Project DULCE Implementation Manual
B.
Creating the Relationship with the Family (First Week & One Month Visits)
“I’m not telling you how to be a parent,
I’m just providing some skills for you.”
At the Two Month visit, Mom and the Family
Specialist had some time in the exam room to
talk before the clinician came in. Mom
mentioned that her son was crying a lot: “It’s
sort of getting better. The thing that really
does the trick when he’s crying is feeding him.”
Mom thought that she did not have enough
milk when breastfeeding; so after
breastfeeding, she also gave her son a
formula bottle. From the baby’s appearance,
the Family Specialist could see that he was
really big for his age.
The Family Specialist mentioned that the
clinician would be going over the baby’s
growth chart and that she could “…see he’s
growing! The clinician will definitely talk about
that.” The Family Specialist then observes
that “… babies don’t cry just because they’re
hungry.” Mom’s concern was about crying and
the Family Specialist’s concern was about
over-feeding. This was the opening to have a
conversation about self-soothing and other
ways this mom could respond to her son’s
crying before giving him a bottle.
One of the first things the clinician states after
viewing the growth chart, “Your baby has
gained a lot of weight since the last visit.” Mom
says, “Yeah, we were just talking about that.”
Mom was assured by the clinician that her son
was getting enough food and growing well –
confirming what the Family Specialist had said
– but now mom has other techniques to use
when her son starts to cry.
The DULCE Family Specialist helps
parents make the adjustments that come
with each newborn baby – and assists
them in engaging with their child’s patientcentered medical home (PCMH).
Project DULCE is a relationship-based
practice. Beginning in the first visits, the
Family Specialist makes sure a family
feels comfortable talking about their new
baby, other family members, and any
pressing needs or concerns that they may
be experiencing. The open-ended trigger
questions in the first two visits encourage
parents to develop this relationship with
the Family Specialist. (Trigger Questions)
(Section 5A, Trigger Questions) Parents
have the opportunity to observe and talk
about their baby – and their experiences
as parents – in a safe and nurturing
environment.
Family Specialists support two important
family matters that come into focus soon
after birth: 1) knowledge of the baby’s
development and related parenting
strategies, and 2) concrete supports for
the family. Through conversations with
the family, the Family Specialist discovers
where the family feels safe to begin – Will
this family discuss their concrete or social
needs first or are they going to lead with
questions about the child’s development?
Once families develop trust in their Family
Specialist, they often speak freely about a
wider range of topics. While some
parents may wait till the four- or even sixmonth visit to ask for help, others feel
comfortable asking right away.
No matter where the family begins, at
each visit the Family Specialist introduces specific strategies for supporting early
learning. These strategies, or “brain messages” (Section 3A, Strategies for Supporting
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Early Learning), make parents more aware of how their interactions with their baby
support their newborn’s brain development.
Relationship-based practice starts with building a trusting relationship with the
family. From the very first meeting, Family Specialists observe a family’s cultural
background, style of communication, and child-rearing practices. For example, in some
families the grandparents may be very involved with child rearing and share the daily
care of the child, and, out of respect, the Family Specialist might address the
grandparents before addressing the mother. How the Family Specialist asks questions
and to whom these questions are addressed may be as important as the words that are
said. If there are extended family members in the room, paying attention to who is
asking most of the questions gives an indication of the family’s hierarchical structure.
However, Family Specialists need to balance respecting the role of the extended family
while also empowering the parents. Making sure that everyone feels respected and
included in the child’s development sends the message that the baby’s wellbeing
matters to everyone: those who come to the clinic visit as well as those who may only
be present at the home visit.
While some babies may come with several family members to a well child visit, many
other babies arrive with just their mother or father. For this reason, trigger questions
like “When you need help with the baby, who helps you?” and “Do you feel safe leaving
the baby with that person?” are very important. It is essential to find out who else helps
to care for this child, how they may affect the child’s care, and if they have questions
regarding the care of the baby. There might be somebody at home who has a
significant influence on the child’s mom or dad. Knowing who is physically there in the
room – and their role – is important, “What is your relationship to this baby?” or “Who
have you brought with you today?” Knowledge of the family’s home life informs the work
of the Family Specialist.
Talking with the family about their child’s development before the pediatric clinician (a
pediatrician, nurse practitioner, physician’s assistant, or a family medicine doctor) enters
the exam room is a great way to begin establishing a relationship with the family. Then,
during the visit, if the clinician talks about a subject previously discussed with the family,
the role of the Family Specialist is validated. For example, many parents raise the
concern about spoiling their child, a topic that is frequently discussed with parents of
newborns. The Family Specialist can start this conversation with: “Has anyone talked
with you about spoiling this baby? You know, babies can’t be spoiled at this age.” At
this point, new parents may state that some family members and/or friends have told
them, “Oh, you are spoiling that child!” Later, when the clinician confirms what the
Family Specialist said about spoiling, the parent may feel a level of comfort and think,
“OK, so maybe my baby can’t be spoiled at this age.” The clinician and Family
Specialist, by explaining normal child development, can teach parents that young
babies are not capable of manipulating others. This knowledge gives parents the
confidence they need when family and friends may be communicating negative
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messages about the baby: “That child is so bossy.” or “Your baby is just being
manipulative.”
As mentioned earlier, in addition to offering support regarding child development and
related parenting strategies, Family Specialists also focus on families’ concrete needs.
