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Two families raise their kids in completely different ways. Both are doing it right. So why do clinicians so often assume one of them is doing something wrong? Najat Fadlalla, a developmental behavioral pediatric fellow, returns to unpack how cultural bias creeps into parent coaching, the first-line, evidence-based approach for children with or at risk of ADHD. This episode is based on her article “How cultural competence transforms modern parent coaching,” published on KevinMD. You will hear why so much parenting research draws from a narrow slice of the world, how the same strict parenting can carry very different outcomes depending on the culture around it, and a real clinic exchange where honoring a mother’s values worked better than correcting them. You will learn to pause on your first reaction, ask better questions, and honor a family’s values while still giving evidence-based advice. You will come away with a practical way to spot your own blind spots and coach families across cultures without pathologizing what is simply different.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Najat Fadlalla. She’s a developmental behavioral pediatric fellow. Today’s KevinMD article is “How cultural competence transforms modern parent coaching.” Najat, welcome back to the show.

Najat Fadlalla: Thank you. Thank you for having me again.

Kevin Pho: All right, and we talked offline that the last time you were here was over three years ago, so thank you so much for joining us again. Now, for those who didn’t get a chance to read this particular article, just tell us why you decided to write it and what it’s about.

Najat Fadlalla: Yeah, so in my training I got exposed a lot to parent coaching. I did some programs on my own, some readings on my own related to parent coaching, and I was so fascinated by the field and the evidence in it. The one question that kept popping up was, what is missing? And that question morphed into, who is missing? And I then realized that a lot of the evidence base for this field was based on a specific population of people, and that other groups have been marginalized, as is the case with a lot of the research in medicine.

This prompted me to think, well, how can we really improve this field? Because it is a beautiful field, and it is something that is very essential, and it is gathering a lot of evidence. So how can we improve it in the sense of not dismantling what is there, but sort of expanding the walls of what is there and letting more light in? And that is how this piece came together.

Kevin Pho: All right. So before talking about that, give us a little bit of context. What exactly is parent coaching? Tell us a little bit more about that.

Najat Fadlalla: Yeah, so parent behavior training is, in a nutshell, coaching parents through how to work with their children on disruptive behaviors, setting routines, building positive relations, having healthy consequences for behaviors, and all of that.

It is the first-line evidence-based treatment for ADHD, or for children who are at risk of developing ADHD. It has been shown time and time again to have long-lasting effects, even sometimes better than medications. So this prompted me to really dive deeper into the field because of its easy application, even though behavior change is never easy. But it is easier. It is more empowering. It gives parents and children more agency. And this is why I am interested in the field, and this is what the field is in a nutshell.

Kevin Pho: All right. And when parent coaching is, quote unquote, “prescribed,” for those who aren’t familiar with what exactly that entails, just walk us through a common scenario of what that may look like.

Najat Fadlalla: Yeah. So if it is prescribed and if it is formal, often what parents end up enrolling in is group coaching. So these are programs that run 12 to 18 weeks of evidence-based modules on parent behavior training.

Another way to do it, very informally, which is probably the more common way of delivering parent coaching, is when pediatricians and other health care providers are providing literal parenting pearls in clinic. They are addressing and responding to disruptive behaviors, but sometimes these big programs are inaccessible or have long waiting lists, or sometimes the pediatricians may feel like this can be solved with a couple of tips here and there.

And this is how parent coaching is delivered. So the formal way, the evidence-based way, is these long group programs. And then the informal way is dispersed in every encounter between a physician and their family.

Kevin Pho: All right. And your article talks about that intersection between parent coaching and cultural competence. Now, for those who didn’t get a chance to read your article, tell us a little bit more about what it’s about.

Najat Fadlalla: Yeah. So the main idea of this article is really to tackle what normal parenting is, and what parenting behaviors we should be encouraging, and how to adjust our own lens so that we are not pathologizing different family structures that have been working for decades, that are normal and have a different set of values and different cultures.

