A Meeting of Minds

How Much Time Should Pediatricians Spend Doing Psychosocial Assessments?

Mar 22, 13 • Managing TimeComments Off on How Much Time Should Pediatricians Spend Doing Psychosocial Assessments?Read More »

Ed. Note – I observed in my ten years in the Mass. AAP mental health task force that we rarely discussed the role of time in how we approach the psychosocial assessment of children and families. The October 2012 task force meeting provided such an opportunity.

The mental health task force recently allowed us consider how much time we might consider doing psychosocial assessments. This is timely to consider because many believe the PCMH may provide us with an opportunity to improve the emotional health of families.

I was offered a brief time to discuss two such challenges. The first one took place long ago when I chose to schedule well child visits at 30 minute intervals. That had implications for how much I would earn from my practice. It turned out to be a good decision because of what it helped me learn from the families in my practice.

But what was the second challenge? As a member of this task force I observed we never discuss the role of time regarding our approach to the psychosocial assessment of children and families. I shared why I believe spending a little extra time is so important in doing good assessments.
I prepared for each member a group of supportive documents. If you examine them, you might conclude you could provide adequate time for your patients and reap benefits not achievable in the usual 15 to 20 minute visit. Consider the following:

The Boston Globe front page story from May 21, 1998
BCBS urges pediatricians to seek payment for talking with families.” A major turning point for us at the time of 1998 Mass. Chapter annual meeting.

Making Time Work For You, July 2002, from www.cehl.org
“By listening to families tell their stories, we unearth family secrets, such as incest, child abuse, or alcoholism.

Narrative and Medicine – NEJM, April 4, 2008, by Dr. Rita Charon
Is there an alternative to the pediatric symptom check list? This article suggests that parents sharing their stories may be such an alternative.

A Tortured Inheritance” – A New York Times, op-ed, April 2, 2010
This op-ed was written by the daughter of a parent who committed suicide. The importance of taking time to discuss such things.

Success Stories – pp. 30 -37 from the Follow-Up Survey of CEHL Participants, 2011.  To help parents become our allies we should consider inviting them back at least once. But what clues can we gain during the well child visit?

Executive summary, 18 months Follow-up survey for CEHL
This report compiled responses 18-months after completing a 12-month course in psychosocial pediatrics showing they could maintain their skills.

MCPAP newsletter – August 2012 – “Managing Mental Health Issues
Time needn’t be a challenge dealing with mental health issues. Tips on how to do so. The key is to acquire the habit of picking up problems early.

“Well parent” services can complement “well child” visits
An article in August 2012 “Pediatrics” illustrated how working with parenting educators can save pediatrics much time.

The Many Faces of Abuse
This article in www.cehl.org, by Mary Byrne, reminds us that nurturing resilience could turn out to be our real goal.
Most pediatricians, if they do a psychosocial assessment, derive a maximum of 3 benefits including making a diagnosis, instituting treatment of brief counseling and medication, and/or making a referral to MCPAP.
In contrast, my colleagues and I take adequate time once to carry out a three generational assessment in our own practice. By doing so we could derive 20 distinct benefits, validating this on a number of occasions.  Here is a list of some of them.

A PARTIAL LIST OF EXPECTATIONS OF PEDIATRICIANS IN THE PCMH

Picking up emotional problems at the earliest time, even at the prenatal visit.

Focusing on the entire family, not just upon the child.

Asking ourselves, “Who is the real patient in the family?  Could it be someone other than the child?”

Asking ourselves whether our personal issues might interfere with understanding family dynamics more clearly.

Improving the capacity of parents to become better decision-makers, including their ability to teach us as well as be our storytellers.

Being mindful how family secrets (mental illness, domestic violence, and addictions) are often passed on from one generation to the next.

Becoming aware that spending time can save time and increase our efficiency, referring to time focused on in-depth interviewing.)

Being aware that “half of therapy is preparation for therapy.”  We need to help families be comfortable with mental health referrals.  (Dr. Les Havens)

Advocating inviting parents to return for a 50 minute visit.  But the real challenge is to use the brief encounters so parents will be motivated to do so.

Being unable to pick up the emotional problems of children without parents willing to trust us with their problems so we may better understand their concerns.

Making sure we achieve parity between the physical needs of children and their mental health needs.

Understanding what is the greatest impediment for parents to trust us with their stories?  The key word is “stigma,” i.e. parents may feel ashamed about their past.

Often overlooking that the well child visit or other brief encounter can provide opportunities for a corrective emotional experience.

Our major clinical objective is nurturing a sense of empowerment within parents.

One of the primary reasons for the PCMH is reducing health care costs.  We will to do so more effectively if parents can helped to be our allies.

One great benefit derived from spending time with parents is  they can become “agents for change” and enhance our ability to reach others.

A good family history should include inquiring back to three generations, on both sides of the family

A good family interview should also assess the child’s or the family’s strengths as well as problems.

Parents’ motivations are enhanced if they feel we have attempted to rule out any contributing physical factors.

The importance of asking, “What are your worst fears?” as well as “Whom do you believe he/she takes after?”

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