Howard S. King, MD, MPH May 7, 2012 A presentation to the Annual Meeting of the American Psychiatric Association
Ed. Note - The following essay was presented to the annual (2012) meeting of the APA. That group had expressed interest how pediatricians and others might be helped to become competent in the psychosocial assessment of parents and families. This essay has three components: the first is how one course leader acquired the skills needed to become competent in this way. The second component demonstrated how such a leader might teach these skills to motivated colleagues. The final component introduced the concept of the patient-centered medical home whereby a group of professionals might learn how to work together, over time, to develop a mutually trusting professional relationship.
My name is Howard King. I have been a solo pediatrician for more than forty years. I plan to describe how, with one other pediatrician, a clinical social worker, and an evaluator, we developed a unique approach to integrating mental health concepts with pediatric care. I believe there is none like it, at least in Massachusetts. But why am I am speaking to psychiatrists about this? As I answer that question, let me review what I intend to discuss in the time we have.
Since our approach owes much to what I was once taught by mental health professionals, especially psychiatrists, I am indebted to you for informing me about concepts which are the foundation of our program.
I will then discuss what I learned from the family secrets many parents shared with me during my professional career.
At the same time, their trust nurtured within me increased self-awareness, helping me listen thoughtfully to the three-generational stories parents often brought to my attention. I will also acknowledge how the time I spent as a medical director as well as what I learned about intimate partner abuse facilitated my professional growth .. Those building blocks helped me develop an informative web site which attracted the interest of funders. But in the last ten years these funders challenged me to see if I could share with other pediatricians what I learned making use of core concepts I had gradually mastered in the early years of my practice.
With their encouragement, “Children’s Emotional Health Link,” known as CEHL was born. Later, I will summarize the essence of Children’s Emotional Health Link and what makes it a different kind of training experience.
Finally, I will reflect on how those experiences may help facilitate a new form of health care, the family-centered medical home, which attempts to integrate mental health with an innovative way of practicing pediatrics with children and families.
Since much of what CEHL does is based upon a narrative approach to assessing the child and the family’s history, it is worth sharing the story of how CEHL came to be.
I received a one-year NIMH fellowship before I began practice to familiarize myself with issues of emotional behavior in children. Most important was learning how to listen to parents and their stories and overcoming the personal blocks that once limited my ability to listen in a non-judgmental way.
Were there negative outcomes from that experience? One might have been the unrealistic view that I could help everybody if they only sat down and shared their story. I learned that not everyone is ready to be helped, at least not in the way we were prepared to do so. I became acquainted with the concept of psychological readiness, i.e. patients or parents change only when they are ready. - The challenge was not to push them to change prematurely. They need to be comfortable sharing with us some of those personal barriers that inhibit change.
A second training experience occurred while I was at the Harvard School of Public Health and also in full-time practice. I learned that a child with a problem could become an agent for change for his or her family. By compelling parents to bring the child with his problem to our attention, the child often initiated a process of change that was important for the entire family system. I discovered that parents had the ability to become our colleagues and with increasing trust, were able to address issues involving not only their children but also themselves and even other family members.
My last educational experience occurred as part of a yearlong seminar at a school of social work on the subject of addiction, especially on the diagnosis and understanding of alcoholism. As the only physician present, why did I take this course? As I will soon explain, because of consistent observations taking clinical histories, I felt I could become more effective in my practice by learning more about the addictions.
In meeting with families over time, I discovered that whenever there was a problem in the child, there often coexisted a family secret. They sometimes accounted for how the child became the “identified patient” in the family. There often seemed to be a history of alcoholism in some family member earlier in time. The effect of that secret was passed on through generational interaction between family members.
That course became a turning point in my understanding how family secrets could have a - powerful effect upon the children and parents for whom we provide care. Many families are influenced by such secrets, which they may be willing to share with us, if they trust us sufficiently.
Here I need to pause and share how a near tragedy in my life helped me become a more thoughtful listener to the parents in my practice.
Our first son was born when I was in the military. Upon completing my military service, I was accepted for a fellowship with the NIMH oriented to primary care physicians.
