The Paediatrician’s role in understanding and supporting parenting practices through a health behaviour lens

What’s the right bedtime for my child?

How do we cut down on junk food at home?

How do I decrease my child’s “screen time”?

When my child has an “episode”, should I give a “time out”?

Today, parents can access a myriad of online resources for advice on strategies to support their child’s health and development. A large proportion of families present annually to their doctor with concerns that require counselling around parenting behaviours, including management of obesity, sleep hygiene, screen time practices, reading and literacy at home, and behaviour management. Indeed, for many of these behaviours, there exist evidence-based recommendations or consensus guidelines that paediatricians can use to advise their patients’ parents. However, it is important to consider how comfortable paediatricians are in providing this advice, and furthermore, how effective they are in helping families to change their parenting behaviours.

Modification of these behaviours is known to impact long-term health outcomes. Households with excessive screen time exposure are associated with increased risk of speech delay, obesity and sleep problems.^1–3 Likewise, families who incorporate structured bedtime reading routines are associated with improved social behaviours, emotional and behavioural regulation, sleep, cognitive development and school readiness.⁴ We understand that caregiving practices are deeply ingrained, being impacted by a multitude of factors such as parents’ own families of origin, culture, education background, parental mental health and financial resources.

There is well-established literature and numerous evidence-based parenting programmes that delineate key features of how parents can encourage positive behaviours and work to extinguish negative ones. In the clinical context, however, reciting a laundry list of strategies or providing parents with a pamphlet, is not sufficient to change outcomes for that family or that child.

Paediatricians regularly encounter families that merit support with their parenting behaviours; however, current medical school and paediatric residency curricula do not explicitly require training to support families in their parenting behaviours. The emphasis is on the content of the message rather than the means by which to deliver it.

Although resources exist in many communities to support parenting and parental mental health, the role of the paediatrician as a medical expert and counsellor is unique. With the deep potential for parenting behaviours to directly impact children’s long-term health outcomes, parenting itself ought to be considered a health behaviour.

Clinically, support and modification of these behaviours should be approached with health behaviour change frameworks. These frameworks come with a breadth of data to substantiate their use in areas of adult medicine, such as smoking cessation, diet modification and substance use; however, they are relatively new in the world of paediatrics and parenting.

A ‘health behaviour’ is defined ‘those personal attributes such as beliefs, expectations, motives, values, perceptions and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behaviour patterns, actions and habits that relate to health maintenance, to health restoration and to health improvement’.⁵

Parenting behaviours are a complex series of interactions that include the individual (parent), the parent–child dyad, the home environment and the broader community context. Therefore, multiple theoretical concepts from health behaviour change can be used to better understand parenting behaviours and provide multiple intervention points using a socioecological model (figure 1).⁶

Figure 1.

Schematic representation of the Health Behaviour Change Appraoch to Parenting Behaviours.

First and foremost, parenting behaviours start with the parent themselves. In order to be an effective parent, parents must believe that they themselves are capable of parenting, and that their parenting strategies are both important for the child’s health and overall development. These map onto the theoretical constructs of self-efficacy and perceived benefits, from the Health Belief Model by Hochbaum,⁷ and frame why parents take specific parenting actions to promote optimal development. These constructs have demonstrated high validity in behaviours that, like positive parenting, are considered preventive and impact health outcomes.

Second, parenting behaviours are an interaction between parent and child, who function as a dyad. The child’s personality and relationship with their parent affects how likely the parent is choose to perform a specific action. For example, a child with an anxious temperament may tend to cry easily when briefly separated from their parent. Even though the parent knows they should work to let the child go, they may not have an intention of performing this behaviour. The importance of behavioural intention, a theoretical construct described in the Theory of Reasoned Action,⁸ is a critical element in positive parenting. Specifically, a parent’s attitude towards a particular behavioural strategy depends on how effective they perceive the behaviour and how they and their child responded.

While parenting behaviours occur primarily in the home, parents also receive input into their parenting techniques from their wider community, which can include other family members, healthcare professionals and educational personnel. The broader social environment plays a critical role in the development of successful parenting behaviours. In particular, cultural norms and beliefs about particular parenting behaviours play a heavy influence in how parents choose their behaviours. The explosion of online and inperson parent groups speaks to the enormous influence of social support. Therefore, effective parenting interventions should consider families’ normative beliefs and social supports as important constructs influencing behaviour change.⁹

A family’s environment and behaviours are hugely affected by the social determinants of health. Poverty, discrimination, social isolation and insecure housing are only a few structural barriers that negatively impact successful parenting behaviours. Adverse childhood experiences, both experienced by the child or the parent, lead to the adoption of negative health behaviours.¹⁰ Strategies and counselling to successfully support parenting interventions must address each family’s unique structural barriers.

Paediatricians are tasked with supporting families in achieving optimal health outcomes for their children—counselling around parenting behaviours to implement these strategies falls into our scope of practice. Although evidence-based training is available to providers through parenting programme such as the Triple P Program¹¹ or The Incredible Years,¹² these courses are not widely attended by paediatricians. To effectively help parents adopt positive parenting behaviours, paediatricians need tools and frameworks to effectively counsel parents around modifiable risk factors and behaviours.

Health behaviour change frameworks provide a useful scaffolding to develop multilevel interventions that paediatricians can play a key role in through advocacy and implementation. A health behaviour change approach accounts for the unique factors surrounding each parent–child dyad and has a higher likelihood of influencing sustainable changes in parenting behaviours.

Furthermore, with the long-term impact of parenting behaviours on children’s health, paediatric medical education curricula (at both the undergraduate and postgraduate levels) need to include content for students and residents to understand and employ health behaviour change approaches with patients’ families.