Paul Engstrom

SAN DIEGO — The physical exam and the behavior of both child and parent during an office visit provide good opportunities for pediatricians to teach parents about child development and to help them improve their child-rearing skills, Dr. Barry Zuckerman said at a meeting sponsored by the Los Angeles Pediatric Society.

Parents' understanding of their own childhood and behavior can be a key factor in these “teachable moments” because such understanding promotes a healthier relationship between parent and child, said Dr. Zuckerman, chief of pediatrics at Boston University.

“The most obvious teachable moment is when the parent comes in and has a question,” Dr. Zuckerman said. But pediatricians can also create such moments. For example, pediatricians can narrate the goals and findings of the child's physical exam.

During office visits, Dr. Zuckerman also watches for parental behavior that might signal a deeper problem. Ignoring the child who is being disruptive or out of control might mean the mother is preoccupied with her job or marriage or is suffering from depression. Pediatricians can model setting limits for the child and try to help the mother understand why she isn't setting limits herself. (See box.)

A mother who intrudes considerably on her child's behavior may be overly anxious and impair the child's need to explore and learn from his environment. The mother may benefit from increased self-understanding of her inability to be comfortable exercising some self-control.

How a parent and child interact during an office visit also reveals important information, Dr. Zuckerman said. In a healthy relationship between a mother and 3-month-old, for example, both are completely engaged, entertaining, able to read social cues correctly, and strongly focused on each other—like Fred Astaire and Ginger Rogers, he said. The baby watches his mother, vocalizes, and waits his turn to contribute to the exchange.

This kind of positive give-and-take may be missing in an unhealthy relationship.

Dr. Zuckerman cited two worrisome behaviors he has seen in about 5% of parents of 1− to 3-year-olds: not setting any limits (letting the child rifle through everything in the pediatrician's office) or setting limits that are too extreme (constantly fussing over the child and pulling him back, discouraging exploration).

Behaviors like these during an office visit provide immediate teaching opportunities, he said. With feedback from the pediatrician, the parent can acknowledge her own behavior and learn how to correct it.

Teachable moments require a certain finesse on the pediatrician's part, according to Dr. Zuckerman. It's important to engage the parent—perhaps through humor or by enlisting the parent's help in getting to the root of a problem—and to provide positive feedback rather than blame or putting the parent on the defensive.

Indeed, thorough assessment of the child may reveal a neurologic deficit for which no one is to blame, he said.

Questions to Aid Self-Knowledge

By asking important questions at critical times, pediatricians can foster self-understanding in parents, Dr. Zuckerman said.

This gives parents insight that, as they raise their children, makes them much less likely to repeat “maladaptive patterns” they learned in their own childhoods, he said.

Here are some questions physicians can consider with parents to promote self-understanding. These questions need not be asked at any one visit, but rather, over many visits:

▸ What was your parents' philosophy about raising children, and what did you like and dislike about it?

▸ How did you get along with your parents?

▸ How did your relationship with your mother differ from your relationship with your father? How were they similar? Give three words that describe those relationships.

▸ How did your parents discipline you as a child? What impact did this have on you, and how does it affect your role as a parent now?

▸ Did you ever feel rejected or threatened by your parents?

▸ If there were overwhelming or traumatizing experiences in your childhood or later, do they still influence your life?

▸ Did anyone significant die during your childhood or later in life? If so, how does that loss affect you now?

▸ How did your parents communicate with you when you were happy/excited or unhappy/distressed?

▸ How has your childhood shaped the ways in which you relate to your children?

SAN DIEGO — The physical exam and the behavior of both child and parent during an office visit provide good opportunities for pediatricians to teach parents about child development and to help them improve their child-rearing skills, Dr. Barry Zuckerman said at a meeting sponsored by the Los Angeles Pediatric Society.

Parents' understanding of their own childhood and behavior can be a key factor in these “teachable moments” because such understanding promotes a healthier relationship between parent and child, said Dr. Zuckerman, chief of pediatrics at Boston University.

