Relationships matter: How clinicians can support positive parenting in the early years

Abstract

A secure attachment relationship with at least one healthy adult is essential for a child to develop optimal coping abilities. Primary care providers like paediatricians and family physicians can help by supporting parents in practice settings. Every clinician encounter is an opportunity to ask parents about children’s relationships and their behaviour, daily routines, and overall family function. This statement, which focuses on children aged 0 to 6 years, describes basic principles in support of positive parenting and recommends in-office practices to promote secure parent–child relationships, engage families and build trust with parents. Crying, sleep, and difficult behaviours are described as opportunities for clinicians to provide anticipatory, responsive guidance to parents.

“Parenting” won’t make children learn – but caring parents let children learn by creating a secure, loving environment. — Alison Gopnik, The Gardener and the Carpenter: What the new science of child development tells us about the relationship between parents and children

Healthy child development depends on the relationships children have with parents and other important people in their lives. Children learn to speak, think, and express emotion from an ‘environment of relationships’, and the parent–child relationship is the one that most strongly affects emotional and behavioural functioning (1). Physicians and other health care providers can engage and support families by observing, assessing, modelling, and assisting these early relationships. This statement proposes the following ‘ABCs’ to help clinicians strengthen relationships with—and within—the families they see:

• Ask questions

• Build on each family’s relational strengths

• Counsel with family-centred guidance

• Develop plans for changing behaviours related to sleep or discipline, as needed, and

• Educate about positive parenting strategies.

Crying, sleep, and difficult behaviours are three issues for which parents often seek advice from a health care provider and, as such, are pivotal opportunities for offering positive parental guidance and resources.

Although workflow and time pressures make integrating such conversations into regular office practice a challenge, the proven benefits of family-centred care in improving long-term parental engagement and health outcomes are indisputable. For many parents, collaborating with a health professional on family issues is empowering, particularly when this conversation is ongoing and combined with practical in-office strategies. Such strategies include proactive, flexible scheduling wherever possible; clear protocols for assessment and follow-up; coordinated effort and communication among staff; and active links with community resources (2–4).

This statement has some limitations:

• It focuses on typically developing children aged 0 to 6 years. Clinicians may need to adapt these approaches for children with special medical or developmental needs.

• Guidance for parenting in conditions of extreme family or community adversity is beyond the scope of this paper.

• Some communities do not have access to the range of resources described here.

• Because parenting is rooted in culture, there may be unique considerations or approaches that are not reflected here. Clinicians should be sensitive to cultural differences in parenting, and adopt an approach that reflects cultural humility: self-reflection, acknowledging personal biases, and developing relationships built on mutual trust (5–7).

THE CLINICIAN’S ROLE IN SUPPORTING POSITIVE PARENTING

Parenting practices are the strongest modifiable determinant of behavioural and emotional health in children (8–12). Challenges with children’s behaviour can arise from a number of different sources.

Regardless of family circumstance, five key principles should always apply when supporting parents:

• 1.Help them build loving, responsive relationships with children, i.e., rich with interaction, predictable, emotionally responsive, and secure (13,14).
• 2.Accept that there are reasons for all behaviours, whether positive or negative. Many challenging behaviours can be managed through secure parent–child relationships, a loving and attentive home environment and purposeful guidance from parents (15–18).
• 3.Help mitigate the impact of early adverse childhood experiences (ACEs, see below) in both children and parents by encouraging protective factors within families (13). Starting with the first well-child visit, look for how a child responds to parents (and vice versa) and reinforce what parents are doing well (14).
• 4.Recognize and respect difference. Family approaches to crying, sleep, and behaviour vary culturally, and navigating points of variance with sensitivity is key to providing culturally safe care.
• 5.Be aware and informed of the parenting literature, credible websites, and books for parents. Build links with at least one trusted, local early years resource (e.g., a public health or community centre) that can help families find and use local resources, including child development and parenting programs, food banks, housing services, legal aid and job centres, literacy supports, and health services (4).

