Abstract
Context:
Residents receive little parenting education despite its potential to improve parenting behavior and decrease child maltreatment despite the inclusion of parenting content on board certification examinations. Teaching residents how to discuss parenting and foster positive parent-child relationships is essential to treating the whole person in osteopathic pediatric medicine.
Objective:
To improve pediatric and internal medicine–pediatric residents’ knowledge, confidence, and skills in providing parenting advice.
Methods:
Four toddler parenting and discipline modules were developed. During continuity clinic, residents viewed and discussed modules with faculty. Residents completed a confidence and knowledge questionnaire before and after the curriculum, provided a self-report of use of skills learned, and completed a feasibility survey. Faculty also completed a feasibility survey.
Results:
Forty-one of 61 residents (67%) participated in the study. Before participation, the median (interquartile range [IQR]) resident score for confidence in giving advice was 6.0 (4.0-7.0) (on a 10-point scale), increasing to 7.0 (6.0-8.0) for those completing 1 to 3 modules and 8.0 (8.0-9.0) for those completing 4 modules. Median (IQR) score on board-style questions was 8.0 (7.0-9.0) (on a 12-point scale) before participating in the modules and 8.5 (7.5-9.5) for those completing 1 to 3 modules and 9.0 (7.0-9.0) for those completing 4 modules after participation; the increase was not statistically significant. Nine faculty and 29 residents completed the modules and responded to the exit survey regarding feasibility and acceptability of the curriculum. On a 4-point scale (4 being excellent), sessions had an overall mean (SD) rating of 3.7 (0.5) by faculty and 3.5 (0.5) by residents. Most residents (27 [93.1%]) reported interest in more modules, and 28 residents (96.6%) reported using information learned from the modules during clinic visits.
Conclusion:
Confidence delivering parenting advice increased among residents who completed the curriculum modules. Faculty and residents reported high feasibility ratings, and residents endorsed application of skills during clinic visits and interest in more modules.
The tenets of osteopathic medicine include that “The body is a unit; the person is a unit of body, mind, and spirit” and that “Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.”
1 In childhood, extrinsic forces, such as interactions with parents, can influence a child's health.
2,3 As noted by Hoghughi,
4 “community pediatricians … are in a key position to promote services for the whole child, delivered through supporting better parenting.” Parenting advice can be useful to parents to improve child problem behavior and alleviate parental stress. In addition, parenting advice (including advice about discipline) could potentially decrease the risk of child maltreatment, which we define as all forms of child abuse, including physical abuse, emotional abuse, sexual abuse, and neglect.
According to the US Centers for Disease Control and Prevention, in 2016, approximately 676,000 cases of child abuse and neglect were reported to child protective services, and 1750 children died from abuse or neglect.
5 Several parental factors increase child maltreatment risk, including substance abuse, mental illness, domestic violence, and child conduct problems.
6 Helping parents improve their effectiveness can also address their mental health needs and improve the chances of recovery from substance abuse.
6 In addition, “parents of children with special health care needs may need additional assistance regarding discipline strategies.”
7 Thus, physicians can play an active role in supporting families at risk or with additional needs and enhancing parenting strategies, therefore reducing risk of child maltreatment.
Pediatricians are typically viewed as credible authorities on child well-being. They are often the only health care professionals that parents of infants and toddlers regularly access before school entry and are often asked to provide parenting advice.
8 The American Academy of Pediatrics advises pediatric physicians to discourage parents from using corporal punishment and to teach parents new parenting strategies.
7 To enhance pediatricians’ efficacy in giving parenting and discipline advice, pediatric residents must develop skills in this area. However, pediatric residents often do not receive formal training in parenting strategies. A limited number of US residency programs are known to have existing parenting curricula, and to our knowledge, only 2 programs have shown the effectiveness of their interventions.
9,10 Prior curricula
9,10 included multiple components; however, most curricula have not tied learning objectives directly to board examination content requirements. Additionally, the time needed for implementation of these curricula (≤12 hours) is challenging for many programs. Therefore, a succint, accessible, and dynamic parenting curriculum for pediatric residents is needed.
The University of Oklahoma Health Sciences Center (OUHSC) parenting curriculum research team conducted a mixed-methods study assessing factors associated with the type of parenting advice residents give, confidence they have in giving parenting advice, and resources they use to generate advice.
11,12 In previous studies,
11,12 residents reported relying on attending physicians, personal experiences, and books/reading material to generate parenting advice rather than evidence-based resources. These results reinforce the importance of implementing a structured parenting curriculum as a means to increase resident knowledge, confidence, and skills in providing parenting advice.
The present study aimed to create a succinct, structured parenting curriculum covering board examination content and teaching specific strategies for giving parenting advice to residents. Toddler discipline was chosen as the overarching topic, as these foundational parenting skills can be applied to parenting older children. This study examined whether the curriculum improved resident confidence, knowledge, and self-reported behavior in the provision of parenting advice.