“The most obvious teachable moment is when the parent comes in and has a question,” Dr. Zuckerman said. But pediatricians can also create such moments. For example, pediatricians can narrate the goals and findings of the child's physical exam.

During office visits, Dr. Zuckerman also watches for parental behavior that might signal a deeper problem. Ignoring the child who is being disruptive or out of control might mean the mother is preoccupied with her job or marriage or is suffering from depression. Pediatricians can model setting limits for the child and try to help the mother understand why she isn't setting limits herself. (See box.)

A mother who intrudes considerably on her child's behavior may be overly anxious and impair the child's need to explore and learn from his environment. The mother may benefit from increased self-understanding of her inability to be comfortable exercising some self-control.

How a parent and child interact during an office visit also reveals important information, Dr. Zuckerman said. In a healthy relationship between a mother and 3-month-old, for example, both are completely engaged, entertaining, able to read social cues correctly, and strongly focused on each other—like Fred Astaire and Ginger Rogers, he said. The baby watches his mother, vocalizes, and waits his turn to contribute to the exchange.

This kind of positive give-and-take may be missing in an unhealthy relationship.

Dr. Zuckerman cited two worrisome behaviors he has seen in about 5% of parents of 1− to 3-year-olds: not setting any limits (letting the child rifle through everything in the pediatrician's office) or setting limits that are too extreme (constantly fussing over the child and pulling him back, discouraging exploration).

Behaviors like these during an office visit provide immediate teaching opportunities, he said. With feedback from the pediatrician, the parent can acknowledge her own behavior and learn how to correct it.

Teachable moments require a certain finesse on the pediatrician's part, according to Dr. Zuckerman. It's important to engage the parent—perhaps through humor or by enlisting the parent's help in getting to the root of a problem—and to provide positive feedback rather than blame or putting the parent on the defensive.

Indeed, thorough assessment of the child may reveal a neurologic deficit for which no one is to blame, he said.

Questions to Aid Self-Knowledge

By asking important questions at critical times, pediatricians can foster self-understanding in parents, Dr. Zuckerman said.

This gives parents insight that, as they raise their children, makes them much less likely to repeat “maladaptive patterns” they learned in their own childhoods, he said.

Here are some questions physicians can consider with parents to promote self-understanding. These questions need not be asked at any one visit, but rather, over many visits:

▸ What was your parents' philosophy about raising children, and what did you like and dislike about it?

▸ How did you get along with your parents?

▸ How did your relationship with your mother differ from your relationship with your father? How were they similar? Give three words that describe those relationships.

▸ How did your parents discipline you as a child? What impact did this have on you, and how does it affect your role as a parent now?

▸ Did you ever feel rejected or threatened by your parents?

▸ If there were overwhelming or traumatizing experiences in your childhood or later, do they still influence your life?

▸ Did anyone significant die during your childhood or later in life? If so, how does that loss affect you now?

▸ How did your parents communicate with you when you were happy/excited or unhappy/distressed?

▸ How has your childhood shaped the ways in which you relate to your children?

SAN DIEGO — The physical exam and the behavior of both child and parent during an office visit provide good opportunities for pediatricians to teach parents about child development and to help them improve their child-rearing skills, Dr. Barry Zuckerman said at a meeting sponsored by the Los Angeles Pediatric Society.

Parents' understanding of their own childhood and behavior can be a key factor in these “teachable moments” because such understanding promotes a healthier relationship between parent and child, said Dr. Zuckerman, chief of pediatrics at Boston University.

“The most obvious teachable moment is when the parent comes in and has a question,” Dr. Zuckerman said. But pediatricians can also create such moments. For example, pediatricians can narrate the goals and findings of the child's physical exam.

During office visits, Dr. Zuckerman also watches for parental behavior that might signal a deeper problem. Ignoring the child who is being disruptive or out of control might mean the mother is preoccupied with her job or marriage or is suffering from depression. Pediatricians can model setting limits for the child and try to help the mother understand why she isn't setting limits herself. (See box.)

