Teachable Moments in Primary Care
Barry Zuckerman
Steven Parker
Margot Kaplan-Sanoff
I. Description. Teachable moments (TM) represent a strategy to help pediatric clinicians provide effective education for parents within the time constraints of a typical office visit. By using the basic assessments of the pediatric visit—history taking, physical examinations, and developmental surveillance—as potent TM, one can exploit the educational opportunities they present for intervention. The strategy of TM is to use the behavior of the child and the clinician-parent interactions in the office as compelling, shared experiences that further parents’ insights into their child and enhance their sense of competence as parents. Using everyday questions and experiences in the office as a shared context for discussion as the visit progresses is an efficient way to address such issues without appreciably lengthening the visit.
The goals of using TM are to:
Enhance parents’ understanding of the child’s needs
Promote “goodness of fit” between parent and child
Model constructive interactions with the child
Improve the relationship between the pediatric clinician and the parent
A. Using behavior in the office as a TM.
1. Discussions of the infant’s or child’s behavior in the office provide a fruitful context for TM. Newly emerging and developed skills and behaviors can challenge the equilibrium between parent and child. Frequently, a specific behavior that parents find disturbing—for example, mouthing toys at 6 months of age, throwing blocks or food at 8 months of age, refusing to lie down to be diapered at 10 months of age, irrepressible exploration at 18 months of age, playing with his penis at 3 years of age—is developmentally normal and expectable. Parents’ concerns about these issues create a special opportunity to promote parental understanding of typical health and development.
a. Concerns that new parents bring to pediatric visits in the first months of a child’s life provide a wealth of TM (Table 3-1). The infant’s behavior creates a special opportunity to promote parental understanding and support. For example, if the infant cries inconsolably during the visit or her cues are difficult to read, the clinician can explore how parents feel and empathize with their frustration at not being able to calm the baby. The goal of this TM is to blend information about development with the message that the parents are “experts” on their baby and doing a good job caring for their child.
2. When a child’s behavior in the office provides a TM, it is up to the clinician to capitalize on it. During these TM, one might infer or “read” the child’s behavior or temperament together with the parents and offer constructive interpretations of its significance. The clinician should then ask parents how they feel about the behavior or use their own reactions to explore parental concerns. If the clinician finds the child’s behavior frustrating, chances are so do the parents.
3. If child behaviors do not produce TM spontaneously, the clinician may employ specific strategies to engage the child and discuss the implications for behavior and development (Table 3-2). Parents tend to watch carefully as the pediatric clinician engages the child in activities—for example, handing the child a toy or a book, rolling a ball back and forth, listening to the heart, or looking into the ears—that demonstrate a particular behavioral or temperamental quality or developmental skill. In some cases, a pediatric clinician can direct his comments to the child rather than to the parents: “You like seeing the pictures of babies in the books, don’t you? This book is making you very excited” as you show parents that even 6-month-olds get fascinated by picture books. If this serves to encourage parents to start sharing books with babies, the first step in learning to read has been taken. When children push the clinician’s hand away as he attempts to listen to the heart, the clinician can talk about other behaviors in which the child is “uncooperative” for the parent.
Table 3-1. Eliciting teachable moments: Exploring relationships
Birth to 4 months of age
Maneuver
Comment
Rock a fussy newborn in your arms and speak softly to console him. Hold a drowsy newborn in a vertical position on your shoulder to bring him to an alert state.
Whether or not your tactics work, explain what you are trying to do and draw the parents’ attention to the infant’s reactions. If their baby is unresponsive or difficult to arouse or console, they may be feeling rejected. By showing them that this is difficult for you too, you help them understand that they are not to blame. Explaining about temperament as an inherent characteristic can encourage them to try new approaches to arousing and consoling their child.
Draw parents’ attention to the reciprocal interaction you see going on between parents and 2- to 3-month-old child as they take turns smiling and cooing at each other.
Tell parents that this playful exchange shows normal emotional development (baby’s smiling, happy face), the beginning of language (vowel sounds, ahs and coos), and cognitive ability (taking turns).
Smile at the 3- or 4-month-old child and try to get the baby to smile back and then ask the parents to try.
Point out that parents got a quicker, bigger smile. Explain that while infants at this age smile at everyone, they smile more readily and more fully at the people to whom they feel closest. This can lead to a discussion of who else gets big smiles (grandparents, the babysitter) and help prepare parents for the next stage when the baby’s general friendliness will be replaced by stranger anxiety.
4. By observing and commenting on the child’s behavior, the pediatric clinician encourages the parents to step back and speculate about its meaning. Unrealistic expectations, which can contribute to parental frustration and lead to child abuse or neglect, can be gently corrected. If parents’ reactions are negative, the clinician can reframe the child’s behavior in a more positive light. The more mobile 12- to 18-month-old child can be described as “exuberant” or “exploratory” rather than “disobedient.” The child who is “uncooperative” with the physical examination is really “asserting his independence.”
a. For example, parents often describe how their 7-8 month old child throws his food off the high chair tray, making a mess for the parents to clean. They then respond by controlling the feeding and not allowing the child to feed himself. The clinician can join with the parents around how messy babies can be. The clinician can reframe the throwing behavior, explaining how shaking and throwing are the infant’s way of exploring objects to discover what the objects can do. This can easily be demonstrated by giving the child a toy in the office and watching him bang, shake, and throw it. The clinician can create a TM by narrating the child’s actions, reframing them as acts of exploration rather than as deliberate attempts to make a mess. The clinician can explain how seemingly unimportant tasks, such as using a pincer grasp to pick up a cheerio, are important windows into a baby’s development and learning.
b. Another example of reframing behavior involves stranger anxiety. Many children are visibly upset by the 12- to 15-month visit because of their heightened stranger and separation anxiety. They may express this anxiety by actively refusing to cooperate with the examination and by protesting when the pediatric clinician tries to examine them. This behavior, often embarrassing to parents, can be used as a TM to discuss stranger anxiety and its developmental function and to explore its ramifications for the families. Parents are usually relieved to understand why it is a developmental inevitability and a sign of positive emotional and cognitive growth for their baby to become wary of strangers and actively and loudly resist separation. They are also pleased to learn that these behaviors are linked to cognitive growth in object permanence.
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