ACEs

Some families you see in practice will have experienced ACEs: stressful or traumatic events in childhood, including abuse, neglect, parental separation or divorce, or witnessing violence. Childhood adversity is common across all socio-economic groups and its effects are cumulative. A strong dose–effect relationship between early life trauma—such as maltreatment, severe parental depression, or poverty—and health risk behaviours and later disease, was demonstrated by Felitti and Anda in the late 1990s and has been substantiated by many studies since (13,19).

‘Toxic’ stress stems from major, frequent, or prolonged periods of adversity and can have early and profound effects across multiple systems: neurological, immunological, psychiatric, and behavioural (20). Early toxic stress puts children at risk for physical, mental, and behavioural problems, and the absence of mitigating factors compounds such effects (13). Recent research on social determinants has further underscored how basic family circumstances impact health and life outcomes (21). However, while adaptive responses to stress during childhood—known as the ‘toxic stress response’—can set a pathway toward negative health (20) and life outcomes, there is good news: caring adults can buffer stress and build resilience in children, even in difficult circumstances or when they are burdened with ACEs themselves (13,22–24).

The vast majority of children (and parents) with emotional and behavioural problems, which can be trauma-related, go unidentified, and untreated (13,24). In the context of a trusting relationship, even opening the conversation around these issues can start an intervention for families.

ASK QUESTIONS

At every visit, clinicians should ask questions about child behaviours, family routines, and overall family function (e.g., “What is your child’s bedtime routine?”).

Consider asking this question with every family you see: “Has anything stressful happened to you [your child] or your family since the last time I saw you?” (13). If a parent describes mental health symptoms—such as depression or feelings of guilt—about any aspect of child care, take time to explore their mental health status and coping strategies, and counsel or refer appropriately. Asking about self-care and routines at home may elicit signals of family stress around money, housing, or serious dysfunction (4,13,25). Screen for depression, substance use, or family trauma when appropriate, using standardized tools (see, for example, www.rourkebabyrecord.ca). Refer children for specialized developmental assessments and interventions as appropriate, but remember that in the meantime, much can be gained by connecting families with community-based early years programs, peer-based support groups, or skills coaching through evidence-based programs such as Triple P Parenting or the Incredible Years (26,27).

The following approaches can increase family engagement and build trust:

• Model interpersonal (attachment-based) communication skills with parents and children. Be open, predictable, kind, and curious. Be nonjudgmental, express confidence in parental choices, ask about feelings, and try to reframe negative exchanges (28) (“I wonder if there’s a more helpful way to think about this behaviour?”).

• To open a pathway for counselling on sensitive issues, ask general questions about a parent’s childhood, such as, “How did your parents help you deal with emotions?” (24).

• Ask about and discuss supports for parents, such as friends, family, or a faith community. Asking “Who do you turn to for support?” may help to identify relational issues or social isolation.

• Motivational interviewing (MI) uses patient-centered communication techniques to help individuals work on challenging issues by talking about why they want to change and taking responsibility for their own behaviour. MI can be used to motivate change, raise parent awareness, and elicit specific concerns (2,22,29,30). Key concepts for clinicians using MI are being empathetic, nonjudgmental, and supportive, and a range of training resources is available online (29).

BUILD ON EACH FAMILY’S RELATIONAL STRENGTHS

By counselling and promoting parenting strategies that nurture and sustain resilience, clinicians can help all families, and particularly those affected by early trauma and toxic stress (13,31).

The following strategies can be useful at every office visit:

• Inquire about protective parenting factors (e.g., a consistent care provider, healthy routines, being read to, using community resources) and health care goals, and positively reinforce improvements (32). Other protective factors may include a parent’s social network, a positive work–life balance, limited family screen time, and a healthy bedtime routine (32).

• Focus on mediating variables that affect daily life but can be changed, such as a parent’s interactional skills or a child’s ability to regulate emotions (33).

