Pediatric medicine, the branch of medicine dedicated to taking care of children, is a relatively new medical specialty, developing in the mid-19th century. Pediatrics emerged as society began to believe that children were different from adults and in need of specialized care. Soon after the development of specialty medicine for children it became evident that many challenging ethical issues were present with children that did not exist, or at least not to the same extent with adults. In some cases, issues are similar, however they become much more complex or challenging when applied to children. The field of pediatrics is constantly changing and developing, with tremendous advancements within the fields of genetics, neuroscience, and clinical research. Developments in these fields have led to the emergence of many new diagnostic and therapeutic interventions for children, but with these new technologies come enhanced ethical issues and challenging decisions. Currently within pediatric medicine, decision-making processes are primarily guided by the models of adult surrogate decision making, in particular substituted judgment and best interests models. The substituted judgment model focuses on executing the wishes of the patient, while best interests asks the surrogate to select the course of action that will most benefit the patient overall. These models are ethically contested within adult medicine, the field in which they originated, and are even more problematic when applied to children, specifically mature minors with varying developmental levels. In pediatrics, the best interests standard is the typical model advocated for because children, as children, cannot legally make their own decisions, however that does not mean they should be automatically excluded from decision making processes or assumed to lack decision making capacity. These issues become larger when dealing with mature minors due to issues of agency, consent and assent, stewardship, and the vulnerable status of the child. Children are not only viewed as vulnerable by society, but many times parents as well. Many parents feel it is their obligation and duty to not only take care of their children but also advocate for and protect them. Additionally, because they are so emotionally invested and connected to the child, it is difficult to comprehend situations where the child is at risk or they are told something they never imagined or thought about, such as that their child is very sick and in need of advanced medical care. There are heightened emotions present due to the parent-child relationship. Despite parents wanting to protect their children, in most medical instances they are unable to do so, leaving parents vulnerable and full of emotion. Making decisions for another is very challenging in all instances throughout medicine, complicated even more so when the person for whom decisions are being made is a relative and a person that one strives to protect and take care of on a day to day basis. Additionally in pediatrics many decisions have higher stakes and longer impacts, due to the age, status, and development of the child. Parents are in very challenging positions when making decisions for their children in light of the tremendous amounts of uncertainty that accompany new and emerging technologies, including obstacles that make determining the child’s best interests and inevitably make a decision challenging. The addition of complicated medical information from presented by the new technologies within the fields of genetics, neuroscience, and clinical research, combined with the and heightened emotions only complicates this process, necessitating an enhanced decision making model. <br>As in areas of adult medicine, decisions are challenging and difficult to work through, complicated more by the lacking of explicit goals of pediatric medicine and an overarching framework to use to structure all decision making processes, which exists in adult medicine. The current decision-making models do not accommodate the fact that within pediatrics there is a long term relationship and partnership that must be created and nurtured by all those involved; decisions are therefore not isolated decisions but components of a continuum. Additionally, they do not ensure that parents receive support and guidance, identify the level of involvement of an older child, or facilitate and assist with decisions when parents and physicians disagree. Along with some of the objective elements of medicine, pediatric decision making has many subjective components, and emerging technologies create even more. On the basis of these considerations, it is argued that there is a need for an enhanced decision making model developed out of the field of pediatrics, centered around the goals of pediatric medicine. Current models need to be reconsidered in order to outline a model that enables parents to make the optimal decision for their child in light of the possibilities of emerging technologies. <br>This dissertation will look at the question “Why should an enhanced model for parental decision making be advocated for within pediatric care, and how can such a model be developed and applied?” In Chapter 2 the history and development of the field of pediatrics will be looked at, followed by an analysis of the current decision making models of adult medicine in Chapter 3, demonstrating that they do not apply well to mature minors and are not sufficient for pediatric medicine. In Chapter 4 the changing field of pediatric medicine will be explained, the new technologies will be introduced, and the ethical issues that the current models of decision making do not accommodate will be presented. In Chapter 5, an enhanced model of shared decision making related to the goals of pediatric medicine will be developed followed by an analysis of the roles of parties involved and how they should work together to achieve the best results for the child who is the patient. In chapter 6 the enhanced decision making model will be applied to areas of genetic screening, neuroscience, and clinical research to show how it will better facilitate decisions within these areas and address the concerns that the new technologies and developments create throughout present-day pediatrics. Pediatric medicine is in great need of an enhanced parental decision-making model that addresses the goals of pediatric medicine to ensure that the best decisions are made in the face of new technologies and the continuous advancement of care for children. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

