Can You, Too, Practice Psychosocial Pediatrics?

by Howard S. King, MD, MPH

Pediatrician involvement in the emotional problems of children

Understandably, pediatricians have reservations about involving themselves in evaluating the emotional problems of their patients. Common concerns are time contraints, reimbursement, lack of knowledge in regard to addressing and treating psychosocial problems, and parental uncertainty and reluctance to become involved.

The most important issue

The concerns listed above should be addressed. But are they the most crucial? For me, the most important issue is, "Can we change behavior by empathic listening?"

If you believe you can, you may be halfway home in helping children and their families understand emotional problems. The rest is a matter of practice.

You believe you can’t change behavior by listening

Suppose you don't believe you can change behavior by empathic listening?

One possibility is to ask yourself why you may feel that way. Perhaps you once tried to seek help for yourself by talking about a problem and it wasn't successful. Perhaps someone you know was unsuccesful in receiving solace from talk therapy. Did you conclude that the process was a waste of time? You might consider the possibility that the process just wasn't handled in the right way.

Furthermore, perhaps you have made intellectual observations that seem to validate your skepticism in regard to the value of “empathetic listening” in the medical encounter with parent and child. What do I mean by this?You may have perceived that some parents seem to hold certain beliefs about their child: "He is just that way ... He was born that way ... He's just like his father ... or my brother ... he'll never change!"

It may often seem that some parents posess a conviction, that thier children have inherited a personality that is resistant to change, so "why even try?"

You want to tell the parent, "He'll outgrow it!"

What do you do if you don't believe you can change behavior and there is a parent in your office who is concerned about her child?

She might be saying, "He's out of control!" "He never sleeps through the night!" "He has these fears!" "He just won't give up the bottle!" "What do I do about those tantrums?"

You may feel the urge to say, "He'll outgrow it!", because experience tells you that is often the case. Most of the time the child will outgrow it. But is it possible that that complaint could be the first step in a pathological process? How can you come to that conclusion if you don't have a way to evaluate the complaint rather than just trust your intuition?

Rationalization for Further Inquiry

Imagine a scenario where a parent comes into your office and says, "My child is tired all the time." You might ask her how long it has been going on and she replies, "For weeks!" Even if you find nothing on physical exam, you might consider the possibility of checking a blood count. Sometimes you might think it a waste of time but, at least in some cases, wouldn't that be a good beginning?

A parent's concern about a child's emotional problem deserves further inquiry, just as a physical problem. Rather than advise, "He'll outgrow it," you may want to consider the possibility that he might not, just like the child who is "tired all the time."

"A Chorus Line" and listening to the family story

Then what do you do? It may be useful to recall the musical "A Chorus Line" to help us remember the importance of individualizing the behavioral issues that parents report to us about their children. I often use the theme of that musical with parents when they ask me whether they should take a problem seriously. If you recall the story, you will remember those wonderful dancers: they looked alike, they danced in perfect rhythm together. But the body of the play involved interviewing eight dancers, men and women. Even though at the end they all looked alike, each of them had a different story to tell. Most of them ended up fine, but two did not.

How do you decide who will not simply end up fine? You may be able to by listening to the family story.

I would suggest that that is how to go about assessing the situation. Even if you don't choose to explore further, think about referring the parent to a professional who will take on that responsibility, rather than suggest to the parent that "He'll outgrow it." Again, how do you know unless, like the actor-producer in "A Chorus Line," you take the time to ask and then listen to their story?

Opening questions

Examples of quick questions you might ask as the parent has one foot out the door, or when your secretary calls on the intercom to say "You're running behind," include:

  • What are your worst fears? (about this situation) or
  • Whom does he remind you of?

Even if you don't have the time to digest the answer, it may start the parent reflecting on the problem. The next time you see her, she may have begun to think about it more deeply and may be willing to engage you about her concerns. Even with limited office time it is possible to open a conversation that can eventually lead to a clearer understanding of the child's problems for both parent and physician.

This is the "pediatric advantage:” you see families over and over again. In the process of catching a few minutes with them now and then, you can gradually introduce the idea of setting aside time to talk about long-standing problems.

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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.