• Match guidance and interventions to positive moderators of adversity, such as family strengths or shared cultural values (33).

• Observe parent–child interactions for sensitive, responsive exchanges and model this form of communication in everyday practice: engage directly with young children, be open with parents (31,34), and involve clinic staff in this approach (e.g., in-office counselling reinforced by nursing staff; a receptionist asking about changes in home address or school location).

• Implement regular, reliable in-office routines, such as clinic hours that accommodate working parents and proactive scheduling where possible (“Let’s make an appointment for early next month” versus “Come back if you’re having difficulties”) (28). Develop protocols for problem tracking, such as a shared schedule of return or longer follow-up visits.

• Involve culturally competent professionals (e.g., interpreters or home visitors) when needed (35). Culturally informed care for Indigenous families may involve outreach to First Nations, Inuit or Métis organizations, services, or personnel.

• Engage all families using programs that promote shared reading, which integrates positive parent–child experiences with early literacy skill-building (8,36).

The research on resilience has shown that protective factors and processes have cumulative, positive effects on children’s well-being: more is better (9).

COUNSEL WITH FAMILY-CENTRED GUIDANCE

When parents seek guidance on important relational issues involving attachment, crying, sleep, and difficult behaviours, consider using MI techniques (see above) (29,30). These are pivotal opportunities for clinicians to counsel, support, and promote positive parenting.

Attachment and positive relational health

Building quality parent–child relationships is a key developmental process and clinicians should attend to security of attachment throughout early childhood (25). Much can be learned simply by watching and listening to parent–child interactions during an office visit—cycles of exploration and return, reaching out, responsiveness, comforting behaviours around immunization—and by listening carefully to what a parent says about their children and family life (26–28,37).

Crying behaviours

Parents often ask clinicians for guidance and reassurance around their children’s crying, especially duration, intensity, and causes. Crying episodes can be frequent and prolonged in infants 2 weeks to 4 months of age. Crying that is inexplicable and seemingly inconsolable is developmentally normal in this period—peaking at around 6 to 8 weeks of age and generally settling by 3 to 4 months (38). Parental feelings of frustration, helplessness or even anger deserve clinical attention, empathy, and support.

For the first 6 months of an infant’s life, parents may need empathetic reminders that:

• Crying is the only way infants can call for help, physical closeness, or to have basic needs met (38).

• Responding consistently, quickly, and warmly to infant needs or distress is essential for secure attachment (31). As parents learn to anticipate and respond to early cues of infant need or to recognize and respond when their child is hungry, sleepy, disengaged or over-stimulated, crying episodes are likely to become fewer and shorter (39).

• Parents cannot ‘spoil’ an infant by responding with warmth and comforting whenever crying escalates or by cuddling or rocking to soothe (40).

• Parents need regular social and emotional support. Feelings of frustration are normal. Parents who are feeling overwhelmed, stressed, or exhausted may need encouragement to take regular, brief breaks or to ask a partner, trusted friend or family member for a spell of child care. All parents need occasional respites for mental or physical self-care.

Clinicians can also share evidence-based information on soothing strategies (for child and parents) (41), link families with a variety of community resources, and empathize with new parents about how challenging these early days and weeks can be.

DEVELOP PLANS FOR CHANGING BEHAVIOURS RELATED TO SLEEP OR DISCIPLINE

Sleep problems

Parents often ask for guidance regarding their infant’s or young child’s sleep: when they should be ‘sleeping through the night’, what is ‘normal’ sleep for age, whether bedtime behaviours are problematic (42,43), and whether involving an outside ‘sleep expert’ is required.