A mother who intrudes considerably on her child's behavior may be overly anxious and impair the child's need to explore and learn from his environment. The mother may benefit from increased self-understanding of her inability to be comfortable exercising some self-control.

How a parent and child interact during an office visit also reveals important information, Dr. Zuckerman said. In a healthy relationship between a mother and 3-month-old, for example, both are completely engaged, entertaining, able to read social cues correctly, and strongly focused on each other—like Fred Astaire and Ginger Rogers, he said. The baby watches his mother, vocalizes, and waits his turn to contribute to the exchange.

This kind of positive give-and-take may be missing in an unhealthy relationship.

Dr. Zuckerman cited two worrisome behaviors he has seen in about 5% of parents of 1− to 3-year-olds: not setting any limits (letting the child rifle through everything in the pediatrician's office) or setting limits that are too extreme (constantly fussing over the child and pulling him back, discouraging exploration).

Behaviors like these during an office visit provide immediate teaching opportunities, he said. With feedback from the pediatrician, the parent can acknowledge her own behavior and learn how to correct it.

Teachable moments require a certain finesse on the pediatrician's part, according to Dr. Zuckerman. It's important to engage the parent—perhaps through humor or by enlisting the parent's help in getting to the root of a problem—and to provide positive feedback rather than blame or putting the parent on the defensive.

Indeed, thorough assessment of the child may reveal a neurologic deficit for which no one is to blame, he said.

Questions to Aid Self-Knowledge

By asking important questions at critical times, pediatricians can foster self-understanding in parents, Dr. Zuckerman said.

This gives parents insight that, as they raise their children, makes them much less likely to repeat “maladaptive patterns” they learned in their own childhoods, he said.

Here are some questions physicians can consider with parents to promote self-understanding. These questions need not be asked at any one visit, but rather, over many visits:

▸ What was your parents' philosophy about raising children, and what did you like and dislike about it?

▸ How did you get along with your parents?

▸ How did your relationship with your mother differ from your relationship with your father? How were they similar? Give three words that describe those relationships.

▸ How did your parents discipline you as a child? What impact did this have on you, and how does it affect your role as a parent now?

▸ Did you ever feel rejected or threatened by your parents?

▸ If there were overwhelming or traumatizing experiences in your childhood or later, do they still influence your life?

▸ Did anyone significant die during your childhood or later in life? If so, how does that loss affect you now?

▸ How did your parents communicate with you when you were happy/excited or unhappy/distressed?

▸ How has your childhood shaped the ways in which you relate to your children?

SAN DIEGO — Closely observing young children during an office visit provides subtle but important clues about whether a child's motor and behavioral skills are developing normally, Barry Zuckerman, M.D., said at a meeting sponsored by the Los Angeles Pediatric Society.

Telltale maneuvers by children aged 6 months to 1 year include how they reach for, grasp, and manipulate objects, and how they respond to adults in the room.

“As clinicians, our greatest skills are observation skills,” said Dr. Zuckerman, chief of pediatrics at Boston University's teaching hospital.

For example, a normal child younger than 6 months typically lunges for a pen offered to him. One or 2 months later, however, he rotates his hand just before clutching the pen so that both are in the same plane, indicating progressive visual and spatial development. At 9 months, he rotates his hand half way through the reach.

Another bellwether maneuver, Dr. Zuckerman said, is a child's pincher grasp. At age 5–6 months, she picks up small objects without much coordination. At 7–8 months, thumb and forefinger do the grasping, and she moves her other three fingers out of the way. At 9 months, she picks up objects from above rather than straight on. By this time, her movement is very efficient and mechanical—a first sign of fine motor skills.

Dr. Zuckerman said that he also watches how a child manipulates objects, like a small toy car.

