Promoting First Relationships in Pediatrics

Editor’s note: This article was sponsored by Seattle Children’s Hospital.

During a recent typical well-child visit, Seattle Children’s pediatrician Abigail Grant, M.D., asked the mother of a young child about her parenting journey.

The mom shared that her child was struggling in day care. Each day, she’d receive written reports about her son’s troublesome behavior. The mom said she felt ashamed and embarrassed.

Grant asked more questions, prompting the mom to consider the source of her child’s behaviors. Grant listened closely and commented on the mom’s empathy. Instead of blaming the child for the problem behaviors, the mom was imagining what might have contributed to his behavior. Grant noted that the mother was in tune with her son.

In that visit, Grant was applying the tools and strategies of Promoting First Relationships, an approach to pediatric care that builds parents’ strengths and confidence while helping them to understand the emotional needs of their child. Instead of simply checking boxes for developmental milestones, practitioners trained in the program learn to prioritize relationships. These evidence-based strategies not only improve the connections between the physician and families, but they can also transform the way parents meet the social and emotional needs of their children.

“Once you use this approach, every visit after it is different,” says Grant, who teaches the program at Seattle Children’s with colleague Jeannie Larsen, M.D. “You’re really focused on relationships.”

Helping medical residents engage with parents

About 50 people a year participate in the four-hour-long Promoting First Relationships course, which was first introduced in 2016. Participants include all of Seattle Children’s pediatric residents as well as Early Childhood Developmental Navigators at three local clinic sites and residents at Sea Mar Community Health Centers.

Even though pediatricians interact with parents on a daily basis, residency training programs typically offer very little instruction on how to engage with and support caregivers of young children, says Beth Crispin, a Seattle Children’s health educator. Promoting First Relationships addresses this gap, bolstering the approaches and strategies residents can use to connect with parents.

The residents, many of whom don’t have children of their own, say the program provides critical guidance, strategies and tools, Crispin notes. In feedback forms, many have expressed how hard it has been to counsel parents prior to receiving the training. Since the course is required for all Seattle Children’s pediatric residents, it provides a foundation and a shared commitment to building family relationships throughout residency.

“The course teaches residents how to work with parents and provide the support they need,” Crispin explains. “They’ll go out and touch thousands of families with their approach.” 

The emphasis on asking open-ended questions gives patients the chance to share their experiences beyond checklists and questionnaires, pediatrician Grant adds. That approach also helps residents connect to patients from diverse backgrounds in a culturally unassuming way.

“If you just go to the checklist, families may leave feeling they weren’t heard,” she says. “You’re missing the whole point of providing care and supporting families.”

Small observations matter

For parents of newborns, that might mean simply asking, “How are you doing at home?”

Such a question may prompt parents to share how hard it is to wake up multiple times at night, or to describe feeding challenges. The provider is learning the same information about the infant’s sleep and eating, but the approach allows the parent to feel heard and supported in a different way.

These questions have led to important discussions around postpartum struggles with anxiety, depression and isolation. Sometimes, Grant’s initial impressions that someone is doing just fine shift the more she listens.

“As I’m in the room longer and asking questions, I’ve been surprised at how much families are struggling and how isolated they feel,” she says.

The program also encourages providers to notice and reflect back to parents their strengths. For example, a physician might notice how an infant responds to their mother’s voice or the way a father playfully interacts with a bored toddler. They’ll then share with the parent what they noticed and how these moments positively impact a child’s brain development.

After a child’s vaccination, the pediatrician might say something to the parent such as: “I’m noticing how you’re comforting your kid when they’re upset.” That comment can spur a discussion about the impact of parental responsiveness on child development.

What’s driving behaviors

As kids grow, the approach also shifts the discussion around problematic behaviors such as tantrums, biting or kicking. Children have underlying social and emotional needs. Undesirable actions are the language of distress, Grant explains. Conversations can explore what factors might be contributing to a child’s discomfort.

More broadly, the approach helps families figure out how to stay connected to their child instead of simply extinguishing the challenging behavior.

“We understand how important early childhood is, how important the relationship between parent and child is,” says Grant. The program “helps people who work with children put this [appreciation] into practice.”

Beyond the doctor’s office

The Promoting First Relationships approach has benefits beyond improving relationships between health-care providers and parents.

Parents might employ the same strategies at home, observing and building on their child’s strengths. They might also use open-ended questions — and empathetic responses — with their child.

The program “is focused on early childhood, but it’s more of an approach to parenting, too,” says Grant. “It’s about trying to understand your kid’s underlying emotions and needs.”

Those strategies and tools helped the mom who had described her child-care struggles. In subsequent appointments, the mom shared that the discussions had resulted in increased confidence in her ability to understand her child and discover the child-care setting that best suited his temperament and needs. Throughout the process, the mom made sure her child understood that she loved him and accepted him. Ultimately, she decided to find a different child-care environment.

As a provider, Grant’s role was simply to slow down, listen and observe.

“She needed another person to listen and let her process,” says Grant. “She knew what was best. She needed the space and someone she trusted to help her think through it.”