While some families are very open to discussing these needs at the outset, other
families might take more time to open up. In one example, a Family Specialist had a
very good relationship with a mom who eagerly focused on her new baby and was
always asking for more information about child development and parenting strategies.
The new mom wanted to know what would be her baby’s next stage, and what she
should be doing to help her child. Even though the visits centered on child
development, the Family Specialist also offered information about housing and utilities
to which mom would reply, “I’ll think about it.” Then, at the six-month visit, mom stated,
“I really do need some help.” What mom and baby needed was shut-off protection for
the gas and electricity and mom wanted to know how to apply for help with paying these
utilities. This mom struggled because she “… didn’t like to ask for things.” However,
because a trusting relationship was established, the mom was able to finally open up
and ask for help with some very basic – and critical – needs for her new family.
The DULCE Family Specialist and clinician work as a team. During the first meeting, the
Family Specialist may discuss child development in general or perhaps a particular
issue with which a parent is struggling. When the clinician later validates what the
Family Specialist said or when the Family Specialist repeats what the clinician said
earlier, the parent thinks, “OK, perhaps I can trust them. They have some good ideas for
me.” This teamwork serves two important functions in linking families with the patientcentered medical home:
 It allows parents to look to the clinic staff as valuable sources of information about
child development and resources
 It encourages parents to view the PCMH as a place where families can safely
discuss the social, emotional, and concrete support issues they face
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FIRST WEEK VISIT
Due to the process of family recruitment, items 1 through 6 are typically addressed by
the First Month Visit if the family is being seen for the first time at that well child visit by
the Family Specialist.
1. Introduce the DULCE model to the family and start developing the relationship with
them during the well child visit by asking the trigger questions below.
2. Trigger questions (the ones in bold are the important ones)
a. Tell me about the baby’s name. How did you choose the name?
b. When you need help with the baby, who helps you? Do you feel safe
leaving the baby with that person?
c. How did the delivery go? How about the pregnancy?
d. What has it been like caring for the baby this first week?
e. What do your other children think about the new baby?
3. During the visit, use the First Week Checklist (Section 9C, DULCE Checklists) to
observe the interaction between the caregiver and the baby and, if necessary,
introduce issues that were shared during the conversation in the waiting or exam
room. Ask domestic violence and community violence questions.
4. Introduce the evocative object to be used in all the well child visits to demonstrate
baby’s behaviors to support parent/child attachment (it can be a ball, rubber ducky,
spoon, or something similar). Use this object to demonstrate baby’s visual tracking
and following.
5. Infuse brain messages into visit as appropriate: soft spot, reflexes, protect the neck,
provide comfort & love by holding & rocking, tracking
6. After the well child visit, offer to continue the conversation with the Family Specialist
in the consulting room/office or offer a home visit or Family Specialist office visit (no
co-pay).
7. Provide parent with Family Specialist contact information and discuss steps for
the next meetings.
8. Give the First Weeks handout: provides information on development, food and
income support.
FIRST WEEK FOLLOW UP
Between the First Week and First Month Visits, the Family Specialist will:
1. Contact the community resources discussed and those which the family and the
health care team have agreed will best address the needs identified by the parent(s).
2. Contact MLP if needed.
3. Call the family one day before the next appointment and ask about the baby and
caregiver and remind them of the appointment. Ask the family if they can arrive 15
minutes before the appointment to talk with the Family Specialist.
4. Offer optional home visit.
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ONE MONTH VISIT
1. Family Specialist asks the family about the past few weeks in regards to caring for
the baby, explain the well child visit and set an agenda of possible issues or
questions to discuss with the clinician.
2. Trigger questions (the ones in bold are the important ones)
a. What has it been like caring for the baby in the past week? What
happens when your baby cries? What do you do? How do you feel?
b. What do you notice that your child can do?
c. What do you enjoy most about the baby? What worries you the most?
d. Are there any major changes in the family since the baby was born?
e. What are your plans for the next couple of months?
3. During the well child visit, use the evocative object to assess the baby’s ability to
follow visual items; use the One Month Checklist (Section 9C, DULCE
Checklists) to ask about developmental accomplishments and concerns. Also
ask about sleeping and eating patterns, household accommodation to the new
baby and family adjustment. During this visit the clinician or Family Specialist will
ask about maternal depression and smoking. In either case, applicable referrals
need to be made. Additionally, if another member of the family smokes, a
referral to a smoking cessation program (i.e. Quit Works) can be made for that
person.
4. Infuse brain messages into the visit as appropriate: opening fisted hands, turning
towards familiar voices, talking
5. Assess the need for extra help (Social Work, mental health, or informal supports
either through the practice or community).
6. Follow up on issues discussed at previous visit, specifically income
resources.
7. Give One-Month Old handout: provides information on attachment, maternal
depression, changes when a baby arrives and protective factors that might help in
the adaptation process.
Note: Assess smoking in the first meeting if there are concerns or clues that the baby is
living in a house where someone smokes or is being exposed to secondhand smoke.
ONE MONTH FOLLOW UP
Between the One Month and Two Month Visits Family Specialist will:
1. Contact the community resources discussed and those which the family and the
health care team have agreed will best address the needs identified by the parent(s).
2. Follow up on income resources.
3. Contact MLP if needed.
4. Follow up call during the month between the well child visits to check in and remind
the family about the next appointment. Ask them if it is possible to come 15 minutes
early to talk with Family Specialist.
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