Fathering in the Early Years: How family physicians can help

1. Fathering in the Early Years: How family physicians can help FIRA conference Toronto, October 24, 2008 Bill Watson, MD, FCFP St. Michael’s Hospital University of Toronto

2. Role of the Family Doctor Ante partum Intra partum Post partum

3. Antepartum • Prenatal visits • General health assessment

4. Intrapartum • Acknowledgement • Keeping in the loop • Jobs to do

5. Postpartum • The biggest task by far!!!!!!!

6. Case 1 • Bill, a 32 yo father, has a difficult year with his son having frequent bouts of bronchiolitis and hospital admissions. In addition, his workplace has been very stressful for him. • While his son is in for a check-up, the doctor notices that Bill has gained a lot of weight. It turns out that he has gained 40 pounds over the past year and his blood pressure is elevated.

7. Mens’ health postpartum • Increased use of HCP • Increased incidence of overweight, hypertension, diabetes and heart problems • Increased incidence of mental health issues, and substance use

8. Father Involvement • Implications for men on their own developmental path • Implications for mothers in co-parenting relationship • Implications for children (social, emotional, cognitive development)

9. Research on Father Involvement • Fathers typically relate to children differently than Mothers do • This promotes development of different competencies in the children • Fathers are important for healthy child development

10. Playing with Children • Fathers seem to influence children primarily through play • Different styles of play • Talked less, touched more • More rough and tumble style of play • Helps children learn about emotions • Practice point: suggest to your dads to get down on the floor for 15 minutes each day to play with your child Allen & Daly 2003, Yogman & Kindlon 1995, Brazelton, 1995, Lamb, 1998, Head Start Bulletin, 2004

11. Emotional Development • 5 month old boys more comfortable with strangers, vocalized more, cried less • More securely attached • Less depression, fewer negative emotions • Better self acceptance, personal and social adjustment • Practice point: before bed, ask about your child’s day Allen & Daly 2003

12. Talking to Children • Mothers explain more, fathers use fewer words • Fathers more tactile and physical, mothers more verbal and didactic • Time for bed exercise • Practice point: Make a point of talking to your child daily

13. Social Development Father’s involvement is positively correlated with: • Social competence, maturity, relatedness with peers • Empathic concern • Positive peer relations • Popular and well liked by peers • Positive sibling interactions Allen and Daly 2003

14. Absent fathers • 35% of all families in Canada are single parent • 2/3 of all black families are single parent • Children growing up without 2 parents have 2-3 times risk serious problems in the future

15. Absent Fathers Boys are more likely to have: • Behaviour problems, bullying • Problems with academics, delinquency • Lower measures of internal moral judgment, guilt, accepting blame, rule conformity Allen and Daly 2003

16. Absent Fathers Girls are more likely to have: • Cheating • Lying • Not feeling sorry for misbehaving • Bullying In boys and girls: • Higher incidence of mental health problems (anxiety, hyperactivity, depression, suicide) Practice point:ask your absent fathers about their children and educate them about the importance of their contact! Allen and Daly 2003

17. Co parenting Relationship • Fathers seem to withdraw from children when not getting along with their mothers • Optimal conditions for children occur when father lives with their mother, in a good partnership Allen and Daly 2003

18. Case 2: Ted, Jane and Ashley cont’d Family visit: • Ted says the house is in turmoil, Jane is rejecting of his help or affection • Ted says Jane is coping well but busier • Jane says she is overwhelmed • Ted feels on the periphery of family

19. Effect of childbirth on Marital Relationship • Less communication • Changes in Sexual relationships • Changes in sharing of household chores • 73% of parents reported feeling stressed and worn out following the birth of their first child • 55% felt they had received enough emotional support • 15 to 20 % of marriages end up separated or divorced by the child’s 4th birthday King, Rogers, Walters & Oldershaw 1995, Oldershaw 2002

20. Causes of Marital Conflict(Cowan 1992 ) • Lack of father’s involvement in household chores • Jealousy of maternal preoccupation with the baby • Difficulty adjusting to the changes in the marital relationship • Loss of intimacy • Decreased self esteem

21. Risk Factors for Couple Conflict after the Birth of a Child • Communication problems • Parent’s low self esteem or depression • Lack of readiness to become parents • Partner’s negative views of each other • Disagreement over division of family labour • Discontent of arrangements of child care • Pessimism about meeting the needs of both partners • Dissatisfaction with marriage overall • Unresolved issues of own childhood experience • Illness • Problems at the workplace Practice point: ask couples how they are doing?

