Partnering with Parents: Pathways to Prevention in the Pediatric Setting

Linda Chamberlain, PhD, MPH

A growing body of research has documented the effects of current and past victimization on parenting skills and the quality of the parent-child relationship.1,2,3  Because of the prevalence of ACEs, many families seen in the pediatric setting are living with the lingering effects that ACEs may have on parenting. The well-documented physical and mental health consequences of ACEs for adult survivors can interfere with parents’ ability to be sensitive to and respond appropriately to their children’s needs.4 Having experienced abuse as a child increases the likelihood that parents will use physical punishment to discipline their own children.5  This impaired parenting can provide the vehicle for the transmission of trauma to the next generation, even when ACEs are not currently present in a household. Conversely, consistent, nurturing parenting skills and secure attachments are protective for children experiencing early adversity.6,7,8

In their policy statement on Childhood Adversity, Toxic Stress, and the Role of the Pediatrician, the American Academy of Pediatrics describes the pivotal role that pediatricians can have in promoting the positive parenting techniques and stable, responsive parent-child relationships that buffer the toxic effects of childhood adversity.

Several key characteristics of a trauma-informed approach to parenting in the pediatric setting are that it: 

(1) empowers pediatric providers with the skills and resources needed to educate parents about the impact of ACEs upon both parenting and their child’s development;9 

(2) recognizes that parenting may unexpectedly trigger memories of parents’ traumatic experiences and meets parents where they are in terms of their life experiences; 

(3) creates an emotionally safe and nonjudgmental space for parents to talk about their own experiences with ACEs and concerns for their children and parenting;

(4) offers universal education, support, and resources that help parents to address their own trauma and the effects of toxic stress on their children;  and

(5) identifies families’ strengths and builds resiliency by promoting positive parenting and healthy parent-child relationships.

Training on the impact of trauma on parenting will help pediatric providers to more accurately assess and assist families. An online curriculum and extensive bibliography with content on toxic stress, the connection between current and past family violence and the use of physical punishment, and positive discipline strategies is available on the Institute for Safe Families site (Partnering with Parents PowerPoint found at Materials).  Futures Without Violence and the American Academy of Pediatrics have launched an E-learning module on addressing ACEs in the pediatric setting which provides free continuing education credits.  This training includes a brief video on ACES for parents and a safety card with supportive self-care and parenting strategies that can be obtained at Futures Without Violence.

Web-based resources on child maltreatment can be found on the CDC's Child Maltreatment site. The site includes a video, “Promise of Prevention: A Survivor’s Story,” which documents a mother’s journey to overcome the abuse she experienced as a child and become the kind of mother she wants to be.

Providers should be familiar with a range of resources, including electronic media such as self-help web sites and apps, to assist parents and children who are coping with issues related to trauma so they can offer warm referrals. “Partnering with Parents: Apps for Raising Healthy, Happy Children” was developed for universal education and anticipatory guidance with parents in the pediatric setting.  This booklet is written in user-friendly language to help parents understand how tough times during childhood can affect their well-being, their children and parenting with an emphasis on building resiliency.  Scannable QR codes and apps provide direct links to resources. “Partnering with Parents” is available on the Institute for Safe Families site.

The Parent Trauma Resource Center offers information about grief and trauma, self-help for parents and children including breathing exercises, meditation and relaxation techniques, and age-specific parenting strategies to help calm children.  

