Vathryn E. Barnard Parent-Child Interaction Model Jula MB. Fine CREDENTIALS AND BACKGROUND a ton University. She also worked as a private OFTHE THEORIST duty nurse, After earning her M.S.N. in June 1962 and a certificate of Advanced Graduate Specializa. tion in Nursing Education, she accepted a position as an instructor in maternal and child nursing at the University of Washington in Seattle. In 1965, she was named assistant professor. She began con- sulting in the area of mental retardation and coor dinated training projects for nurses in child devel opment and the care of children with mental retardation and handicaps. Barnard became the Project director for a research study to develop @ Kathryn E. Barnard was born April 16, 1938 in Omaha, Nebraska. In 1956, she enrolled in a Prenursing program at the University of Nebraska and graduated with a B.S.N. in June 1960. Upon graduation, she continued at the University of Ne- braska in part-time graduate studies. That summer, she accepted an acting head nurse position and be. ‘me an assistant instructor in pediatric nursing in the fall.’ In 1961, Barnard moved to Boston, M assa~ chusetts, where she enrolled in a Master's program i uthors: julia M.B. Fine, fill K. Baker, Debra A method for nursing child assessment in 1971. 7 "Debra Irnka Cochran, Karla G.Kallofen, Naney following year, she earned a Ph.D. in the ecology © (eae Jean A. Heacock, Hizabeth Godtey Terty, Cynthia A carly childhood development from the Universit The author neg tie Yeager of Washington.” Mhedhapten NK Kathryn F Barnard for reviewing In 1972 » Barnard accepted a position at the L a 484 Yersity of Washington as a professor in parent-childMs, { «_ since 1985, she has, momar of psychology at the University ot Weak Mon ad served a Associate Dean for Acadern jor the School of Nursing from 10x74 urs F recto h grants and projects, including the ey tion of Early Head Start pr 197910 the present, she has served as the principal researcher and advisor for the Nursing CI int Satellite Training Project (NCAST) In addition to these provided consultation, presented lectures interna tionally, and served on multiple advisory boatds for nursing and for state and national government. She has published articles in both nursing and nonnurs- ing journals since 1966, Her books include a four- part series on child health assessment, two editions related to teaching the mentally retarded and devel- opmentally delayed child, and work focusing on fam- ilies of vulnerable infants.’ Her most recent publica- tions focus on the efficacy of hospital and home-visit interventions for improving interaction between caregivers and their children and the long-range ef- fects of risk factors in either the caregiver or child.” Barnard is a member of the American Nurses As- sociation (ANA), where she has served on the Exec- utive Committee for the Division of Maternal and Child Health Nursing, She is also an active member of nine other national organizations, including the Society for Research in Child Development, Sigma Theta Tau, American Public Health Association, and the World Association of Infant Mental Health. 7 She and com> ard has served as the projeet 1 or principal investigator for more than 39 reseatl ams since 1996, Fp ld Assess- me! research efforts, Barnard has J on numerous advisory boards 'sof these and other professional groups In 1969, Barnard’ was presented with the Lucille Perry Leone Avward by the National League for Nur ing for her outstanding contribution to nursing ¢ Fellow of the American eof and of the Institute e Barnard with Ucation, She was elected Academy of Nursing in 19 Medicine in 1985.’ The ANA honored i the Maternal and Child Health Nurse of the Year Award in 1984 and named her the Nurse Sclentis the Year in 1987." In May of 1992, the American Ast ‘ciation for Care of Children’s Health Berar her with the 1. Brazelton Lectureship Award SMe R27, ‘athryn E. Barnard 485, Was the 1 ecip Thet 1M Of the ¢ 'a Tau in 1995, “Ameo Award from Sigma THEORE NICAL SOURCES, Although Barnard cites v th rious nursing theorists, such as Florence Ni : ence Nightingole, Viginia Henderson and Martha Rogers, their direct influence on her ee search and theory development is uncertain Uamard refers to the Neal Nursing Construct which has four expressions of health and illness oy se cognition, (2) sensation, (3) motion, and (4) affilia tion. Neal worked on a construct for practice” and, Barnard and her associates developed measures re: lated to the period of infancy. Barnard*!"