But we are sometimes inadvertently pathologizing it because of the way our recommendations are built and because of the way our evidence is built. So the core idea of this article is really to look at our own glasses when we look at parenting behaviors. Let’s make sure that we are not pathologizing normal parenting just because it is different or it is based on different values. And then the next step would be how to really deliver culturally competent care in this field.

Kevin Pho: I can only imagine there’s such a wide spectrum when it comes to how different cultures parent. Even without training, just looking from afar, I could only guess that parents from different cultures are going to instill different values, or prioritize different values, in their children. So speaking to an expert like you, how do you discern the different cultures and the different values that parents instill in their children? And as someone who is formally trained like yourself, how do you incorporate those nuances when you treat them?

Najat Fadlalla: Yeah, so I think the first step is having the conversation with the family, because you can read all you want, you can be exposed to as many cultures as there are, but as you said, cultures are different and families are very different.

So I think the first step is having an open conversation with the families, and approaching these questions with curiosity rather than pathology or judgment. So really understanding, OK, why are we doing this? Why is this important to you? And having that conversation. Because what I noticed is that when it comes down to really distilling those values, there are differences between cultures, but all cultures want to instill similar values in their kids.

They want their kids to be relatively independent. They want their kids to be able to self-advocate. They want their kids to respect others and to respect hierarchy. It looks different in different cultures, and the priorities can shift from one culture to the next, but there are some universal principles out there. And I think once we keep an open mind in conversations with families, this is how we can best explore what would work for this family so that they are instilling their values, but we are also providing evidence-based care.

Kevin Pho: Now, can you give us a story or an example of what that conversation would look like? What type of questions would you ask to determine the values that a particular family has? Just give us a picture of what that may look like.

Najat Fadlalla: Yeah. So there was one specific instance when a mother was asking for advice on how to approach some disruptive behaviors that her daughter, who has a disability, was exhibiting. And she clearly said, “I am against positive, modern, Western parenting, and I want to show her that there are consequences for her actions, and I think consequences are important.” She said that right at the start, which made things a little bit easier. So she made her claim.

So the next step was that I validated the part of her point that I completely agreed with. I said, “Yes, consequences are important, and it is very essential that kids know that actions have consequences. How has that worked out for you so far?” So I explored that piece, and I also said, “OK, consequences are very helpful in stopping behaviors right in their tracks. They do not necessarily teach alternative behaviors. Let’s think of ways we can use consequences, and also think of ways where we can encourage these alternative behaviors.”

And that was a way where I did not challenge her idea. She thought hierarchy, respect, and consequences are extremely essential, and I used those same values. I respected those values. I kept them there, and I added some pieces where this could be helpful. Because at the end of the day, even families that are coming in with different cultural backgrounds are coming in for advice, but they want to feel that the advice is tailored for them, and not standard advice that they are going to have to apply with a different set of values.

Kevin Pho: Now, you mentioned the word pathologizing again, and in the past. How easy is it for clinicians to pathologize parenting techniques, or something that they see in the exam room, when it may be within the cultural norms of that particular family? Do you find that a lot of your colleagues fall into that trap?

Najat Fadlalla: I think we all do. I am not immune to that, even though I come from a different culture myself. But sometimes we get so wrapped up in the evidence and the recommendations that we do not notice the pieces that are based on evidence that was synthesized from a different culture.

So one example that I always give is authoritarian parenting versus authoritative parenting. There is a lot of evidence out there that authoritarian parenting is associated with a lot of negative mental health consequences for children.

Kevin Pho: Now, for those who aren’t familiar with the distinction between those two terms.

Najat Fadlalla: So authoritarian is basically when there is a lot of discipline and not a lot of emotional connection or emotional expression in typical ways. And authoritative is when there is a balance. There is discipline, but there is also a lot of emotional connection and positive relations, again, in a typical way that we know of. So it is sort of this sweet spot of balance in authoritative, whereas authoritarian is often very much based on disciplining and rules, and not a lot of availability in terms of emotions.