But then my wife became pregnant. Unfortunately, she developed a hydatid mole within her uterus during that time. The NIH was studying the use of a drug to see if such moles could be made to disappear in order to preserve the uterus. Hospitalized at Washington’s NIH, she was there for several months. The treatment was successful and several years later, she gave birth to our second son.
How did this affect me? To make a long story short, I began “losing things,” right and left – keys, important papers. A friend suggested that I consider psychotherapy, which gradually evolved into psychoanalysis.
I became aware that my losing things, really fearing I might “lose” my wife, recapitulated the fear of losing my father, who had been seriously ill when I was a child. That illness had a profound impact upon my family. I had repressed my feelings about that experience until the my wife’s illness and my fear of losing her reawakened those memories.
In addition to helping me come to terms with that issue, the analysis also helped me become familiar with the process of “associations,” i.e. many statements parents express to us as physicians have hidden meanings. We are often unaware of those associations or choose not to acknowledge them. But being attentive to a parent’s history may disclose periodic, seemingly inadvertent associations. If we are mindful of them and parents are able to elaborate upon them, we may discover important insights.
All of you have discovered the usefulness of associations in taking what seems like a routine history. Two things are a prerequisite for doing so, at least for pediatricians; one is a willingness by us to provide parents with sufficient time to tell their story and not feeling rushed by us.
The second is a genuine curiosity for the human condition and a respect for parents’ role as storytellers. If we want to learn, they will teach.
In summary, the discoveries from those experiences, one from my childhood, the second from coping with the possible loss of my wife, contributed to my ability and willingness to reach out to parents, if they are willing to share key issues in their own lives.
What was the consequences of achieving better outcomes with the families in my practice? Having developed and continually refined psychosocial pediatrics over the years until it felt successful, I designed a training program to teach pediatricians how to become similarly competent.
Later, I became an assistant medical director for a regional health plan and earned their trust. Because of that relationship, the health plan administrators as a result of our shared learning and collaboration, decided to experiment with a new flexibility about billing and time. As a result, they encouraged me to invite parents back for an hour long visit in order to take a comprehensive history and be reimbursed accordingly. A precedent was established for other MDs to seek such reimbursement.
At the same time BCBS asked me to organize its annual meeting to help pediatricians increase their competence in the diagnosis of childhood depression. Because of my work organizing that meeting, BCBS allowed other pediatricians the opportunity to code differently and be able to spend an hour making such a psychosocial assessment. Unfortunately, many chose not to spend such an hour doing so.
It was during this time I became familiar with the importance of screening for intimate partner abuse. With a colleague and the support of BCBS, we distributed a guide entitled, “Routine Screening for Domestic Violence in Pediatric Practice,” to every Massachusetts physician. In time, we uploaded that document to a web site. We soon added much information to that site and you will have a chance to review the home page along with other handouts at the conclusion of this talk.
We looked to funders to help support the development of the web site, But, they, in turn, encouraged us to organize a yearlong training program for pediatricians to increase their competence in the psychosocial assessment of children and parents. We have been successful with such training and documented that with four evaluations including our most recent follow-up, 18 months after the completion of our third training program. I will provide you with an executive summary of that final evaluation.
In the four years we have offered the program, most participants have found it very useful; some have found it transformative. At each monthly meeting, we invited an expert to discuss topics related to psychosocial pediatrics. They included utilizing reflective listening and empathic interviewing skills; understanding the role of family systems; the initial management of childhood depression; the art of the therapy referral; professional boundaries; and other issues related to building an expanded skill base.
In an effort to utilize these skills, each participant presented a case from his or her practice. In preparation they received clinical supervision from the course leaders. Participants discussed these cases and considered ways to help parents address the issues that arose.
When parents express worry that their child or adolescent may have an emotional or psychosocial problem, or when pediatricians identify such problems, we encourage course participants to invite the parent to return for a fifty-minute interview. As a result, we anticipate participants will better understand how the child’s problem came to be and how to develop a plan with us for management and support.
What benefits might pediatricians and families anticipate by asking a parent to return when a problem is identified in the well-child visit? This is the essence of the CEHL approach.
