Engaging fathers during office visit

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant financial disclosures. E-mail her at [email protected].

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant financial disclosures. E-mail her at [email protected].

Do you breathe a sigh of relief when fathers are present for the visit? Or maybe if they are not? Even though the number of fathers as primary caregivers is increasing, most pediatric visits are still with mothers. Working with mothers probably has been your main experience and training. Whether you are a female or male clinician, you also may think working with the mother is just easier, and you may feel your heart sink when a father is present! If he is alone with the child, is he going to have the information about the child that you need? If he is present along with the mother, is the conversation going to take twice as long? Please note that by "father," I am referring to any adult male involved in the regular care of the child. Proof of paternity not required.

Don’t give up so fast! There are many reasons to put in the effort to engage fathers, especially in visits concerning child behavior problems. Fathers bring a unique perspective and added information on the child. Their ideas should be heard simply because it concerns the child. And they may, in fact, be part of the cause of the problem. In all cases, you, the mother, and the child need the father to be part of the solution. His involvement is often the key to an effective resolution of a child behavior problem.

So how to engage fathers? First, invite them! How many times had I gotten midway into a visit and asked the mother about what the father thinks, just to have her say, "Well, he’s out in the waiting room (or car). Do you want me to get him?" before I learned this lesson? Head that one off by making it clear when the appointment is made for all behavior problem visits that the presence of all key caregivers is hoped for. Get your staff to send all parties into the room, too. And when you go in the room, ask if anyone else came along.

Once you are in the room, be sure you know who is present. Sometimes I formally introduce myself, hoping for a counter intro to help me out. Some offices take photos of each family member for the EHR and, by the way, to prevent insurance fraud. What a help that is!

When should you turn to the father? I always talk to the child first and get as much information and rapport as possible with him or her. In reviewing family relationships, I always ask the young child if the father is "nice, or mean, or what," ask him to give examples of what they like to do together, and ask him to say what is "the hardest part" of living with dad. Kids are brutally honest, if not always accurate. A child who can’t think of a single joint activity probably has had few. For a father (or mother) to hear these answers can be a more effective wake-up call than anything you can say.

I like to take advantage of the adult interview time to have the child do a "family kinetic drawing" with instructions to "draw everyone in your family doing something." When finished, the picture may reveal fun times, isolation in boxes, or even some members left off altogether. I have had children put in mom’s boyfriend, or leave off the new baby; once a boy even depicted himself throwing a grenade at his father. Asking the child to tell a story about the drawing often gives invaluable information to check out with the parents, especially the father.

Then ask the father for his concerns or understanding about the child. A father is in the awkward position of not knowing what the mother may have reported about him, and may think you are already biased against him. A father may defer, but don’t let him off the hook. Push for his opinions and examples, emphasizing that his "male point of view" is valuable even if he is not home as much as the mother. Use your body language (such as an outstretched arm, leaning in) and steady eye contact to ensure that the father is not blocked out by the mother from contributing to the story. Her dominance may be revealing of family dynamics, but then engaging him is even more important.

What do you need to know from the father? At least you need to ask: What are your concerns about your daughter? What do you think is causing this behavior? How much of a problem do you think this is? What have you tried so far? What do you think might help? Those are the obvious questions you would ask about any problem and of any caregiver. You can even have a "virtual family visit" when the father is not present by asking the mother, "What would her father say?" about these questions.

But, to get more valuable information from the father, I also ask: How would your parents have handled that when you were growing up? How did that work out? What do you want your relationship with him to be like when he is a man? Expectations that can throw the father-child relationship out of whack usually come from the father’s own past.

How can you tell when it is family dynamics that are causing or interfering with the resolution of child behavior problems? It can help to consider common scenarios. Be open to being totally wrong, but listen to the family’s examples for "syndromes" of what may be happening at home. Some examples:

• Father is pressuring child to succeed, or pressuring the child to be aggressive, and the child rebels.

• Father steps in when mother is having trouble and thereby undermines her authority, making the child sassy.

• Mother steps in when she thinks father is being too tough, undermining him, making the child oppositional.

• Father feels child management is "not his responsibility," but then blocks mother’s efforts when he can’t stand the child’s crying.

How can you interpret these dynamics to help move the family to more adaptive patterns? At the risk of seeming too traditional, draw a family system figure showing the "ideal" of two parents with a close and equal relationship with the child below them (with lower power), but equal relationships with each. Ask each parent how they would draw their own family balance. Then problem solve with them on how they can make their balance more like your figure. This might mean mother deferring to father more, father showing more affection to mother, or both at least not interfering in the other’s management of child behaviors.

We clinicians need to watch out – we are not immune to bias about fathers that can be subtly transmitted and interfere with good care and problem-solving. Maybe we are more inclined to think that men will overuse corporal punishment, be uninvolved, or initiate domestic violence or sexual abuse. We may add this prejudice to race or culture bias. Bias may also make us expect men to be more effective in child management, or more brave or reliable. Our biases can come from general statistics or from our own family experiences. To really engage fathers, we need to step back and be open to each parent for their strengths and weaknesses, regardless of gender.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant financial disclosures. E-mail her at [email protected].