Background
Infancy and early childhood are vulnerable periods of brain development [
1], and strong indicators of risk linked to brain development are evident by age three years [
2]. Multiple risks and resilience factors affect infant mental health, and deviant behaviour in infants and young children is associated with psychopathology later in life [
1,
3]. Thus, identifying and addressing health risk factors in infancy and early childhood may avert future physical and mental health problems [
4‐
6]. Parent-child interaction and relationships are the most important factors affecting infant mental health; low parental sensitivity (responsiveness) and insecure or disorganised attachment constitute significant risk factors, whereas sensitive parental behaviour and secure attachment serve as protective factors [
1,
7‐
10]. Parental behaviour is in turn affected by parents’ psychosocial circumstances [
1,
11,
12]. These include poor mental health [
11,
13‐
16], poor general health, split homes [
17], low income [
16], more than three children in the home, multiple moves [
11], domestic violence [
13,
16], lack of social support [
13] and low maternal education [
14]. Furthermore, economic stress and relationship stress can directly influence maternal depression [
9]. Addressing parental psychosocial functioning may therefore be important when aiming to detect and mitigate risk factors in infancy and early childhood and improve future health in children [
1,
18‐
20].
Many healthcare systems offer developmental assessments to monitor child development and to identify preventable health problems early [
21‐
24] by so-called universal prevention [
1]. Developmental assessments are offered in different settings [
25], and provide an opportunity to detect risk factors and potentially refer to relevant interventions [
18‐
20,
24,
26]. The approach to preventive developmental assessments is, however, heavily influenced by cultural factors affecting both the process of the assessments and the expectations held by healthcare professionals and caregivers regarding the clinical focus [
22,
23,
25]. Traditionally, developmental assessments have their main focus on the physical examination [
26‐
28], and assessment of the child’s environment including parental psychosocial circumstances has never gained equal status with physical assessment [
29,
30]. This is reflected in the inconsistency in which clinicians assess psychosocial factors and in the parents’ expectations of the developmental assessments [
29,
30].
We have previously examined clinicians’ views on having an increased family psychosocial focus during the developmental assessments reinforced by use of structured child records [
31]. While the clinicians usually had a systematic approach to addressing and examining physical development, it was novel to approach parents’ psychosocial circumstances systematically. Through use of the structured child records, clinicians gained an increased psychosocial focus, which improved their knowledge of the families, strengthened clinician-parent relationship and helped uncover psychosocial challenges early in the child’s life. Addressing family psychosocial circumstances did sometimes raise feelings of discomfort in the clinicians, especially when addressing sensitive matters not expected by the parents or if clinicians did not have a solution to the parents’ psychosocial challenges [
31]. Clinicians considered that the reasoning behind addressing parental psychosocial aspects might not be obvious to parents attending developmental assessments with their children. Thus, there is a need to explore parental views on an increased psychosocial focus in the developmental assessments to discover whether parents find it meaningful and acceptable, and to establish their views on how these topics can be covered.
Based on the study of clinicians’ experiences with the structured child records with increased psychosocial focus [
31], we generated the hypothesis that most parents would not initiate discussion of their psychosocial circumstances during their child’s development assessments. The Health Belief Model was found relevant in shedding light on factors important to changing parental perspectives on psychosocial discussions at these assessments [
32]. The Health Belief Model has previously been used to examine parental behaviour towards their children, for example in relation to acceptance of vaccines [
33]. It builds on the idea that in order to be motivated to change behaviour, there should be a potential treat (perceived susceptibility and severity) and the benefits of changing behaviour should outweigh the burdens [
32]. Often cues to action can be identified, in the form of factors facilitating the change of behaviour [
32].
The current study investigates parental perspectives on the implementation of developmental assessments with an increased psychosocial focus, aided by structured child records within Danish general practice. The aim of this study is to explore parents’ experiences of these child developmental assessments, which include discussion of the family’s psychosocial circumstances within the consultation.
Discussion
Parents found it meaningful to discuss family psychosocial functioning with the clinician during their child’s developmental assessments, since they believed that the wellbeing of the family influences the wellbeing and development of the child. Despite various backgrounds, most participants had experienced psychosocial challenges in relation to becoming parents. Overall, they believed that the clinician could help the family’s psychosocial challenges e.g. by giving advice or making referrals. Barriers to disclosure by parents of their psychosocial circumstances included time pressure, stigmatising questions and lack of knowledge about how the information would be used. Positive actions included the clinician leading the conversation about psychosocial aspects along with attention to their communication style. Furthermore, parents found potential for improved expectation alignment to facilitate discussion about psychosocial aspects.