Research suggests that behavioural sleep problems presenting in infancy persist in at least 20% to 30% of young children, with possible negative impacts on cognition, emotion, and function as well as on parental sleep duration and health, and on family function generally (42). The Canadian Sleep Society recommends that health care professionals (44):

• Regularly assess for paediatric sleep deprivation or disorder at well-child visits;

• Search for potential causes of sleep problems, starting with an appropriate history and physical examination (e.g., using the Rourke Baby Record);

• Determine when more thorough investigations need to be conducted;

• Offer intervention and counselling; and

• Refer appropriately for sleep disorders that do not respond to traditional interventions.

The clinician’s role is to support bedtime routines that work for individual families (i.e., that ensure everyone gets sufficient, safe sleep), which can vary for cultural or other reasons (42,45).

Sleep planning

A solid body of literature supports the behavioural treatment of bedtime problems and night-waking in infants, toddlers, and preschoolers (42,45). However, to intervene appropriately, health professionals must be sure to evaluate and diagnose sleep problems accurately. They must determine whether a child is having difficulty settling at bedtime or experiencing problematic night-waking (or both) (45–47), and whether parent or family factors are involved (48). While it is beyond the scope of this statement to describe or recommend specific sleep training strategies, the following evidence-based principles generally apply:

• Allow normal circadian rhythm cycle to develop in infants (e.g., wait until they are at least 6 months of age [42,47]) before considering sleep intervention strategies.

• It is normal and healthy for babies to wake up, stir, and ‘signal’ during the night. Consistent, calming sleep routines (‘bath, book, bed’), settling babies into their cribs drowsy but still awake, putting them to bed without a bottle, waiting a few minutes to see if they settle to sleep on their own after waking, and avoiding overstimulation during night-time feeds or diaper changes, are healthy strategies that encourage self-soothing (46–50).

• Gradually withdraw parental attention while maintaining a presence at bedtime (e.g., by lying near but not interacting with children until they fall asleep [48] or leaving the room and not returning for 2 to 5 minutes before responding to crying, then lengthening that interval [51]).

• For toddlers and preschoolers, a consistent, calming bedtime routine, ideally carried out in the child’s bedroom and definitely not involving electronic screens (52), is essential.

• Being active during the day and after dinner—but preferably not within a couple of hours of bedtime—helps children sleep better at night (47).

• Sleep begets sleep. Children who have better sleep hygiene for daytime naps will generally have fewer night-time wakings (44).

Interventions that focus on self-soothing and improve parent understanding around sleep behaviours and management appear to be more effective than strategies to prevent night-waking (53). In fact, current research strongly supports parent education as the first-line strategy to prevent sleep problems in infants and young children (45,47).

Used appropriately, behaviour modification strategies such as controlled comforting and differential reinforcement (i.e., nurturing desired sleep behaviours and generally ignoring undesired behaviours) can reinforce self-soothing and reduce or eliminate crying at bedtime (45,53,54). Research also suggests that early sleep interventions can reduce sleep problems in parents and ease maternal depression (42,48,51,54).

Challenging behaviours

Positive discipline is guidance that teaches children appropriate behaviour rather than punishing them for inappropriate behaviour. This approach respects the essential dignity of children and presumes they are capable—with help—of problem-solving and self-control (40). Positive discipline encourages parents to use ‘I’ statements such as “I don’t like it when you do that” (as opposed to “What’s wrong with you?”).

The purpose of positive discipline is to foster independence and communication skills, along with children’s abilities to get along with others, manage feelings, solve problems, set goals, take responsibility for behaviour, and, ultimately, to become emotionally intelligent adults. The aim is never to shame or punish (18).

Some degree of noncompliant, disruptive, or aggressive behaviour can be expected between 2 and 5 years of age (55), but many parents seek professional help with a disciplinary issue only after relations with their child have become tense, negative, or strained.

At no time should parents use physical punishment—spanking, slapping, hitting—or behaviour that shames children. Disciplinary methods that are angry or violent are detrimental to both parent and child health and well-being (56).