He said a 6-month-old reaches for the car and puts it in his mouth; a 7- or 8-month-old bangs, drops, and throws it; a 9-month-old moves the car with his hand and explores it, demonstrating good coordination of visual and motor skills; and a 1-year-old moves the car as though it were being driven.

In addition, he said, children should be able to sit by 6 months and, by 1 year, to stand or walk and perhaps say one or more words.

Observe fine-motor and cognitive skills only when the child is healthy and relaxed, because sick or stressed children tend to regress, Dr. Zuckerman advised.

He cited several social and emotional indicators between the ages of 6 months and 1 year:

▸ If a child isn't curious about an object offered to him or isn't interested in exploring it, his development may be delayed.

▸ At about 1 year, a child signals who the primary caregiver is by crying when that person leaves the room or by turning to him or her when a stranger enters. Use such information to identify and provide surveillance feedback to the primary caregiver, who may not be the mother, Dr. Zuckerman said.

Children at this age can retain an image of the primary caregiver when the adult is absent and may cry as a result, he said. In contrast, children 6–7 months won't cry when that person leaves, because “object permanence” hasn't developed. For them, the adult is “out of sight, out of mind.”

▸ When a parent and child are together, body language says a lot about the closeness of their relationship, Dr. Zuckerman said, and offers an opportunity for parents to learn from the physician about their own child-rearing behavior. Signs of a good relationship include total engagement between parent and child, and the child's positive affect, such as joyful facial expressions.

Reading and other shared activities foster a high level of engagement, which is absolutely critical in early childhood, he said.

However, he cautioned that some parents are overloading and stressing their children with too much information.

“We all believe stimulation is important,” he said. “But parents are putting so much pressure on themselves to do the perfectly right thing every minute with their child. That's not what being a parent is about. It's the downtime—taking it easy and enjoying each other.”

SAN DIEGO — Closely observing young children during an office visit provides subtle but important clues about whether a child's motor and behavioral skills are developing normally, Barry Zuckerman, M.D., said at a meeting sponsored by the Los Angeles Pediatric Society.

Telltale maneuvers by children aged 6 months to 1 year include how they reach for, grasp, and manipulate objects, and how they respond to adults in the room.

“As clinicians, our greatest skills are observation skills,” said Dr. Zuckerman, chief of pediatrics at Boston University's teaching hospital.

For example, a normal child younger than 6 months typically lunges for a pen offered to him. One or 2 months later, however, he rotates his hand just before clutching the pen so that both are in the same plane, indicating progressive visual and spatial development. At 9 months, he rotates his hand half way through the reach.

Another bellwether maneuver, Dr. Zuckerman said, is a child's pincher grasp. At age 5–6 months, she picks up small objects without much coordination. At 7–8 months, thumb and forefinger do the grasping, and she moves her other three fingers out of the way. At 9 months, she picks up objects from above rather than straight on. By this time, her movement is very efficient and mechanical—a first sign of fine motor skills.

Dr. Zuckerman said that he also watches how a child manipulates objects, like a small toy car.

He said a 6-month-old reaches for the car and puts it in his mouth; a 7- or 8-month-old bangs, drops, and throws it; a 9-month-old moves the car with his hand and explores it, demonstrating good coordination of visual and motor skills; and a 1-year-old moves the car as though it were being driven.

In addition, he said, children should be able to sit by 6 months and, by 1 year, to stand or walk and perhaps say one or more words.

Observe fine-motor and cognitive skills only when the child is healthy and relaxed, because sick or stressed children tend to regress, Dr. Zuckerman advised.

He cited several social and emotional indicators between the ages of 6 months and 1 year:

▸ If a child isn't curious about an object offered to him or isn't interested in exploring it, his development may be delayed.

▸ At about 1 year, a child signals who the primary caregiver is by crying when that person leaves the room or by turning to him or her when a stranger enters. Use such information to identify and provide surveillance feedback to the primary caregiver, who may not be the mother, Dr. Zuckerman said.

