Strengthening Parent-Child Relationships Through the Well-Child Visit

In the earliest years of life, a baby’s environment and experiences directly impact the rapidly developing brain, shaping the brain architecture itself. Research shows that strong parent-child relationships during those early years not only foster healthy brain development, but also protect the brain against the harmful effects of toxic stress that might arise from adverse childhood experiences—experiences often associated with extreme poverty and neglect. Encouraging nurturing, responsive parent-child relationships, then, can help give more children the opportunity for a healthy brain and a healthy start.

Since pediatric health professionals see parents especially frequently during those critical early years, they can play a pivotal role in supporting parent-child relationships, says Ken Tellerman, MD, a pediatrician and Chairman of the Committee on Emotional Health for the Maryland Chapter of the American Academy of Pediatrics. “By supporting positive interactive experiences during the well-child visit, we can strengthen parent-child relationships, and support children’s cognitive and social and emotional development.”

Tellerman leads one of 18 pediatric practices participating in Pediatrics Supporting Parents, a NICHQ-led initiative seeking to leverage the well-child visit to encourage positive interactions that foster healthy social emotional growth. Over the past four years, Tellerman and the Maryland Chapter of the American Academy of Pediatrics (MDAAP) have developed a program and materials designed to help pediatric health professionals promote loving connections between parents and children. Now, Tellerman is working with NICHQ to further test and eventually scale ideas for embedding more social emotional support into the well-child visit.

“We wanted to discover what we could do during a well-child visit to support and build positive, nurturing relationships between parents and their child,” explains Tellerman. “Our goal was to create a program that was cost-effective, time-sensitive, easily implemented by pediatricians, and in a format parents would find engaging.”

Following extensive research of programs across the country, and studies on the most effective way to support positive interactions, Tellerman’s vision evolved into Grow Your Kids: TREE (Talk, Read, Engage, Encourage), a program that supports healthy parent-child relationships by observing and promoting the four TREE concepts during the well child visit:

• Talk: bathe your child in language
• Read: read regularly and enthusiastically
• Engage: have fun together and make your baby feel safe and loved
• Encourage: be your baby’s cheerleader

During a well-child visit, pediatric professionals use the TREE pneumonic to inform their observations and inspire their conversations with families, highlighting positive interactions (enthusiastic reading, for example) and pointing out opportunities for further engagement (adding in encouragement, for example). Talking to families about these different concepts during the well-child visit supports parents in engaging children in positive interactions that encourage healthy relationships. Dr. Tellerman has coined the term PIECES (Positive Interactive Early Childhood Experiences) to describe what the TREE program aims to promote.

“The TREE program helps organize conversations with families around concepts that pediatricians can easily observe, and families can easily understand,” says NICHQ Project Director Colleen Murphy, MSMOB. “It’s also something that can easily be integrated into a well-child visit and adapted to fit different practices’ needs, which makes it a promising strategy for enhancing well-child visits across the country.”

Interested in introducing TREE into your work? Below, Tellerman describes five steps for incorporating TREE into a pediatric well-child visit and offers insights on why these strategies have been effective. His takeaways not only highlight the potential of the program; they also offer general principles that any pediatric provider can use to enhance parent-child relationships through the well-child visit.

Five Steps for Integrating
TREE into the Well-Child Visit

1. Open with play.

Begin the well-child visit by handing the child a toy or book, which unobtrusively encourages parents and children to interact. While the pediatric health professional fills out the electronic medical record, the parent and child engage in play. The pediatric health professional can then observe those interactions while keeping the TREE pneumonic in mind—is the parent talking to the child enthusiastically, is the parent engaging the child in a positive way?

“When we have a little structure, we can more easily observe the behaviors going on in front of us and gather a lot of information, very quickly,” says Tellerman. “And importantly, beginning with play starts the visit off on a positive note rather than on an assessment.”

Takeaway: Provide a toy or book to promote positive-interactions that pediatric health professionals can observe during the well-child visit. 

2. Next, ask parents, what are some fun things you enjoy doing with your child?

Tellerman wanted to move away from monolog style anticipatory guidance towards what his MDAAP committee calls participatory guidance—a conversation that genuinely engages parents rather than a lecture telling them what to do. After testing multiple questions to spark productive conversations, Tellerman found that this seemingly simple question has a powerful effect and, it can be easily embedded into the developmental assessment part of the visit.

“Asking parents to share something they enjoy about their relationship with their child sparks a positive charge that enhances the whole visit. We watched parents’ faces light up as they talked about their children, and they then remained engaged throughout our conversation.”

Takeaway: Rather than lecture families, engage them in conversations that build off positive interactions.

3. Share TREE concepts

Once parents have shared their experiences and are engaged, introduce them to one or two TREE concepts that complement the activities they already do with their child. For example, if a father says he talks to his child every night while cooking dinner, ask if he has ever tried singing to his child during bath-time. Or, when discussing the games that a mother plays with her child, pause and reaffirm the importance of encouragement. Tellerman recommends giving only one or two hints during each session, so parents don’t feel overloaded.

Takeaway: Use a strengths-based approach to teach parents about interactive activities, providing one or two ideas that complement activities that they are already doing.

4. Introduce a second question: First, acknowledge that their baby is changing, and then ask, so what fun things would you like to do with your baby between now and the next visit?

It’s important to help parents understand what to expect as their baby grows and what they can do to support each phase of development. By asking parents about their future hopes and plans, pediatric health professionals again favor an interactive conversation over a didactic lecture. Once parents share their expectations, pediatric health professionals can describe what families can expect in the upcoming months and discuss ways to integrate TREE concepts that are appropriate for their child’s development.  

Tellerman recommends talking about development in terms of phases rather than milestones, finding that a process-oriented narrative is easier for parents to understand, and therefore support.

For example, says Tellerman, “when talking to parents about play, we can tell parents that their baby is moving from the phase of doing something with an object (mouthing or grasping) to doing something to an object (dropping or banging), so they may want to have toys they can shake, like a rattle. We’ve found that describing development in phases is an easier and more engaging way for parents to learn about their child’s developmental trajectory.”

Takeaway: Talk to parents about the next phase of their child’s development and what they can do to support positive interactions.  

5. Conclude by offering parents a “TREET”

At the end of the visit, describe what parents did well during the visit and connect those successes with the TREE concepts. For example, describe how they did a wonderful job playing with their child or comforting their child during a vaccine. Positive reinforcement encourages them to continue these behaviors at home, reaffirms the TREE concepts, and ends the visit on a positive note.

“This approach has changed the dynamic of what happens at our well-child visits,” says Tellerman. “It touches families on an emotional level, engages them in a dialogue that enlivens the whole experience, and enhances the pediatric-parent relationship, as well as the parent-child relationship.”

Takeaway: Always end a visit on a positive note, reaffirming what parents are already doing right.

Interested in learning more about enhancing the well-child visit to support parent-child relationships? Read this recent insight that includes advice from three parent partners.