*"% ined, stated, “In reviewing both the Maryland construct and the Washington research, we were impressed with how the design and results of the Nursing Child Assess: ment Project (NCAP) fit into the [Neal] construct.” Barnard credits Florence Blake for the beliefs and values making up the foundation of current nursing he descr bes Blake as: a great pediatric nursing clinician and educator [who] turned our minds toward an orientation on. the patient ratherthan the procedure. Blake saw the principal function of parenthood and nursing to be the capacity to establish and maintain constructive and satisfying relationships with others. She ampli fied for nursing important acts such as mother infant attachment, maternal care, and separation of child from parents, She helped nursing understand my the importance of the Many of Barnard’s publications were coauthored by writers such as King and Pottulo, indicating variety of influences, Barnard also coauthored the book, Teaching the Mentally Retarded Chil {t Family Care Approach. with Powell. OF greater Tfucnce were the coinvestigators and consul 2” faarnard and colleagues! state ants of the NCAP da hey were influenced by child. development such as Piaget, sal gaeral systems’ theory in addition fier d® states that Rubin's ing interventions dur- tha theorists, Brazelton, to nursi work was influ rey Brunner, Sander, and 13 theorists Lin et ing pregnaaso UNIT TV USE OF EMPIRIC AL EVIDENCE of mal cll, in the evolution of razelton, Ainsworth, and Bell, 0 t = ‘atehildl interaction and adapta tion” The rescarch findings contributed valu: ple Knowledge for the task of developing tools to assess ind measure the interaction between a caregiver nda child. In addition to tapping other conducted her own. She be} by studying mentally and phy children and adults, In the early 1970s, she st the activities of the well child and later expanded her study to include methods of evaluating the growth and development of children. The majority of these research studies were funded by grants from the US. Department of Health, Education, and Welfare and later the Department of Health and Human Services.” From 1976 to 1979, Barnard and colleagues from the University of Washington‘ initiated work to determine how research results could be communi- cated to practicing nurses across the nation. This led to the evolution of the NCAST. In 1977, Barnard began researching methods for disseminating infor- mation about newborns and young children to parents; in 1983, she commenced research with interventions for premature infants; and in 1996, she began projects to evaluate the national pro- gram, Early Head Start.°°” \ Barnard® continues to study the mother-infant re- lationship, examining the nurses’ role jh relation to high-risk mothers and infants. The NCAP formed the basis for Barnard’s Child Health Assessment In- teraction Theory. This was a longitudinal study of 193 caregiver-child pairs continuing from the prena- researchers, such as Barnard used findings her model of ? research, Barnard research in 1968 ally handicapped wudied hi Major Concepts DEFINITIONS ‘A major focus of Barnard’s work was devel- oping assessment tools to evaluate child health, growth, and development while viewing, the parent and child as an interactive system. Bar- nard stated that the caregiver-child system was influenced by individual characteristics of each Tlcorics and. Middle. Range Lhvovees tal period to the second grade"to identity po, Yevelopment] outcomes before they ig nine the variability of the scree “the NCAP team realized that any chy nd assessment plan mur ment gressed, 7 Tipe. hensive sereening beyond the child 10 the transactions betveen child and her social and physical environmen,» From the findings of this project in 1979, Barnarg fined the Nursing Child Assessment Feeding (Nejs and Teaching, (NCAT) scales.”” After use in numes Gus research studies, the NCAST instrumenty 2 mained “essentially unchanged” in the 1994 rey 2d evised form. Researchershave used the NCAST instruments far research and asa basis for public health nursing inter vention for families with problems including sub stance abusing, depressed, adolescent, and abusive parents.”? Barnard and colleagues'” developed and implemented the Nursing Systems Toward Effective Parenting-Preterm (NSTEP-P). Research using the NCAST instruments include populations of preterm infants, twins, infants with failure to thrive, infants with developmental disabilities, and infants exposed to human immunodeficiency virus (HIV).!°"" ‘The NCAST instruments have been standardized and normed for several different ethnic groups in cluding Caucasian, Hispanic, and African Amer: can.'° The instruments were also used to assess ur ban Native Americans,'”"* Alaskan Eskimos" and Hmong refugees.'