Children at this age can retain an image of the primary caregiver when the adult is absent and may cry as a result, he said. In contrast, children 6–7 months won't cry when that person leaves, because “object permanence” hasn't developed. For them, the adult is “out of sight, out of mind.”

▸ When a parent and child are together, body language says a lot about the closeness of their relationship, Dr. Zuckerman said, and offers an opportunity for parents to learn from the physician about their own child-rearing behavior. Signs of a good relationship include total engagement between parent and child, and the child's positive affect, such as joyful facial expressions.

Reading and other shared activities foster a high level of engagement, which is absolutely critical in early childhood, he said.

However, he cautioned that some parents are overloading and stressing their children with too much information.

“We all believe stimulation is important,” he said. “But parents are putting so much pressure on themselves to do the perfectly right thing every minute with their child. That's not what being a parent is about. It's the downtime—taking it easy and enjoying each other.”

SAN DIEGO — Closely observing young children during an office visit provides subtle but important clues about whether a child's motor and behavioral skills are developing normally, Barry Zuckerman, M.D., said at a meeting sponsored by the Los Angeles Pediatric Society.

Telltale maneuvers by children aged 6 months to 1 year include how they reach for, grasp, and manipulate objects, and how they respond to adults in the room.

“As clinicians, our greatest skills are observation skills,” said Dr. Zuckerman, chief of pediatrics at Boston University's teaching hospital.

For example, a normal child younger than 6 months typically lunges for a pen offered to him. One or 2 months later, however, he rotates his hand just before clutching the pen so that both are in the same plane, indicating progressive visual and spatial development. At 9 months, he rotates his hand half way through the reach.

Another bellwether maneuver, Dr. Zuckerman said, is a child's pincher grasp. At age 5–6 months, she picks up small objects without much coordination. At 7–8 months, thumb and forefinger do the grasping, and she moves her other three fingers out of the way. At 9 months, she picks up objects from above rather than straight on. By this time, her movement is very efficient and mechanical—a first sign of fine motor skills.

Dr. Zuckerman said that he also watches how a child manipulates objects, like a small toy car.

He said a 6-month-old reaches for the car and puts it in his mouth; a 7- or 8-month-old bangs, drops, and throws it; a 9-month-old moves the car with his hand and explores it, demonstrating good coordination of visual and motor skills; and a 1-year-old moves the car as though it were being driven.

In addition, he said, children should be able to sit by 6 months and, by 1 year, to stand or walk and perhaps say one or more words.

Observe fine-motor and cognitive skills only when the child is healthy and relaxed, because sick or stressed children tend to regress, Dr. Zuckerman advised.

He cited several social and emotional indicators between the ages of 6 months and 1 year:

▸ If a child isn't curious about an object offered to him or isn't interested in exploring it, his development may be delayed.

▸ At about 1 year, a child signals who the primary caregiver is by crying when that person leaves the room or by turning to him or her when a stranger enters. Use such information to identify and provide surveillance feedback to the primary caregiver, who may not be the mother, Dr. Zuckerman said.

Children at this age can retain an image of the primary caregiver when the adult is absent and may cry as a result, he said. In contrast, children 6–7 months won't cry when that person leaves, because “object permanence” hasn't developed. For them, the adult is “out of sight, out of mind.”

▸ When a parent and child are together, body language says a lot about the closeness of their relationship, Dr. Zuckerman said, and offers an opportunity for parents to learn from the physician about their own child-rearing behavior. Signs of a good relationship include total engagement between parent and child, and the child's positive affect, such as joyful facial expressions.

Reading and other shared activities foster a high level of engagement, which is absolutely critical in early childhood, he said.

However, he cautioned that some parents are overloading and stressing their children with too much information.

“We all believe stimulation is important,” he said. “But parents are putting so much pressure on themselves to do the perfectly right thing every minute with their child. That's not what being a parent is about. It's the downtime—taking it easy and enjoying each other.”