In developmental assessments, physical examinations are known to be expected and accepted by parents in line with findings of this study [
31,
41,
42]. Parents have emphasised that developmental assessments also constitute a unique opportunity to discuss their child’s development along with their own concerns [
41]. Parental concerns have proven an important indicator for abnormal child development and behaviour [
43‐
46], however, concerns regarding child behaviour and development are often overlooked or not handled adequately [
46‐
48]. Furthermore, only a third of parents voice their concerns about their child to the GP [
46]. In line with findings of this study, parents have previously addressed the importance of clinicians initiating conversation about topics outside the physical focus [
41].
In accordance with our findings, child development and behaviour are culturally accepted topics during developmental assessments [
29,
30,
41,
42], while psychosocial aspects related to the family are often viewed as more sensitive [
29] and difficult to identify [
49]. Postnatal depression screening might offer a useful comparison. A systematic review investigating its implementation found that women “might feel anxious and reluctant to answer questions honestly” [
50](p. 338). As in our study, expectation alignment was an important factor when introducing a sensitive topic: if the mothers were informed about the content and purpose in advance, the questions would be more acceptable [
50]. Maternal mental health was a topic that mothers in this study found very appropriate to discuss during the developmental assessments. This might relate to the fact that health visitors offer all Danish mothers postnatal depression screening, and therefore it would not be novel to them to discuss their mental health with a clinician. Expectations influence satisfaction with clinical encounters [
51], thus use of a pre-consultation questionnaire can facilitate discussion of concerns, improve time management, increase support and patient satisfaction [
52]. Furthermore, patients’ concerns identified with pre-consultation questionnaires are often not expected by clinicians [
53]. Similarly, questionnaires have been suggested prior to developmental assessments to help align expectations and manage time [
31,
41,
42]. The results of this study indicate that parents have mixed feelings about this idea. It could pose problems if parents felt the questions off-putting or stigmatising or if they did not answer honestly [
51]. In such a case, the developmental assessment could get off to a bad start. Pre-consultation information or expectation alignment without a questionnaire could potentially improve the acceptability of discussing psychosocial aspects.
In line with our findings, previous studies have also pointed to the need for extended consultation time when addressing psychosocial factors [
30,
31,
41,
47,
54]. Pre-consultation preparation might improve time management, but an increased psychosocial focus in the developmental assessments might require less time to be spent on other aspects like physical examination.
Communication was identified as an important theme and interpersonal communication theories might be more useful to shed light on how to change parental communication behaviour [
55]. Shared decision-making plays an important role, thus talking about psychosocial aspects during developmental assessments has to be negotiated between parents and clinicians while respecting parental autonomy and preferences [
55]. Clinicians having an open-minded attitude and interested communication style as well as parental trust in their clinician are other important factors that influence the acceptability of addressing psychosocial factors [
29,
30,
55‐
58]. Disclosing private information involves boundaries regarding whom the information is shared with and mechanisms to protect the information from outsiders [
59]. Seen in this light, it is understandable that parents have concerns when disclosing psychosocial aspects and about how their information is used. Furthermore, parents prefer a flowing conversation about psychosocial aspects, giving them opportunities to explain and ask clarifying questions [
50]. Addressing psychosocial aspects in a flowing conversation contribute to the clinician appearing sincere and interested. It reduces the fear of being judged and makes it easier to be honest [
50].
While developmental assessments are widely used in many western countries, there is variation in where they occur and who conducts them [
22‐
25,
60]. This could lead to a debate about what is most efficient or whom parents prefer to turn to with concerns about their children. Parents with children who previously experienced health problems might primarily consult their GP regarding their child’s behaviour, while young mothers tend to use their health visitor to discuss their child’s behaviour [
61]. Some mothers at risk felt especially vulnerable when a health professional was visiting their home [
56,
58], which can be a barrier for discussing psychosocial challenges. Others have suggested that psychologists would be better equipped to discuss psychosocial challenges [
49,
62], but it is unlikely that they could provide a universally accessible service. Preferences differ and may depend on previous experiences, established relationships and ‘chemistry’ with the clinician [
56,
58,
61]. The different types of clinicians have different attributes regarding time frame, continuity, knowledge of family history, facility to visit family homes, expertise etc. Most important, collaboration and cross-referral can play an important role in assessing and handling children’s psychosocial wellbeing [
30,
62,
63].
