AAP Voices Blog

People Don’t Care What You Know Until They Know That You Care 

As a psychologist who specializes in infant and perinatal mental health, I chose to work in the pediatric primary care setting because well-child care is a nearly universal touchpoint. I see patients ages 0-3 years and their families in a pediatric clinic in New York City. By collaborating with a pediatric health care team, I am able to support healthy development and family well-being, which is critical for early brain development and lifelong health. 

However, with multiple competing demands, providing effective care can be difficult. Primary care visits can be short, problem-focused (rather than family strengths-focused), and formulaic. This can lead to provider burnout, decision fatigue, unintentional bias, and, subsequently, a decrease in quality of care. It seems there is never enough time to address growing mental health needs and an increased demand for services, which is concerning given that the most common obstetric complication affecting caregivers and infants – postpartum depression – has tripled in rates since the onset of COVID. 

What can be done to provide postpartum depression intervention within the pediatric primary care setting that is accessible and effective amid a growing mental health crisis?  

With this question in mind, in 2023, I had the opportunity to participate in the Perinatal Depression Learning Community hosted by the AAP. I enrolled because I was seeking more support for the parents and caregivers I see in our clinic and some practical strategies to overcome all the challenges we see. During these seven 90-minute sessions, I learned from collaborative and supportive discussions with both faculty and peers. Among my most important takeaways was the importance of relationship-based care. Positive relationships, including communication focused on building partnerships, between providers and caregivers foster trust and protection and bolster the effectiveness of interventions. I had the opportunity to learn a relationship-based model of care that all levels of pediatric primary care staff can deliver —Facilitating Attuned Interactions, or FAN. FAN spans 5 domains: 

1. Mindful Self-Regulation: The provider notices their own emotions or reactions and takes steps toward self-regulation.  
2. Empathic Inquiry: The provider offers emotional support and attunes to how the caregiver is feeling. 
3. Collaborative Exploration: The provider works with the family to understand their concerns and they make a plan together to address them.  
4. Capacity Building: Once a plan is identified, the provider works with the family to teach or build new skills that address their concerns. 
5. Integration: In this last section, the provider and patient reflect on the new learning or insight gained during the encounter.  

Emphasized throughout the FAN model is the importance of first building a relationship with the caregiver and ensuring that both the caregiver and the provider are ready to move to the next phase of the arc. The strength of this model is that it centers attunement in all phases, increasing engagement with the family and prioritizing what matters most to the family. This strengthens the relationship between provider-caregiver and caregiver–infant (i.e., parallel process), which ultimately increases the efficacy of the intervention.    

The pediatric primary care clinic that I work in serves a historically underserved community. Almost 80% of patients identify as racial and ethnic minorities and 90% are publicly insured. There are times when I am overwhelmed by the enormity of the psychosocial stressors our patients face. I recently saw a 2-month-old whose appointment was initially for mild eczema, but during the visit, the patient’s mother also screened positive for postpartum depression. I had already seen several caregivers that day who also screened positive for depression, and I began to feel the weight of the growing mental health needs of our patients and the chaos of the clinic day.    

“It reminds us that supporting infant health begins with a connection and support to the caregiver.” 

  
I used the FAN model to structure my next visit. Before entering the room, I started with Mindful Self-Regulation, allowing myself to acknowledge that as much as I love the work I do, it is also hard. After a moment of self-compassion, I was able to be more present with the mother and her child. As the mother began to share that she did not know what to do about her baby’s fussiness or eczema, I resisted my initial urge to quickly solve the mother’s concerns. I did not reassure her that her baby’s eczema is mild and common or provide education that the crying curve peaks between six and eight weeks and her baby will likely be less fussy soon. Instead, I started at Empathic Inquiry and asked her to share how it has been for her to care for her son and tried to see the baby that she saw. Soon, the mother began to tearfully share that she frequently blamed herself for her son’s pain because of her history with eczema as an infant. I concluded by affirming that I heard her story, guilt, and pain and that I saw her desire to do the best for her baby. 

Only after the experience of attunement resulted in her regulation did we move into Collaborative Exploration. We wondered together about what might be happening with the dyad of this mother and son—how the eczema, typical newborn fussiness and crying, and the guilt were all contributing to the larger picture of this mom’s postpartum mood. We explored what her son may be trying to communicate and that perhaps it was not always about eczema discomfort. After finding common ground in our understanding of her son’s needs and her own, we moved into Capacity Building. We highlighted the ways she attuned to and soothed her son, even in the exam room. She shared how he started smiling at her and interacting more with her and the delight she experienced in those moments. We reviewed a couple of strategies for soothing along with a couple of ways she could take care of herself when she felt overwhelmed or inadequate as a caregiver. We ended with Integration where the mother shared that she would take with her reminders of her favorite part of being his mother and affirmed confidence in the ways she was already doing a good job. 

My use of the FAN with this family, and many others, reinforces that how we deliver care is just as important as the intervention itself. By inviting providers to pause and become attuned listeners before jumping to solutions, the FAN model challenges us to center building strong relationships between provider and caregiver. It reminds us that supporting infant health begins with a connection and support to the caregiver.  

Through the power of a simple pause and moment of reflection, I learned how I can offer a different kind of relationship-focused care for postpartum depression. We can leverage the accessibility and trust of the primary care setting and center the power of relationships by seeing and hearing caregivers so that they can see and hear their own babies. This is what ultimately promotes maternal and infant health.