22. Divorced and Separated Fathers • Need to separate parental from spousal roles and responsibilities • Encourage to stay strongly involved with children Baum 2004

23. Case #3 Hassan and Bindu • Both parents come for 2 week well baby check • Baby and Mom doing well • Mom is concerned about Dad’s lack of interest in the baby • Hassan seems sad and quiet, is having difficulties at work, depression 5 years prior • He feels child care is not part of his cultural role

24. Men’s Passage into Parenthood • Priorities remain same as pre birth • Increased sense of responsibility • Change in relationship with spouse, decreased communication • May feel isolated , with shifting perceptions of self, spouse, parents and friends • Often feel “shut out” of babies lives by mothers and by health professionals • Can experience “blues”, depression (1 to 25 % in community, 24 to 50 % in partners of women with PPD) • Family of Origin issues are very important Belsky and Kelly 1994, Cowan and Cowan 1992, Brandt 1989, Osofsky 1985, Goodman 2004

25. Do men get postpartum depression? • 1-20% in community studies, double in maternal PPD • Often associated with pre-morbid depression, or depression in their partners during pregnancy or postpartum • PPD in fathers can be significant and should be treated Practice point: screen for depression in fathers

26. Case 4: Joey and the temper-tantrums • John and Marie bring their 18 month old son, Joey, to your office for his check-up and immunization. They have done the Nipissing and it scores normal except for some difficulty with consonants. During the course of the examination, which was normal, both parents mention that they are becoming frustrated with Joey’s behavior. They cite biting, temper tantrums and screaming and his saying “no” to everything he is asked to do. John seems exasperated and asks you how to discipline his child. He seems a little embarrassed that his child is behaving this way. Both parents work and share equally in the child care and appear genuinely concerned. • What is Joey’s stage of psychological development? • What other information would you like to know about the family in this case? • How would you counsel Joey’s father about discipline. • What further information or resources could you provide for this family?

27. Fathers and discipline • One of the biggest challenges for fathers is selecting appropriate discipline for their children. • Discipline is all about modifying behavior, not about anger or retaliation. • Discipline is better understood as guidance and teaching, not controlling and punishing.

28. If you can answer yes to even one of the list below, this newsletter is for you.  It will, quite simply, transform your life:Which of these apply to your children? • Rude and defiant • Frequent temper tantrums • Won't take NO for an answer • Won't settle to bed • Won't do as they are told • Treat you like their personal slave • Won't do their homework • Aggressive or violent • Lying and/or stealing • Hyperactive, always on the go and into everything • Constantly in trouble at school • Sullen and moody • Poor self esteem, depressed, anxious • Won't go to school

29. And to you? • Tired and stressed • Feel like you are failing as a parent • Find yourself constantly shouting at your children • Arguing with your partner about how to manage the kids • Feel blamed or criticised by your friends, neighbors, school teachers, even doctors and therapists • Feel hopeless that you will ever have a normal, happy family life • Every day you fear that phone call from the school about yet another problem • Worried that your children will drop out, or be expelled from school • Worried that your children will end up on drugs or in jail • Considered putting the children into care as you simply cannot cope

30. Recurring questions from parents • Is there some way to get those kids of yours to behave? • Is there some way to replace stress, anger and chaos with fun, laughter and love?

31. Consequences of good discipline • Children learn appropriate behavior and self-control • Engagement in fun play, conversation and use of fair consequences are times when discipline can be used in positive, nurturing ways Head Start Bulletin, 2004

32. Consequences; positive and negative • Consistency important • Promises important-do what you say • Especially important when father does not live at home • Time-outs:allow parent and child to cool down

33. Teenage Fathers • Tended to be involved significantly in the lives of their children • Fathering helped them to have a more positive sense of self • Remember their life cycle tasks of maturation need completion Glikman 2004

34. Areas that could be explored by the Family Physician • Expectations of the parenting roles for mother and father • Renegotiation of the couple’s relationship (time, affection, intimacy) • Issues around sexuality in pregnancy and post partum • Division of household responsibilities • Couple communication and conflict resolution skills • Anticipatory guidance about life after baby • Practical advice and education (medical and psychosocial) • Support systems available (family, friends, parent groups etc.)

35. Practical Suggestions for New Dads • Take one to two weeks off work • Take a regular turn caring for baby (baths, diapers, walks etc.) • Limit visitors • Monitor Mom and Baby for problems (PPD etc) • Support breastfeeding • Increase household chores, errands etc. • Anticipatory guidance (development, etc)

36. Case #5: Ed, Sarah, and Anthony • 35 yr old Dad, 30 yr old Mom • Both come to 2 week well baby check • Baby is growing well • Both parents are enchanted with baby • No concerns

37. Case #5:cont’d • Parents have 3 other children in care of CAS • History of Alcoholism in both parents, they have both attended treatment, and have abstained for 6 months

38. Children of parents with substance use disorder (SUD) • Increased risk of childhood antisocial personality and conduct disorder • Decreased salivary cortisol response to an anticipated stressor among sons of SUD fathers • Hyporeactivity as an adaptation to chronic stress may be salient to the intergenerational transmission of substance abuse liability.

39. Community Resources-what/where are they? • Prenatal classes • Fathers programs • Parenting classes • Ontario Early Years Centres Practice point: check out community resources, go to a OEYC

40. Balancing the dual role of father/employee • Increased workplace stress • Fathers don’t talk about it • Paternity leave is available but still frowned upon in the corporate world

41. Tips to keep connected with your children while working • One on one with each child • Lots of hugs and physical affection • After work, enter the child’s flow • Talk about their day • If traveling, share details about the journey and what you are doing there, and call a lot

42. Summary • Evidence suggests that fathers are important for healthy child development • Physicians should make efforts to involve fathers in the care of children and provide role modeling where possible

43. Questions??