® These researchers found that the instruments were useful for both research and clini cal use because the conceptual framework was unk versal,'* but recommend comparing scores (0 4° propriate group means and considering “the imps of culture and education”? member and that the individual characterist®® were also modified to meet the needs of the | Japtive beha tem, She defines modification as ad ; nd chil ior. ‘The interaction between parent and MY | is diagramed in the Barnard model in Figut®?”" | ooCHAPTER 27 Wathryn & Barnard 487 Major Concerts “DEFINITIONS —cont’d saynard as defined the terms in the diagram parnate getollows fANT'S CLARITY OF CUES IN snicipate in a synchronous relationship, the Te must send cues (0 his or her caregiver sige inf eres to engage or disengage in the inter- ee The skill and clarity with which these cues action Fill make it either easy or difficult for Megwers to discern the cues and make modifica- sarin their behavior. Ambiguous or confusing iis sent by an infant can interrupt a caregiver’ adaptive abilities." INFANT'S RESPONSIVENESS TO THE CAREGIVER | «The infant's ability to respond to the caregiver’s at- | tempts to communicate and interact.””""” The child responds to the caregiver by stopping crying, by vo- calizing, or by smiling. These behaviors reinforce the caregiving behaviors during an interaction. CAREGIVER’S SENSITIVITY TO THE CHILD'S CUES “The caregiver’s ability to recognize and respond to the child’s cues.”"” Caregivers modify their be- havior and use “timing, force, rhythm, and dura- tion. .. to set the tone of the interaction.””” CAREGIVER’S ABILITY TO ALLEVIATE THE INFANT’S DISTRESS “The caregiver's ability to soothe or quiet a dis- tressed child:””” This ability involves the care- Biver’s recognition of distress cues, selection of ap- Propriate action, and being available to recognize and respond. CAREGIVER’S SOCIAL AND EMOTIONAL GROWTH-FOSTERING ACTIVITIES Includes the affective dom “ates a positive feeling tone.”?” n and communi- “The caregiver sup- Plies a supportive environment using voice, tone, touch and movement. This reinforces caregiver PARENT’S COGNITIVE GROWTH- FOSTERING ACTIVITIES. | “The type of learning experience the caregiver makes available to the child.’*"" Caregiver verbal- izations, encouraging child response, and allowing exploration “are some examples of cognitive growth fostering, “The break in the arrow (//) represents inter- ference, an interruption in the adaptive process | that causes the interaction to break down. This in terference can originate in cither the caregiver, the child or the environment.”?°* As the NCAP continued, Barnard’s model be- came the foundation for her Child Health Assess- ment Interaction Theory. Three major concepts form the basis of this theory. characteristics of ‘physical appearance, temperament, feeding and sleeping patterns, and self regulation.” CAREGIVER The child’s caregiver has characteristics, “includ- ing psychosocial assets, physical and mental health, life changes, expectation and concerns about the child, and most important—the care- o208 givers care giving style and adaptation skills. ENVIRONMENT ‘The environment affects both child and caregiver and includes “available (or the lack of) social and financial resources such as the presence of a sup- portive adult, adequate food and housing, a safe home, and community involvement” CHILD In describing the child, Barnard used the personal From Sumnes Unies ee 4 Spietz, A. (Eds.). (1994). NCAST caregiver/parent-child interaction teaching manual. Seattle: NCAST Publications,488 lange UNIT IV Sheories and. Uhl Caregiver/parent choracteristics * Sensitvity to cues * Alleviotion of distress * Providing growth: fostering stations Re ure 27-1 Barnard Model. (From Sumner, G, & A. (Eds, ich choracteristics * Clarity of cues * Responsiveness to coregiver/porent (1994). NCAST caregiver/parent-child manual |p. 8). Seattle: NCAST Publi cations, University of Washington, School of sing.) MAJOR ASSUMPTIONS Nursing In 1966, Barnard defined nursing as “a process by which the patient is assisted in maintenance and promotion of his independence. This process may be educational, therapeutic, or restorative; it involves facilitation of change, most probably a change in the environment.” Fifteen years later, in 2 1981 keynote address to the first International Nursing Research Conference, she defined nursing 2s “the diagnosis and treatment of human responses to health problems.”** In the context of family centered care, the role is to assist families in provid- ing conditions that promote “growth and develop- ment of individual members.”?!"!7 Person When Barnard describes a person or a human being, she speaks of the ability to take part in an interac- tion to which both parts of the dyad bring qualities, skills, and responses that affect the interaction.” This term includes infants, children, and adults, Health of the six members of the Executive Com- mittee of the ANA Maternal and Child Nursing Di- Theories vision in 1980, Barna rd helped defi Scope of Practi ‘ne health ¢ Statement as: a forthe extent Purpose of ths document, health i¢ continaum that includes wellness and gee E being possesses various strengths and limitations resulting from the interaction of envinn a and hereditary factors. The relative cece the strengths and limitations determines w, a vidual’s place on the health. continu t ness to illness, Possible. Fog Viewed as 4 uum from wel. During periods ofillnes,trauma,or disability an individual or family may require varying degrees of Personal assistance in coping with the manifest Problem, with the treatment plan. designed to allevi ate the problem, or with the sequelae. During ods of wellness, an individual or family may require varying degrees of assistance to obtain information on matters of health, to receive anticipatory guid. + ance and therapeutic counseling to resolve prob- lems or to manage usual health practices when faced with a progressive or chronic health problem.'