The paternal perspective is largely absent from the current paper as only one father was included. We know from to the literature that paternal mental ill-health can lead to adverse child outcomes by a combination of pathways, modified by child characteristics and parental psychosocial factors [
64]. Fathers tend to seek support related to parenting and mental health among their social network or they may seek informational support online [
65,
66]. Some turn to their GP when mental health problems become severe [
65,
67]. Formal support from paternal groups is rarely accessible but may be desired by fathers [
65,
66,
68]. Some fathers have previously emphasised the importance of addressing and normalising psychosocial challenges related to becoming a father [
67,
69].
Strengths and limitations
There were certain strengths to this study: During sampling, variety in socioeconomic status was sought along with variety in clinicians’ psychosocial focus was ensured by recruiting from both the intervention group and the control group of Project Family Wellbeing. All the participants had attended at least two developmental assessment in general practice prior to the interview.
The study also posed limitations: The fact that clinicians agreed to participate in Project Family Wellbeing could be associated with them having more interest in psychosocial aspects and mental health compared to clinicians outside the study. If this is the case, it is plausible that they were better at implementing the novel child assessments and discussing the family psychosocial environment compared to other clinicians, and that would affect parents’ experiences. At the same time, the families who agreed to participate in Project Family Wellbeing might have been more open to discussing psychosocial challenges compared to the wider population. In Denmark, the population in general has high living standards. It could have been useful to include vulnerable participants (or from low socioeconomic status), however, these could not be identified within the cohort.
Only mothers were recruited, except for one interview that was conducted with both parents including the father. More effort could have been put into illustrating the paternal perspective, but Project Family Wellbeing generally experienced challenges in recruiting fathers, which will be described in a separate paper.
The first author/interviewer’s (SV) former position as a doctor in general practice might have affected the participants’ answers [
70]. All authors were, however, aware of this during analysis.
Implications for practice
Checklist systems have been proposed to help increase the psychosocial focus in child consultations [
20,
30,
62], in line with the purpose of the structured child records used in Project Family Wellbeing. The results of this study indicate that the structured child records allowed systematic data gathering in the consultation without parents experiencing it as a questionnaire-driven process. The actual questions were individualised and adjusted to the family and the situation allowing a flowing conversation as oppose to screening tools, which parents found important.
Aligning expectations prior to the developmental assessments could contribute to normalising psychosocial aspects being addressed in the consultation [
31,
41,
50,
51]. This have recently been attempted with pre-consultation information to parents aiming to prepare them for psychosocial questions during the developmental assessment [
71]. In Denmark, digital secure mails are sent to parents reminding them to schedule their child’s immunization. Similarly, an invitation to the developmental assessments could be sent to parents including an information letter about the purpose of the visit. It could also encourage parents to consider what they want to discuss and if they have any specific concerns.
Clinicians conducting developmental assessments need adequate training in interviewing and counselling techniques to be equipped to address disclosure of psychosocial challenges [
31]. Explicitly addressing the presence of sensitive topics and setting the boundaries could ease parental concerns and show respect for patient autonomy [
59]. Our findings align with the principles of the reciprocity rule in patient-clinician communication in which clinicians offer counseling or referrals in exchange for patients/parents sharing sensitive information [
31,
59]. To effectively navigate these interactions, clinicians might benefit from training in brief counselling techniques and strategies to help families activate their resources and apply useful coping techniques [
72].
Implications for research
Evaluation of counselling techniques to assist clinicians in helping parents handle psychosocial challenges could be beneficial [
31,
72]. In addition, creating closer collaboration between different actors (e.g. GPs, nurses, health visitors and social workers) could improve the way families’ psychosocial challenges are handled [
30,
62,
63] Further research is needed to identify focus points and to test strategies in this area.
The implementation of structured child records with increased psychosocial focus should be investigated in other regions with similar health care systems. Other approaches to increase psychosocial focus in the developmental assessments should be examined as well. Besides evaluating clinicians’ and parents’ experiences, quantitative outcome measures could be included - for instance number of counselling sessions, referrals and diagnoses. Finally, more research in developmental assessments is needed to gather evidence of the predictive validity of the various elements (e.g. discussion points and tests) of developmental assessments.
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