The curriculum was developed by a team of child development experts, including a developmental behavioral pediatrician, a pediatric psychologist, and 3 general pediatricians, using Kern's Six Step Approach to Curriculum Development for Medical Education, as follows
13:
1. The problem of lacking parenting education among residents was identified.
2. Resident educational needs in terms of parenting were assessed.
3. Goals and objectives for the curriculum were created.
4. Educational strategies (ie, TPDC) were created.
5. The curriculum was implemented.
6. The TPDC was evaluated and feedback was obtained.
The TPDC was divided into 4 modules: (1) Fostering Positive and Supportive Parent-Child Relationships, (2) Promoting Desired Behavior, (3) Reducing Undesirable Behavior, and (4) Tantrums/The Angry Toddler. Each module included the following components:
1. Brief recorded lecture with accompanying PowerPoint presentation (reviewing the most clinically relevant aspects of the subtopic)
2. “Ways to Put This Into Practice” section on how to use the material during patient encounters
3. Brief video showing an example of how to use material learned in giving parenting advice
4. List of printable parent handouts related to the selected topic with a link or URL to access the documents online in the future
5. Opportunity for group discussion (because of time limitations, group discussion was optional and occurred without the use of guiding questions)
Continuity clinic faculty and residents viewed lectures and example videos together during 5- to 10-minute didactic sessions before clinical activities at the beginning of each continuity clinic half-day. Viewing took place once weekly over 4 weeks during March and April 2016.
The TPDC was evaluated using the first 3 levels of the Kirkpatrick evaluation framework: level 1, satisfaction with the curriculum; level 2, change in knowledge; and level 3, self-reported behavior change regarding provision of parenting advice.
14,15
A survey regarding confidence and knowledge in parenting topics was emailed in March to residents before the TPDC was implemented. Resident parenting confidence was assessed through 2 survey items using a Likert scale of 1 (“not confident at all”) to 5 (“very confident”): (1) “Please describe your confidence discussing parenting discipline strategies with parents of toddlers” and (2) “Do you feel confident locating and/or identifying handouts for parents regarding toddler parenting and discipline?” “Twelve multiple-choice questions assessing resident knowledge of parenting advice were taken or adapted from the American Board of Pediatrics board examination preparatory question banks. After the TPDC was completed in April, residents were emailed the same survey to determine their confidence and knowledge in parenting topics.
In addition, 6 weeks after participation in the TPDC, exit surveys were emailed to all participating residents and faculty to assess the feasibility and acceptability of the TPDC. The exit surveys had 9 questions. Residents were asked how many of the modules they completed, were asked to rate the modules from “poor” to “excellent,” and were asked how long on average they spent on the modules each week. In addition, residents also self-reported use of TPDC information (“How many times have you been able to implement the skills you learned from the toddler discipline modules?”) with patients and their families in the 6 weeks after the modules were completed. They were also asked to provide qualitative free text responses to the questions “What did you enjoy most about the modules” and “What would you change about the modules?” There were three “yes” or “no” questions regarding whether participants planned to use the resources provided, whether they had difficulty accessing or using the modules, and whether they would be interested in participating in more modules.
All surveys were completed electronically and anonymously at a time convenient to the respondent without a time restriction. The surveys were created by the same team of child development experts who created the curriculum. Surveys stated that participation was entirely voluntary. While participation in the curriculum was incorporated into the typical didactic session preceding residents’ continuity clinic, survey consent was implied by completion of the surveys, which stated, “Your completion of this questionnaire is entirely voluntary. Full completion of the questionnaire will provide the most useful information, but you may opt to leave a question blank at any point if you do not feel comfortable answering it.” Demographic information was not collected in the surveys.
At the time of this study, there were 61 residents (49 pediatrics residents and 12 internal medicine–pediatrics residents) at OUHSC who met the inclusion criteria. Forty-one of the 61 residents (response rate, 61%) completed the survey before the TPDC was implemented. Although demographic information was not collected in the survey,
Table 1 reports these data for the 61 residents who met the inclusion criteria. Most residents were female and either white or Asian. Of the 33 residents who completed the post-TPDC survey, 8 completed 1 to 3 modules, 21 completed all 4 modules, and 4 did not complete any of the modules and were excluded from analysis. Twenty-nine residents responded to the exit survey.
Table 1.