One - diagnosing emotional problems at the earliest time, even in the prenatal visit. Two - focusing on the entire family and not just on the child. Three - asking ourselves, “Who is the real patient in the family? Could it be someone other than the child?” Could the child be expressing the feelings or even the experience of someone else in the family? Four - asking participants to consider whether their own personal issues might interfere with understanding family dynamics more clearly. Five - improving the capacity of parents to become better decision-makers, including appreciating their role as our teachers and our storytellers. Six - being mindful how family secrets including mental illness, domestic violence, and the addictions may be passed on from one generation to another. Seven - becoming aware that spending time can save time and increase our efficiency. I am referring, of course, to meetings focused on in-depth interviewing. Eight - being aware that “half of therapy is preparation for therapy.” We need to help families be comfortable with mental health referrals. We owe much to the late Leston Havens, a psychiatrist, for clarifying the importance of this goal.
In summary, what did our participants learn from this course?
First, pediatricians can’t effectively pick up the emotional problems of children and families without the willingness of parents to trust us with their family problems so we may clarify and understand their concerns.
Second - we advocate inviting parents to return for a 50 minute visit when it is timely to do so. But the real challenge is to use the brief encounters within the doctor-parent relationship so parents will be motivated to return to share their stories.
Third - there should be parity between the physical needs of children and their mental health needs. But will physicians learn how to improve their skills to facilitate the earlier assessment of children’s emotional problems, and referral when necessary?
Fourth - Parents need trust to share their stories and family secrets. But we need to know how to nurture such trust within the families for whom we provide care.
Fifth - who is the real patient? Parents often believe it is the child. But in taking a good history it often turns out to be another family member. A family history may disclose that the environment in which their parents grew up may have been adversely impacted by depression, alcoholism, abuse or unresolved grief.
Sixth - what is the greatest impediment for parents to trust us with their stories? The key word is “stigma,” i.e. parents are often ashamed of what transpired with them or one of their relatives. It is unlikely but pediatricians, at least, may want to acknowledge that unconsciously we may have our own stigmatizing attitudes.
Seventh - we often overlook that the well child visit or other pediatric encounters can provide opportunities for a corrective emotional experience. We are in a perfect position to act upon this if we listen with our third ear, if we spend sufficient time attending to the cues that parents share without realizing it and if we convey dignity by listening respectfully.
Eighth - it is worth noting that magic ensued when our participants met monthly, taking turns sharing cases from their practices and providing mutual support.
What do I hope you will take from this presentation?
Our main objective is nurturing a sense of empowerment within the parents in our practice. If we do, parents can help make our work so much easier.
I regret when I hear colleagues say, “I’d love to do what you do but I just can’t find the time.” But if they took advantage of this kind of training, they could find time to do an assessment as good as most families require.
Even though our primary focus is on quality, is there some way we can collaborate with parents to help us reduce health care costs? A recent publication from our program put it this way, talking about the CEHL approach. Imagine two different outcomes of the same scenario: You are just getting ready to leave your child’s pediatrician’s office and you stop to say, “I am concerned about my daughter’s behavior at school, but otherwise things are going well.” Your pediatrician smiles and says, “Well, every child has good days and bad days. If you’d like, I can refer you to someone who may be helpful. See you in a year.” In the second, your pediatrician replies, “That is a very important issue – changes in behavior at school. I would like to talk with you more about that, but today there isn’t enough time. Would you like to come back so we can talk about your concern? I’ve set aside time later in the week.” If these ideas make sense, some of you may wish to encourage your colleagues to consider developing such a model of care in your local area. That has been the hope of our funders from the time we first started working together.
But let me conclude with a word of caution regarding the concept of the family- centered medical home. There is no doubt that this will become the pediatric delivery system of the future. There are two possible outcomes. I hope that pediatricians will embrace the ideas I have shared with you. I hope they will become responsible and sophisticated leaders of these health care teams, making more likely the success of the family-centered medical home.
The other possibility is that they may choose to leave it to others to pursue psychological issues and continue their long-standing focus on physical matters.
You and I can only guess what that outcome would be like for families and, particularly, for pediatricians, in terms of their professional satisfaction and what might have been their opportunity to make a meaningful contribution to a holistic system of care.
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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.