Behaviour planning

Clinicians can often address a family’s behavioural concerns with anticipatory guidance or by suggesting practical strategies (57). Sometimes, a discipline plan and parent education are needed to target a specific behaviour or interaction pattern. Parents under stress may need empathetic reminders that offering comfort proactively—before a child loses emotional control—is key to responsive, positive parenting. Reinforce that both parents and children learn emotional competencies by staying engaged and involved during difficult interactions (58,59).

With any disciplinary issue, the clinician’s first task is to listen, empathize, and make sure children are safe at home. One approach is to describe the problem as perceived by parents, consider the scope of ‘positive opposites’—guidance that minimizes words like, ‘stop’, ‘no’, or ‘don’t’ (60,61)—and assess the behaviour’s severity. Helping to change an unacceptable behaviour means first understanding why it may be happening. Ask parents for background: what events precede a problem behaviour (its antecedents) and how are parents currently responding? Raising family awareness around antecedents, behaviours, and consequences (‘the ABCs’ of positive discipline) can help identify patterns and make links between what is happening from the child’s perspective and a specific behaviour. Helping parents see what happens right before and after an undesirable behaviour can yield clues as to how to respond differently (40). Ask about environmental factors (9)—living conditions, transitions, scheduling, and possible interferences—that could be contributing to stress but may be modifiable.

The next step is to review how parents are responding to a problem behaviour, and specifically whether they are using preventive guidance techniques or interventions to full effect.

Educate about positive parenting strategies

Connect and redirect

Parenting strategies that ‘connect then redirect’ are at the heart of ‘time-in’. It is essential—though difficult—for adults to recognize their own reactions and responses to children’s behaviour. Connection helps move both child and adult from reactivity to receptivity and builds relationships (62,63). Connective principles also involve letting go of previous, unhelpful patterns or fears, or of misinterpreting behaviour (e.g., “He’s doing it on purpose”). Parents should focus on why a behaviour may be occurring, and concentrate on their own response: what to say and how to say it. Connective strategies include communicating comfort (e.g., from below a child’s eye level, with a gentle nod or touch or an empathetic look), which can sometimes diffuse a difficult situation and ensure resolution.

Recommendations for family-centred guidance.

Crying

• Promote responsiveness and proactive comforting for crying or signs of child stress.

Sleep

• Evaluate bedtime routines and sleep duration. Be sure to obtain an accurate diagnosis before intervening for any sleep-related problem.

• Prioritize strategies that encourage self-soothing over those that prevent night-waking, and educate parents around normal sleep patterns and behaviours.

Challenging behaviours

• Ask whether parents have any concerns about their child’s behaviour or emotional life. Listen, empathize, and offer anticipatory or responsive guidance, as needed.

• Remind parents when misbehaviours are normal for age and stage, have meaning in developmental terms, or may occur for a reason.

• Explore the ‘ABC’s’ of problem behaviours with parents, and help with discipline planning, if needed.

• Recommend targeted reading, community supports, and skills training, as appropriate.

By acknowledging a child’s feelings (even when discouraging an associated behaviour) adults validate both the emotion and the child experiencing it. By listening rather than arguing, then repeating what children have said back to them, parents let children know they are heard. Two principles of redirection are to wait until both the child and parent are emotionally ready to re-engage, and to be consistent without being rigid. While these approaches may take longer initially, with time both child and parent learn to reconnect and talk sooner.

Steps comprising the REDIRECT acronym (58,63) are to:

• Reduce words,

• Embrace emotions,

• Describe (without lecturing),

• Involve the child in discipline,

• Reframe a ‘no’ into a ‘yes’ (with conditions),

• Emphasize the positive,

• Creatively approach a disciplinary situation, and

• Teach.

Connective approaches may need to be broken down into simple, manageable strategies that families can work on. Families experiencing significant disruption may require more intensive interventions.