Demographics of All Pediatrics and Internal Medicine–Pediatrics Residents, 2015-2016 (N=61)
| Demographic Characteristic | No. (%) |
| Residency | |
| Pediatrics | 49 (80.3) |
| Internal medicine–pediatrics | 12 (19.7) |
| Year of Residency | |
| First | 20 (32.8) |
| Second | 20 (32.8) |
| Third | 18 (29.5) |
| Fourth | 3 (4.9) |
| Sex | |
| Female | 43 (70.5) |
| Male | 18 (29.5) |
| Race | |
| American Indian/Alaska Native | 1 (1.6) |
| Asian | 17 (27.9) |
| Black | 5 (8.2) |
| Hispanic/Latino | 1 (1.6) |
| Hispanic-Latino/white | 1 (1.6) |
| White | 36 (59.0) |
Table 1.
Demographics of All Pediatrics and Internal Medicine–Pediatrics Residents, 2015-2016 (N=61)
| Demographic Characteristic | No. (%) |
| Residency | |
| Pediatrics | 49 (80.3) |
| Internal medicine–pediatrics | 12 (19.7) |
| Year of Residency | |
| First | 20 (32.8) |
| Second | 20 (32.8) |
| Third | 18 (29.5) |
| Fourth | 3 (4.9) |
| Sex | |
| Female | 43 (70.5) |
| Male | 18 (29.5) |
| Race | |
| American Indian/Alaska Native | 1 (1.6) |
| Asian | 17 (27.9) |
| Black | 5 (8.2) |
| Hispanic/Latino | 1 (1.6) |
| Hispanic-Latino/white | 1 (1.6) |
| White | 36 (59.0) |
×
Among the 41 residents who responded to the initial survey (prior to TPDC participation), median (interquartile range [IQR]) resident confidence in discussing parenting strategies with parents of toddlers and locating or identifying handouts for parents regarding toddler parenting was 3.0 (2.0-4.0) on a 5-point scale for both items. After TPDC participation, the median (IQR) scores for those completing 1 to 3 modules rose to 3.5 (3.0-4.0) and 4.0 (3.0-4.0), respectively, and for those completing all 4 modules rose to 4.0 (4.0-4.0) and 4.0 (4.0-5.0), respectively. Median (IQR) total confidence score (obtained by adding both confidence scores and thus on a 10-point scale) rose from 6.0 (4.0-7.0) before the TPDC to 7.0 (6.0-8.0) for those who completed 1 to 3 modules and to 8.0 (8.0-9.0) for those who completed all 4 modules (
Figure and
Table 2). Individual confidence question scores and total confidence score increased significantly from the pre-TPDC to post-TPDC survey (Mann-Whitney test,
z=5.0,
P<.001). For those who completed 4 modules, the median total confidence score was significantly higher than before the TPDC (Mann-Whitney test,
z=5.0,
P<.001) and higher than that of those who completed 1 to 3 modules (Mann-Whitney test,
z=5.0,
P=.02).
Table 2.
Median (IQR) Confidence and Knowledge Scores Before and After Participation in the TPDC
| | After TPDC |
| Measure | Before TPDC (n=41) | Completion of 1-3 Modules (n=8) | Completion of All 4 Modules (n=21) |
| Total confidence scorea | 6.0 (4.0-7.0) | 7.0 (6.0-8.0) | 8.0 (8.0-9.0) |
| Knowledge scoreb | 8.0 (7.0-9.0) | 8.5 (7.5-9.5) | 9.0 (7.0-9.0) |
Table 2.
Median (IQR) Confidence and Knowledge Scores Before and After Participation in the TPDC
| | After TPDC |
| Measure | Before TPDC (n=41) | Completion of 1-3 Modules (n=8) | Completion of All 4 Modules (n=21) |
| Total confidence scorea | 6.0 (4.0-7.0) | 7.0 (6.0-8.0) | 8.0 (8.0-9.0) |
| Knowledge scoreb | 8.0 (7.0-9.0) | 8.5 (7.5-9.5) | 9.0 (7.0-9.0) |
×
Before TPDC implementation, resident median (IQR) score (number of questions answered correctly out of 12) on board-style questions was 8.0 (7.0-9.0). Median (IQR) knowledge score rose to 8.5 (7.5-9.5) for those who completed 1 to 3 modules and to 9.0 (7.0-9.0) for those who completed all 4 modules (
Table 2). However, total knowledge score did not differ significantly across groups (Kruskal-Wallis test, χ
22 = 3.136,
P=.2), and on an itemized analysis of each knowledge question, responses were similar between groups.
In the exit survey, when residents were asked 6 weeks after TPDC completion whether they had applied the skills they learned, 28 of the 29 responding residents (96.6%) reported skill implementation. Regarding frequency of using the skills, of 28 respondents, 18 (62.1%) reported 1 to 5 times, 7 (24.1%) reported 5 to 10 times, and 3 (10.3%) reported 10 to 15 times.
Of 29 respondents, nearly all residents (27 [93.1%]) were interested in participating in more parenting modules during continuity clinic. When asked what they enjoyed the most about the TPDC, residents indicated that the videos and the modules were “quick” and “concise.” Furthermore, the module content was “helpful and practical,” “very informative,” and “pertinent”; had “easy and effective skills to practice”; and was helpful in “learning useful information that I could share with patients.” Additionally, residents reported that the resources for parents, “discussion after the modules,” and format of the modules were helpful.