* Environment Environment is an essential aspect of Barnard!’ the- ory. In Child Health Assessment, Part fl: The Firs Year of Life,”* she states, “In essence, the environ: ment includes all experiences encountered by the child: people, objects, places, sounds, visual and tac- tile sensations.” The environment includes social and financial resources, other persons, and ade- quacy of the home and the community, all qualities that also affect the caregiver.’ THEORETICAL ASSERTIONS Barnard’s Child Health Assessment Intraton Theory is based on the following 10 theoreti assertions: 1, Im chil health assessment, theultimate #04 is to idertity problems at a point before ! ould be develop and when intervention woul most effectivefor determining child health outcomes, inf ple of @ dyad’s ongoing experiences and expectations ‘4, Each adult caregiver brings to caregiving a base personality and kil level that ithe foundation upon which their caregiving ski pendson these characteristics and character- istics of the child and of the environment. 5, Through interaction, caregivers and chib dren modify each other's behaviors. That is, the caregiver's behavior influences the child and, in turn, the child influences the care giver so that both are changed. 6, The process of adaptation of caregiver to in fant (and infant to caregiver) is more modi- fiable than the mother or infant's basic characteristics. Therefore in intervention, the professional should lend support to the way in which caregivers react to theit chil- dren rather than trying to change caregivers foundational characteristics. 7. An important way to promote learning is to respond and elaborate on child-initiated be- haviors and reinforce the child's attempt to try new things. 8. A maior task for the helping profession is to promote a positive early learning environ: ment that includes a nurturing relationship. 9, Assessing the child’s social environment in cluding the quality of caregiver-child inter action, is important in any CO} child health care model 10. Assessing the child’s physical environment § equall hild health assess- ment model.” mprehensive important in any ch The Child Health Assessment Interaction Model Was developed to illustrate Barnard’s theory Figure 2-2,."The smallest circle represents the child and histher important. characteristics 1994). NCAST aa a rom Sur nner G. & S Daten child interact Ah Permission, HAPTER 27 Hathryn E Barnard 489 Environment Rorosrcer Ironia Temperament Pagulotion Figure 27-2 Child Health Assessment Model (From Sumner, G. & Spietz, A. (Eds. (1994]. NCAST child interaction teaching manual |p. 3)- Seattle: NCAST Publications, University of Washington, School of Nursing.) caregiveriparent largest circle represents the characteristics of the caregiver. . . . The largest circle represents the en- vironment of both the child and the caregiver." ‘Those portions of the model where the circles overlap represent interaction between any two con- cepts. The dark center area represents interaction among all three concepts. Barnard’s theory focuses ‘on this crucial mether-child-environment interac- tive process.” LOGICAL FORM “According to Chinn and Kramer,'**! “With induc- tion, people induce hypotheses and relationships by Sbserving of experiencing an empiric reality and venching some conclusions.” Inductive logic is the form Barnard used in developing her Child Health reresment Interaction Theory: This theory was an the investigation and findings of the “tates that al of the theoretical as- ted by evidence from research outcome of the NCAP. Barnard sertions are Supper490 NITIV Shea vins and. Unhd lo ACCEPTANCE py T JE NURSIN COMMUNITY ° Practice Education The nursing satelite training project i satellite communication: Research Barnard has continued to refine the assessment scales and continues to conduct research. She is well Fecognized for her work. She has received awards Fecognizing her work from several organizations, in. cluding the American Medical Association, the ‘American Public Health Association, and Sigma Theta Tau International. The NCAST scales have been used in numerous research studies in both the United States and other counties. The University of Washington NCAST maintains a normative data bank with over 2100 observation records,2" FURTHER DEVELOPMENT Barnard’s model is a middle-range nursing theory, specifically targeting the caregiver-child relation. ship. The concepts are operationally defined and de- Th tailed. In a series ferent levels of preventive intervening hing has become “more focused on the Barn among the parent, child, and in nati model only includes the reatona Ppt Th Parent and child, not the Telationship of n° the Yenor with each. This is an ie « inte. development. OS Teng In the Child Health Ass ony Me caregiver is identified ag and all other humans are included, the dea of the environment, Barnard® has Noted th, - in Primary caregivers in Westen nang the mother’s employment and the tion of caregivers in nonWese scholarship and research hav nuclear family; we now need the young child is no essment Interaction Ty Kept Tidtign changes S thr contrast ine tn cultures, “Nunn been focused on ie to broaden our len, longer primarily in the carcoy Parents."""