So it has been shown time and time again in the literature that authoritarian parenting is associated with negative outcomes in children. However, there have been studies coming out of very different countries, particularly the Far East and some in West Asia as well, showing that authoritarian parenting is not associated with negative outcomes in collectivist communities where the values of hierarchy and respect are prevalent. So it is very consistent with the culture where the kids are raised, and it is not associated with psychological outcomes.

I think this was the first moment when I thought, “Oh, so I need to really expand the way I see things.” So it is associated with negative outcomes in some settings, but not in all settings. And this was the first time I realized that I myself pathologize a lot of parenting behaviors, even though I come from a culture with all sorts of different parenting values.

Kevin Pho: How difficult do you find it to approach this with curiosity? Because that is something that you mentioned early on. The pediatricians who may be listening to you, of course, bring their own biases into the exam room based on how they themselves were raised and their own cultural norms. Now, whenever they encounter a family that differs from their own cultural norms, how difficult is it, and can you give any tips on how they could put aside their own biases and approach that particular family in front of them with curiosity rather than judgment?

Najat Fadlalla: Yeah, it is very difficult, I will say that. I think we all come with our own biases, not just because of our training, but also, as you mentioned, because of our own backgrounds.

I think the first step is acknowledging that we do have biases. I think the first step is that when we have an automatic thought of, “Oh, my God, how are they doing this?” we just pause and then really explore that with the family. So explore why that makes sense, even if this parenting technique that this parent is using sounds very awful. And it could end up being a bad technique that we want to fix, but the way to approach it is with curiosity.

This does not mean that we do not correct behaviors that we think are just obviously wrong. It is about how to approach that conversation from a place of curiosity, and how to keep those values there. It is often the case that all of these techniques are coming from the best of intentions, but we want to be curious about, OK, why is this value important to you? How can we instill that value while promoting something else?

So I think a first step would be to be aware of your own biases. The second step would be that whenever you have an automatic thought, pause and examine that thought. Where is it coming from? Is it coming from a bias? How can we have the conversation? And then the third step would be to really have an open conversation with the family, thinking that whatever recommendation I am going to give is not going to be something that I am giving to them. It is going to be something that we deliberate on.

Kevin Pho: You mentioned earlier that a lot of the evidence that is in this field may not be representative of the various cultures that one may encounter in the exam room. So tell us more about that evidence in terms of what is out there. What are the cultural norms of the current evidence?

Najat Fadlalla: Yeah, so there is an interesting article that turned into a book, and it is called “The WEIRDest People in the World.” And WEIRD is actually an acronym for Western, educated, industrialized, rich, democratic, which describes the common features of the populations that are the study samples of a lot of the evidence in psychology and sociology that is out there.

And the claim that the author made in his article and later in his book is really just to say that we have to be humble about the evidence, because a lot of the evidence is synthesized from populations that are not necessarily the norm for the rest of the world or for other cultures. So this book really shows how a lot of the evidence out there is coming from these types of populations more so than from the rest of the world. And on top of that, it shows how some studies from different parts of the world are showing conflicting results in terms of the conclusions in these fields.

So the conclusion is obviously never to dismantle the field or throw conclusions out the window. It is really just to expand it. And it comes down to our responsibility as clinicians and also as researchers to really be inclusive of other cultures, other opinions, and other voices in the studies that we do, so that our evidence is more generalizable.

Kevin Pho: We’re talking to Najat Fadlalla. She is a developmental behavioral pediatric fellow. Today’s KevinMD article is “How cultural competence transforms modern parent coaching.” Najat, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Najat Fadlalla: Yeah. I think my main take-home message is that we all need to examine our own biases. We need to stop and pause whenever we have an automatic thought about how a family is operating, or how a mom or a dad is parenting. And then we need to really keep an open mind to new evidence, and to the different ways that people around the world are parenting or approaching all of these domains. And eventually we have a responsibility to really look at the evidence with a different lens and make sure that whatever recommendations we are giving are both evidence-based and culturally relevant and appropriate.

Kevin Pho: Najat, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Najat Fadlalla: Thank you. Thank you for having me.