When asked what they would change about the modules, several commented “nothing” and “continue as they are.” One suggested making the modules “more interactive,” and another suggested adding “a short bullet point list overview at the end of each module.”
On a 4-point Likert scale (4 being excellent), exit survey results from faculty (n=9) revealed a mean (SD) feasibility and acceptability rating of 3.7 (0.5), whereas residents reported a mean (SD) rating of 3.5 (0.5). Regarding the length of time spent completing a module, 2 residents (7.4%) stated that it took up to 5 minutes, 12 (44.4%) stated 5 to 10 minutes, and 13 (48.2%) stated 10 to 15 minutes. Additionally, 27 of 29 residents (93.1%) stated they did not have difficulty accessing or using the modules, and 26 of 27 residents (96.3%) stated that they use or plan to use the resources suggested in the modules.
The unique curriculum created for this project was concise, multifaceted, and interactive. Additionally, the learning objectives were related to board examination contents. Confidence in delivering parenting advice improved significantly for residents who completed the pilot curriculum. Knowledge on toddler discipline increased; however, results were not statistically significant, perhaps owing to the small sample size. The TPDC was found to be feasible and acceptable by faculty and residents, and almost all residents reported using the skills they learned during clinic visits with patients and their families.
According to the tenets of osteopathic medicine, “The body is a unit; the person is a unit of body, mind, and spirit.”
1 For children, extrinsic forces that influence a child's mind and spirit include the child's interactions with his or her parents, and this interaction can influence the child's health.
2,3 Thus, this curriculum directly addresses important components of osteopathic pediatric medicine that should be addressed within other residency programs that serve pediatric patients. This curriculum would support important components of pediatric osteopathic medicine around the topic of parenting and discipline. In addition, the TPDC addressed the Accreditation Coucil for Graduate Medical Education's Core Competency for Interpersonal and Communication Skills: “Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.”
16
This study had several limitations, including a small sample size at only 1 institution. Also, because the pre- and post-TPDC surveys could not be linked, group comparisons were treated as independent samples. This comparison, however, likely provides a conservative estimate of the effect of the intervention compared with using a paired samples comparison method. Additionally, due to logistical challenges, the study design did not include an observation of resident-parent interactions. Furthermore, we did not follow patients to monitor long-term outcomes, such as child maltreatment. It should also be noted that there was no control group in this study; however, creating a control group would have limited the learning opportunity for the residents.
To further assess the impact of the TPDC, parents could be queried regarding perceptions of parenting advice from physicians who have completed the TPDC compared with those who have not. Furthermore, follow-up studies that involve observational components through a patient/parent simulation model or live clinical observations could assist in modifying and improving the existing TPDC.
Subsequent parenting modules covering other relevant parenting topics could be created in a similar fashion to the TPDC. Additional topics that could be considered include parenting school-aged children, parenting adolescents, and parenting children with complex medical needs.
Data from other studies are encouraging, but physicians’ advice on parenting needs further study, including the type of advice given, the resources from which advice is derived, and the training received during residency in providing advice on parenting.
17 Periodic surveys of members of the American Academy of Pediatrics have shown that over time, pediatricians have increased their discussions of disipline with parents, and 51% of pediatricians discuss discipline in 75% to 100% of wellness visits.
18 However, in other studies, only 23% to 43% of parents perceived that their physicians discussed discipline during their child's examinations.
19,20 This further highlights the need for clear and helpful parenting advice provided to patients and their families by physicians. The TPDC is one effort toward improving the provision of parenting advice to parents. Our results showed that residents used the material they learned with their patients and families, and residents were more confident in doing so.
One barrier to the use of parenting curricula is time, and while prior curricula include up to 12 hours of training, the TPDC was implemented in 5- to 10-minute sessions before continuity clinic.
7 Thus, the TPDC offers a multifaceted, effective, and succinct way to implement parenting concepts to pediatric and internal medicine–pediatric residents and provides an option for programs needing a succinct way to train residents in parenting concepts.
This curriculum increased resident confidence in delivering parenting advice. Knowledge on toddler discipline increased, though not to a statistically significant degree. The curriculum was feasible, acceptable, and subsequently used by residents with their patients and their families. Thus, implementation of the TPDC at other institutions would likely be feasible and valuable for resident education and care of the whole patient. Use of the TPDC at other institutions could result in improved resident confidence and knowledge related to the delivery of parenting advice, which could positively affect parenting strategies used by parents of toddlers in their clinics and thus improve pediatric patient health. Pediatric residency programs should consider implementation of the TPDC or other similar parenting curricula in an effort to improve resident provision of parenting advice.