There are a growing number of evidence-based and promising practices that address the effects of domestic violence, substance abuse, and other forms of trauma on parenting and the parent-child relationship including Connections and Breaking the Cycle, the CAFA Parenting Program, Caring Dads, and Child-Adult Relationship Enhancement.  Referrals to home visitation programs provide a unique opportunity to provide social support to families and enhance parenting skills while working in the home setting. The Nurse Family Partnership, a home visitation program that has demonstrated reductions in risk factors for and the occurrence of child maltreatment, works with high-risk, first-time parents.10,11 Nurse-visited mothers used less physical punishment with their infants, provided more developmentally appropriate home environments, and were more likely to use community-based services.  Testimonies from parents and a reference list of evaluation studies that spans over 30 years can be found on the Nurse Family Partnership site.  Some home-visitation programs use paraprofessionals who work with families to promote child health and prevent child maltreatment by addressing malleable risk factors such as parenting skills and family functioning.  In a randomized, controlled trial of the Healthy Start program, mothers who were home-visited by paraprofessionals reported less domestic violence victimization and perpetration.12

The success of the Triple P Positive Parenting Program in preventing child maltreatment and improving the quality of life for children and their parents demonstrates the value of working with parents before things go wrong. Triple P is a multi-level system of parenting and family support that works with other service providers including childcare staff, health care providers, mental health practitioners, and child welfare workers.

In addition to being familiar with the trauma-informed interventions for parenting that are available locally, pediatric providers should take a leadership role as vocal advocates for implementing best practices in their service settings and communities.  The Safe Environments for Every Kid (SEEK) model is an example of an evidence-based practice to prevent child maltreatment that is implemented in pediatric primary care settings. The SEEK intervention includes training for pediatric providers, a parent screening questionnaire, collaboration with social workers, and educational resources for parents.  In a randomized, controlled trial, families who received the SEEK intervention had lower rates of child abuse and neglect and used less harsh punishment to discipline their children. In addition, their children were more likely to be up-to-date on immunizations.13,14  

Resources

1. Banyard VL, Williams LM, Siegel JA.  The impact of complex trauma and depression on parenting: an exploration of mediating risk and protective factors.  Child Maltreat. 2003;8:334-349.

2. Min MO, Singer LT, Minnes S, Kim H, Short E. Mediating links between maternal childhood trauma and preadolescent behavioral adjustment. J Interpers Violence. 2013;28(4):831-851.

3. Graham AM, Kim HK, Fisher PA.  Partner aggression in high-risk families from birth to age 3 years: associations with harsh parenting and child maladjustment. J Family Psychol. 2012;26(1):105-114. 

4. Danese A, McEwen BS.  Adverse childhood experiences, allostatis, allostatic load, and age-related disease.  Physio Behav. 2012;106:29-39

5. Chung EK,  Mathew L, Rothkopf, Elo IT, Coyne JC, Culhane JF.  Parenting attitudes and infant spanking: The influence of childhood experiences.  Pediatrics. 2009;124:3278-e286.

6. Graham-Bermann SA, Gruber G, Howell KH, Girz L.  Factors discriminating among profiles of resilience and psychopathology in children exposed to intimate partner violence (IPV). Child Abuse Negl.  2009;33:648-660.

7. Busch AL, Lieberman AF.  Mothers’ Adult Attachment Interview ratings predict preschool children’s IQ following domestic violence exposure.  Attach Hum Dev.  2010;12(6):505-527.

8. Borrego J, Gutow MR, Reicher S, Barker CH.  Parent-child interaction therapy with domestic violence populations.  J Fam Viol. 2008;23:495-505.

9. AAP’s Early Brain and Child Development web site.

10.Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.  Prev Sci.  2002;3(3):153-172.

11. Olds DL, Henderson CR, Kitzman H.  Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life?  Pediatrics. 1994;93(1):89-98.

12. Bair-Merritt MH, Jennings JM, Chen R, Burrell L, McFarlane E, Fuddy L Duggan AK.  Reducing Maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start home visitation program.  Arch Pediatr Adolesc Med. 2010;164(1):16-23.

13. Dubowitz H, Feigel S, Lane W, Kim J.  Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) model. Pediatrics. 2009:123(3):858-864.

14. Dubowitz H.  The Safe Environment for Every Kid (SEEK) Model: Helping promote children’s health, development, and safety.  Child Abuse Neg. 2014;38:1725-1733. 

© 2015 by Academy on Violence and Abuse