°? When there are multiple and gon. Parental caregivers, Barnard’s model may need tobe modified CRITIQUE Clarity * Clarity, in general, refers to how well the theorycan be understood and how con, stently the ideas are conceptualized.”"*"°! Barnard identifies all and de fines almost all of her model's concepts both seman: tically and operationally through the NCAST sas and uses the concepts consistently. “In a theory with structural clarity, . . . concepts are interconnected and organized into a coherent whole.”"*! Concep- tual interrelationships in Barnard’s Child Health As sessment Interaction Model are relatively easy ‘ot the reader to understand. Barnard is consistent in the use of an inductive form of logic. Simplicity The Child Health Assessment Interaction Model EB simple way of communicating the main focus Barnard’s work as it relates to the caregiver-chi ei teraction and the development of acurate ment tools. However, how interventions aft f° model is not easy to visualize. Seeking to clarilsahip could enise theme become omples mee Generslity original work involved inte rhe orii actions between the Thetyer and chill during the ehilds mee he . Subsequent work leng ‘ssment to 36 months, sonths of fil ay of the child riv Ir voaly, nurses can only generalize to caregive ps only 8 regiver-child Jmeractions in the first three years of life. "the rrent-child interaction model approaches. mick Pipge theory as defined by Chinn and Kramer." pe. spite the narrow scope, Barnard’s theory is applica, He not only to nursing, but also to other disciplines that deal with the caregiver-child relationship. “The trainees have expanded from nurses to other profes. Sionals including psychologists, psychiatrists, social workers, nutritionists, occupational and. physical therapists, early childhood educators, speech and hearing specialists and psychoanalysts.”* Empirical Precision Much research was included in Barnard’s original work. The scales were tested for reliability and estab- lished as reliable by studies of internal consistency and through test-retest procedures. By requiring certified NCAST training for clinicians or re- searchers to use the scales, Barnard and her col- leagues have ensured a high degree of precision and reliability in the many research studies using the scales. The Feeding and Teaching scales were signifi- cantly correlated for each subscale concept. 2° Both criterion validity (including concurrent and predic- tive) and construct validity (including discriminant and intervention and evaluation) have also been addressed,” Derivable Consequences “NCAST Training in the Parent-Child Interaction Scales and Keys 10 Caregiving has reached over 20,000 individuals” Nurses in the United States and in ‘ther countries use the observational skills in daily Sinica practice. Keys to Caregiving, a series of six sell HAPTER 27 Kathryn & Barnard 491 instructional tapes Site gn fabes based on the Barnard mode, a ommunicating the knowledge about ant state, cuen “The Teachin k ‘i ul interaction ents.” on to new parents, Sealehasheen used in seve lies includ din several national opment Progra Study both spon: trat ing, the Comprehensive Child Devel Y and the Barly Head Start National wored by the United States Adminis of Children Youth and Families." In discussing a 18 Fesearch challenges, Barnard?” The rte of the ary environment in develop thecortalfedback spent relate the ape sion is emerging as one of the major issues in new. tocence My chalenge to muningcallegice st ince our atentonta thier arene Roman fanetion, inthe hope tha nursing scence wl bring ne nightie ts dmenaton of han fanttoning~the formation of compusonate and ating eationships wth one another ‘The Barnard model and the Child Assessment Model, combined with the many research projects ‘of Barnard and colleagues, furnish nursing with the tools to create these new insights. CRITICAL THINKING Meh ilies 7. You are a public health nurse in Alaska.You provide health services to a number of tra- ditional Yup'k Eskimo villages. The state Divi- sion of Public Health Nursing has urged use of the NCAST scales for assessment be- cause there has been a recent statewide in- crease in child abuse and the need for early identification and intervention to prevent problems. You must gain the permission of the village councils to assess the village farni- lies, State the points you would cover and how you would explain Barnard's Child Health Assessment Interaction Model, the NCAST scales, and nursing interventions to the village councils Do you think it would be possible to adapt Barnard’s Child Health Assessment