Time-in and time-out

A re-examination of the ethics and efficacy of time-out as a routine disciplinary strategy is underway in the scientific literature and in the media (64), and its use in child care and other service settings is increasingly discouraged (15). Research indicates that time-outs are often misused (65) and implemented incorrectly (66). However, the strategy is still included in several evidence-based parent training programs to help with significant misbehaviours when other, more positive methods have failed, and continues to be provisionally recommended by the American Academy of Pediatrics (67,68).

Time-out is based on the simple premise that attention feeds behaviour. Stopping a behaviour involves creating a brief break in all types of attention—demands, explanations, apologies, eye contact and hugs (58)—in a distraction-free spot (e.g., a safe, quiet chair, or corner) (68). With time-in, on the other hand, the caregiver invites the child to sit and talk about their feelings and behaviour in an age-appropriate way. Time-in emphasizes connection and comfort. Preferential use of time-ins and other positive parenting strategies should not necessarily preclude selective, targeted use of time-outs for specific misbehaviours in children over 3 years old (69).

While counselling parents on appropriate disciplinary techniques is beyond the scope of most well-child visits, directed reading and referring parents to an evidence-based behavioural training program are helpful steps. For serious, disruptive, or intractable child behaviours, early clinical recognition is essential. Connecting parents with an evidence-based Parent Management Training program is usually the first-line intervention (57,60,70).

Build awareness of and links with supportive community resources

All parents can benefit from connections with their community. Clinicians can encourage engagement, enhance family life, and help to mitigate family stress or adversity by building awareness of and connecting parents with local supportive resources, such as:

• Parent resource centres, such as EarlyON in Ontario and Parent Link Centres in Alberta (see www.cps.ca/en/first-debut/community-resources for links)

• Parent training interventions (70), where available, and supports (e.g., community centre outreach)

• Home visit or skills coaching programs, with links to social services

• Public health, which can also help guide clinicians to other community programs and services for families in greater need.

Increasingly, primary care physicians are invited by early years professionals to advocate for local resources because their clinical perspective is valuable. Physicians are also likely to be involved with providing contact information for social services, writing individualized referrals (4,13,25,31), and coordinating follow-up care. Finally, they have an important role to play as advocates for research on positive parenting, and to make clinical interventions and parenting programs more effective.

RECOMMENDATIONS

As part of routine care, primary care physicians must assess and nurture relational health in young children, along with other aspects of growth and development. To be effective, a trusting relationship between physician and family is essential. Physicians can then positively affect family health and well-being, support parents, and connect families with community resources. The CPS recommends incorporating the following strategies into every well-child visit:

• Build on each family’s relational strengths and protective factors, reinforce healthy routines, use anticipatory guidance to prepare parents for developmentally normal (and possibly challenging) behaviours, and help modify specific behaviours or skills, when needed.

• Model responsive communication and use motivational interviewing techniques.

• Develop an office or clinic environment that promotes relational health, through family-friendly hours, proactive scheduling and follow-up, and knowledgeable, interested staff. Support parents with empathy and understanding—both of expected daily stressors or serious adverse childhood experiences—and with strategies that build resilience.

• Encourage self-care and follow-up for parents with mental health risks. Refer parents directly to specialist services and supports when appropriate.

• Foster clinical connections with community resources, parenting programs, and specialized services.

CANADIAN PAEDIATRIC SOCIETY EARLY YEARS TASK FORCE

Members: Robin C. Williams MD (Chair); Sanjeev Bhatla MD, College of Family Physicians of Canada; Jean Clinton MD; Andrea Feller MD; T. Emmett Francoeur MD; Kassia Johnson MD; Katherine Matheson MD, Canadian Academy of Child and Adolescent Psychiatry; Anne Murphy Savoie MD; Alyson Shaw MD.

Principal authors: Robin C. Williams MD, Anne Biscaro RN, Jean Clinton MD

All Canadian Paediatric Society position statements and practice points are reviewed regularly and revised as needed. Consult the Position Statements section of the CPS website www.cps.ca/en/documents for the most current version. Retired statements are removed from the website.