Parenting as Primary Prevention.

Social-emotionalandbehavioraldysfunctioncontributes substantially to adverse health outcomes such as obesity, asthma, and cardiovascular disease; poor quality of life; andexponentially increasinghealth care costs. Theseconditionsoftenhaveroots inchildhood,whenopportunities exist for primary and secondary prevention andearly intervention.However, theseopportunitiesare seldom realized for many reasons, including limited attention to behavioral and/or mental health concerns during pediatric and family medicine training programs andthe lowpriorityofprevention in theorganizationand financing of health care in the United States. Pediatric primary care practices have taken on the responsibility to be themedical home for children from birth through young adulthood. These settings offer a consistent, trusted,andsupportivecontext inwhichparentsandchildrenarewelcomedandencouragedto raise awide range of concerns and to access a variety of preventive and treatment approaches. Almost all children in the United States have a primary caremedical home and see a physician frequently during their first few years—for monitoring health, growth, and development, and for providing parental guidance. The2010PatientProtectionandAffordableCareAct (PPACA)promotespatient-centeredmedicalhomesthat incorporate mental health services for adults and children.1 Thehealth supervisionguidelinesofBrightFutures, published by the American Academy of Pediatrics, are incorporated into the PPACA, thus theoretically making a broad range of behavioral and mental health preventive services available to almost all of America’s children. Just as immunizations are provided on a recommended schedule in primary care to prevent infectious diseases, we believe that primary care settings also present a remarkable opportunity for primary prevention of many childhood and adult physical andmentalhealthmorbidities. Inaddition,anationalmomentumsupporting routineand repeateddevelopmental and behavioral surveillance and screening as a central responsibility of pediatric medical homes2 has createdanopportunity for secondarypreventionbyaddressingrisks forbehavioralhealthproblemsbefore they become severe. Almost all parents do the best they can to nurture andcare for their children, butmanyare limitedby their owneducational,mentalhealth,economic, social, and/or family circumstances. Education and support for parents to learn and practice important skills of parenting have the potential to promote supportive behaviors, parenting confidence, and their children’s well-being. From a primary prevention standpoint, by learning the principles of child development and strengthening their skills for interacting with and guiding their child’s social-emotional development, parents can learn strategies that promote cognitive and language development, emotion regulation, and attention skills in their children. Parents with personal risk factors such as depression or substance abuse may also be identified and linked to services available in the community or in adult medical homes. Programs that promote strong skills for parents of young children, such as the Family Check-Up program, Triple P (Positive Parenting Program), Incredible Years, andParent-Child InteractionTherapy, havebeenshown to improve parenting skills and children’s disruptive behaviors. Typically these programs have been centered in mental health settings and thus presuppose identification of the child’s behavior as “pathological” or representing “at-risk” parenting to justify access. Parents report hesitation in accepting such referrals because of the stigma attached to their children’s behavior and their own effectiveness. Participation in these programs is also detached from ongoing health care relationships or support, and payment mechanisms limit participation. There aremanybenefits of locating suchprograms instead in theprimarycarecontext: (1)Theybecomepart of theuniversal preventive “well-child” services that are accepted for all children. (2)Accessdoesnotdependon identificationofachildorparentaldeficitorproblem,and parentsare thusdetached from implicit critique. (3)Prevention occurs within the longitudinal continuum of a trusted relationshipwith thehealthcaresystem. (4)Programs can be made available to all parents who recognize challenges in their own or their children’s behaviors (primary prevention), or by referral based on screening for thewell-beingofchildrenand familymembers (secondary prevention). (5) Payment mechanisms can be made consistent with public and private insurance arrangements. (6) Perhaps most important, primary health care is the only current opportunity to provide prevention education and intervention for all children and their parents, beginning at birth and continuing through young adulthood. The Healthy Steps model, in itsoriginal formandvariousmodifications,3has pioneered the value of support and assistance for new parents in primary care. Several evidence-based parenting education programs have been integrated into primary care contexts with fidelity, and their effectiveness in improving parent strategies and decreasing problem behaviors has been demonstrated.4 Providing parent-focused programs such as these in primary care pediatric contexts presents considerable feasibility challenges, and requires changes in expectations, staffing patterns, and billing procedures. Emerging interest in creating pediatric primary care practices that provide both traditional health care and behavioral health expertise (collaborative or integrated care models) positions pediatric primary care to address child behavioral VIEWPOINT