In order to understand parents' child care decision making for young children (under 6), this interpretive research interviewed 24 parents and 7 child care professionals from a mid-sized region in Virginia. Using a constructivist research design, the research question explored how parents make child care decisions. Working hypotheses focused the data collection on the role of experience in shaping parents' preferences, the relationship between family needs and child care decisions, and the interactions with family and child care services. The research product is a narrative case study. Child care decision making is conceptualized as an ongoing process bounded by the family context and the child care resources of the community. The four major conceptual categories describing the decision making process are: Multiple Pathways to Child Care Decisions, Selecting Child Care, Child Care Experiences, and Positions Regarding Changes in Child Care.Lessons learned were that families came to any child care decision with different circumstances, resources and preferences. Families' options appeared related to the resources they had: financial, support from others, and supportive workplaces. When selecting child care families experienced both external and internal challenges; accessing information was a common challenge. Another challenge to child care decision making voiced by parents were the trade-offs they felt compelled to make given the mismatches between their preferences and the child care resource context. Limitations to existing child care information, referral and assistance programs were noted and viewed as related to state policy limitations. Parents emphasized the importance of relationships with providers in selecting care and in maintaining quality child care. Parents were able to articulate what worked and didn't work with their child care choices: provider/child and provider/parent compatibility, connection to other families/children in care, work demands, transitions to child care, and a family's resources.Implications for policy and practice include increasing child care services, supporting caring partnerships among families and child care providers, enacting policies that support increasing options for families, and involving the business sector in creating child care resources that better correspond to families' needs. Further research into developing relational models of child care decision making, the role of values, the meaning of trade-offs, and the intersection of time with decision making are suggested.

Blood and marrow transplantation (BMT) has become an increasingly acceptable treatment for children with life threatening malignant diseases. Survival rates for transplant recipients vary from 23% to 63%. Children with complications from BMT, typically die in the hospital after a prolonged stay. The parental decision to allow a child to die a natural death is typically made in an aura of emotional duress and bewilderment at the complexity and volume of new information that must be assimilated.The purpose of this study was to describe the process of parental decision making for Do Not Resuscitate (DNR) or to withdraw life support in pediatric BMT.The framework for this study was developed from the author's epistemology that blends neo-modernism (recognition of individual uniqueness yet acknowledgment that certain underlying universal principals exist) with the idea that the nature of all things may be viewed as an ongoing, self-constructing process.Grounded theory methodology was used. The sample (determined through theoretical sampling) consisted of seven parents of children who died following BMT and for whom the parent made an end-of-life decision. Data was analyzed using constant comparative analysis, a method that combines both substantive and theoretical coding of data with a qualitative style of theory development.The realization of parental knowing was the process that parents used to navigate the human problem of having to make the end-of-life decision for their children who were dying following blood and marrow transplantation. This process consisted of four categories: Developing Trust, Committed to Seeing It Through, Facing My Worst Fear, and Acceptance of Self.The knowledge gained from this study will inform nurses who care for children who are dying following pediatric BMT. Strategies may be developed that will assist nurses to support the development of parental trust, to help sustain the commitment of parents as they move through the BMT treatment journey, and to assist parents as they face their worst fear. As a result, parents should be better able to achieve an acceptance for themselves that will facilitate a more satisfying experience of the ever changing process occurring in their own lives.

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In view of the scarcity of educational marketing/public relations studies in Taiwan, particularly at the kindergarten level and the need to recruit and retain students in a highly competitive environment, this research was conducted among a sample of parents whose children attend a large private kindergarten in one of the major cities in Taiwan. Both quantitative and qualitative methods were used to collect data for this study. The objectives of the study were to find out the demographic profile of the parents whose children enrolled at the kindergarten, their information seeking patterns regarding kindergarten education, factors affecting their choice of kindergartens, and their opinion about the services of the kindergarten where their children are enrolled in the areas of curriculum, faculty, and administrative services. The research revealed that parents of the kindergarten students studied are judicious shoppers for their children's education; they shopped extensively for a kindergarten which offered the highest cost-benefit ratio. For their children, they want a kindergarten which has a kind, warm, dedicated, and highly qualified faculty. They prefer a kindergarten which not only offers a balanced bilingual curriculum but also helps their students make a smooth transition into elementary schools. The study suggests that the parents are overwhelmingly satisfied with the curriculum, the faculty, and the administration of the kindergarten where their children are enrolled.

Parents make decisions on behalf of their children on a daily basis. Some parents in the United States face the unique decision of whether or not to allow football participation for their child at a very young age. Using sensemaking theory, I examined how parents assessed the risks involved in making the decision to allow their child to play tackle football. I interviewed 24 participants in the form of 12 parental couples who had children playing middle school football and coded their responses to identify themes and strategies for risk assessment. Themes that emerged were decision-agency (parent and child agency), risk assessment (downplaying risk, acknowledgement of risk with rationalizations, zero risk assessment), and decision-making concepts (cultural influence, familial identity, social influences, information sources). I expanded on the sensemaking supposition of individual identity by arguing that familial identity can also impact decision-making. A key finding to this study was the typology of parents that emerged including football families-parent agency, hesitant family- parent agency, and child focused family-child agency. The type of family reflected families' reception to community culture, impact of social influence, and openness to information sources. Family type also impacted the risk assessment process and belief of control over outcomes in football participation.