by Howard S. King, MD
It is your usual busy day. You may even be running behind. But you have a feeling about the way the parent is describing the child that there may be something going on beneath the surface. You should move on to the next patient but you think about inviting the parent to come in again, either by herself or with her husband. How do you go about making that decision? When the parent asks, "Could it (the particular symptom) be abnormal?," what questions might you ask?
The problem that has been raised may have greater significance if the child is experiencing difficulties in more than one area of his or her life.
You are tempted to say "it is common for the age." Maybe it is, but hesitate for a moment to avoid reassuring the parent prematurely. The child could be doing the parent a favor by prompting her, through his or her behavior, to bring up the symptom. If the parent discovers a sympathetic ear, she may begin a process of considering whether the particular symptom could have deeper meaning.
If you can engage the parent in a dialogue about these issues, there is the possibility that you may gain some deeper understanding of the child's problem.
Parents are more likely to be responsive to your questions if they have been concerned for some time. It also helps if the parents have developed a relationship of trust with you, perhaps from your management of a past illness with this child or another sibling.
Think of every visit, especially the "well-child encounter," as an opportunity to reach out to parents regarding the functioning of all the family members, not just the child whose visit it is. In short, you can make each visit, potentially, a family assessment.
Sometimes parents will bring up a problem directly. Often, they may raise the problem just as they are about to leave.
For example, if you asked at the end of the visit, "Is there anything else I can do?," the parent might reply, " ... not unless you know how to help me with ..." At such times, there are at least two options. One is to be frustrated that they are raising a complicated issue with one foot out the door. The other is not to hesitate to take them up on it! You might suggest that you would be glad to give them time on another day to discuss it with you. It will be interesting to see who might take you up on that.
The idea of asking parents to come in another time is sometimes alien to pediatricians' thinking. There is something about our style, and perhaps of physicians in general, that leads us to believe we should make decisions in a single encounter. Oftentimes we can. We decide whether the child with a high fever and rapid breathing has pneumonia, or whether the pain in the right-lower quadrant should prompt a work-up for appendicitis.
But behavioral issues require a different approach. You often need a second chance with that symptom. You need to feel less rushed, perhaps at a time of day or week when you don't have to worry about the next patient, or answer 5 or 6 telephone calls. Be good to yourself. Allow yourself the luxury of enough time to ask the parent sufficient questions to make an appropriate assessment. The time you take that once, with a willing parent, could provide you and the parent with insights for years to come.
The next step would be to ask the parent if she or he would like to come in again and discuss the problem. Are they motivated to do so? Do they seem "psychologically- minded?" Many parents may not be ready at that time. Even if they decline doing so, it is worth noting that in your chart.
You might say, "I think it is something you might consider addressing ... But you may have good reasons for not wanting to go into it at this time ... Let me know if you would like to do so at some future time ..."
It is important to discuss, early on, the confidentiality of discussions regarding behavior and family issues in your practice.
You should consider that behind any emotional problem of the child, there may reside some family secret involving the child, the parent, or some other relative, now or in the past. Accordingly, the parent will be more comfortable sharing such information if, at some point, you make explicit the issue of confidentiality, as well as exceptions to confidentiality such as mandated reporting.
If the parent wishes to address the problem, with whom do they wish to discuss it, at least initially? It could be with you, but it might be that they would be more comfortable discussing it with a mental health counselor. Even if they decide to discuss it with you, and you are ready to do so, consider the possibility that at some point they may prefer someone else, particularly if it involves discussing personal issues.
Families provide you with many opportunities over time to address such problems, often because of the human need to bring up distressing conflicts again and again in an attempt to resolve them, in order to feel better. If parents choose not to deal with the problem once, you can anticipate that the problem will surface at some other time, perhaps in some other form. Conversely, just as parents are always striving for resolution, they may try to keep the problem underground if it feels too painful to talk about.
It is obviously worthwhile trying to intercede as early as possible with the motivated parent. But parents need to confront these issues on their own time table. You may be reluctant to give up addressing the problem now, but they should do so when they are ready, perhaps with someone else.
Sometimes, taking the time to respond to a parent's query may actually lead them to dismiss the problem, saying it is not really that important and they don't need to discuss it now. Even if you feel otherwise, it is wise to give them space and time to reflect on the issue and have them exercise their own initiative on another occasion. Regardless of what they choose to do, you may have set in motion a reflective process, to be revisited at a later time.
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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.