you about a routine event or something that happened on a special occasion. First, use an open-ended question (“Tell me more about…” “What happened?”), followed by more specific questions (“What happened first?”, “Who was there?”) to help your child sequence the events from memory (32,39). •Read baby books together, look at old photos, and keep family traditions (4). |
Perspective Taking Strategies |
3 years. Perspective taking (accurately perceiving and understanding another person’s thoughts, intentions, and emotions) develops gradually throughout childhood and adolescence (39), but it can begin at 3 years once he understands that other people have thoughts, intentions, and emotions that are separate and different from his own in the same situation (theory of mind) (4,19). |
•When reading books, discuss what the characters might be thinking and feeling (4). |
4 years. He lies (denies or blames other) because he understands false belief (believing something that is in reality incorrect) (39). |
•Remain neutral so as not to induce excessive shame (3,39). •To coach moral problem-solving, say the problem (“I see you ate the cake; the problem is I was saving it for company.”), ask why he did that (“I’m wondering what happened?”), understand his feeling (“It’s not easy to resist when you can see it.”), plan a better solution for next time (“Let me know when you want some; I can help you wait.”), help him make amends for upsetting you (“Please get cookies out to serve.”) (3,26,39). |
5 years. His categorizing skills make him compare himself to others; he might brag without recognizing impact on peers (26). |
•Let him know how the peer might feel and perceive him, ask how he would respond to someone showing off to him, and help him choose a better solution for next time (“I know I’m better than him at soccer, but I don’t need to tell him that because that might hurt his feelings and he is trying his best.”) (26). |
Perspective taking fosters his ability to listen to other children’s point of view and more often offer sympathy (4), but he might need help noticing how someone else feels and disagreements are common (34). |
•When he upsets someone, coach perspective taking with problem-solving (‘You and your sister’s friend are having fun playing together. Have you noticed your sister is upset? Why do you think she might be upset? What could you do to help her feel better when her friend is over? Yes, playing by yourself so that they can be alone is a good idea!’) (22). |
Because he is developing a conscience, he may be quite strict to peers about rules (4) and tattle to please the adult (26). |
•Coach perspective taking (‘Do you think she might feel hurt that you got her in trouble?’) and problem-solving (‘Next time, could you ask her to tell me herself?’) (26). |
© Dosman C, Koscielnuk D, Gallagher S 2023. Published by Oxford University Press on behalf of the Canadian Paediatric Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
CONCLUSION
Self-regulation and attachment relationships are foundational in shaping children’s brain development. They lead children to develop insight into self and others. This article presents pearls of wisdom (detailed strategies) that help clinicians guide parents in supporting the critical development of specific skills in their children through the first 6 years of life.
Supplementary Material
ACKNOWLEDGEMENTS
We acknowledge with gratitude Keith Goulden MD DPH FRCPC for the précis of Tantrum ‘In the moment’ Steps (safety, empathy, proximity, distraction); Miranda Holliday and Monika Igali for the Parenting Pearls handouts information design; Infant/Child Mental Health for their input to the Parenting Pearls handouts; Patricia LaBerge M.A. R-SLP for her input to home languages (Attachment Building Strategies) and language samples (Table 2 Coping with fears, Reward System, Perspective Taking Strategies, and Parenting Pearls handouts); Daniella Ongaro MScPT for her input to movement play (Sense of Self Beginning); Carolyn Webster-Stratton, MS, MPH, PhD, Professor Emeritus and Developer of Incredible Years programs, for her collaboration on problem-solving (Reflective Dialogue Sequence); and Debbi Andrews MD FRCPC (1954-2020) who established the general pediatrics resident rotation in developmental pediatrics (University of Alberta) and the teaching of child development and anticipatory guidance on the first day of the rotation. Those roles were subsequently transitioned to Cara Dosman, Sheila Gallagher, and others while Dr. Andrews continued her enthusiastic passion of child development teaching and of inspiring physicians to practice developmental pediatrics, through her leadership roles with medical student and resident elective rotations.
Funding: There are no funders to report for this manuscript.
Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Contributor Information
Cara Dosman, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada.
Dorrie Koscielnuk, Nexus Psychology, Edmonton, Alberta, Canada.
Sheila Gallagher, Division of Developmental Pediatrics, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada.
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