by Howard S. King, MD
Pediatricians can make significant contributions to preventive mental health for children and families. As much as we already do, we could do even more in the areas of addiction, mental illness, and family dysfunction.
What has kept us from doing so? In part, we may underestimate our capacity to be effective "agents for change." We may only see ourselves as taking care of "little people," overlooking that the family system requires equal concern. It is also possible that we may be unaware of how effective we could be by being more attentive to parental concerns.
The result may be that we end up doing less in the area of preventive mental health than we might, possibly depriving families of crucial intervention. By missing such opportunities, society and insurers may end up spending more financial resources because of delayed recognition of such problems.
In pediatric practice, time and thoughtful listening are the tools for change. If we spent more time listening to how families struggle to cope, we might reduce the frequency of drug abuse and mental illness.
By listening to families tell their stories, pediatricians may unearth "family secrets," such as incest, child abuse, or alcoholism. At the same time parents are raising their children, they may unknowingly be repeating much of their own life, including harmful behavior they experienced as a child.
If we pediatricians attempted to listen more effectively (with our own "third ear"), particularly at times of transition or change, we might uncover subtle pathology. What would happen if we did? We might have the opportunity to encourage the capacity for change in how parents view their children.
But how do we harness time in the service of these goals? Given all the tasks for which we are responsible, particularly in an era of managed care, how can we use time in a way that is practical for us, financially? When a parent raises a troublesome problem over the phone or in the context of a routine well child visit, what can we do?
Sometimes, we can consider asking a few questions that might help us determine if the child is in difficulty or, alternatively, is doing well with many strengths. If the latter is the case, we can reassure the parent that nothing further needs to be done at this time.
Most of the time, however, it is difficult to be certain. Then what? One possibility is to invite the parent or parents to come back at a quiet time of the week (it could be a weekend, evening, or designated afternoon). The important thing is that it be at a time when you won't be interrupted by another patient, secretary, the phone or other distraction. If the parent perceives our mind is elsewhere, our effectiveness is diminished.
A second, equally alternative is to consider referring parents to a trusted colleague who is a psychologist, child psychiatrist, or clinical social worker. We should not underestimate the value of a pediatrician briefly assessing a parent's degree of concern and, sensing that some exploration would be valuable, helping to expedite a referral in a supportive, non-stigmatizing way. It has been wisely said that "half of therapy is preparation for therapy." (Dr. Leston Havens) If pediatricians could accomplish that, they would be making a great contribution to the mental health of the child and the family.
If we do encourage parents to come in to talk, they may be delighted (although anxious) and pleased that we would be willing to give them time. Or, they may suddenly decide that the problem is not so serious and decide to wait. At such times, there can be what is sometimes called "a flight into health" and the child seems to get magically better. (Anything rather than discuss the problem with the doctor!) Or, finally, the parents may consider that the problem is serious enough to accept a referral to a psychologist, clinical social worker, or child psychiatrist, rather than return to meet with you.
By our taking the problem seriously, parents are obligated to decide whether they are serious themselves. We may have already saved ourselves time by asking parents to decide whether they want to continue complaining (thinking that we won't pick up on it), or whether they want to roll up their sleeves and begin to work on the problem.
Suppose the parents take us up on the offer of a return visit. How much time would it take? If we chose to, we could help parents describe the problem, its history, contributing factors, their feelings about it, and what to do about it in 45 minutes to an hour. We will become more skillful with time and practice, but if it is a definitive and thorough evaluation, it could take as long as an hour.
That seems like a long time. I would propose, however, that if we do this once in a child's development, that is often all it takes to start solving problems in the child's life, and thus the family's life. It may not cure the problem but, at least, we and the parents will begin to understand what is going on. From that standpoint, that hour is really very short and, potentially, very productive.
For me, it is helpful to ask parents at the beginning, "What would you like to gain from this meeting?" Not only does it keep the meeting focused and productive, but it also helps parents feel empowered and in control. It is not the pediatrician's visit, it is theirs. They are the decision-makers. As we help them become active, we may be helping them gain control over their lives and affect their child's behavior in positive ways.
What have we accomplished in that hour, besides our own understanding of the problem, if we have done it right?
Do the medical insurers care about what has been accomplished? Do they value what we have done? Several local insurers have pledged to reimburse pediatricians for spending this time, with the following stipulations:
Oftentimes, just one meeting may clear the air. At that point, we may be able to reassure parents that the child is basically fine, the problem is transient, that it can be explained by a situational factor, and no further exploration is needed. Alternatively, we may discover with them that the problem is serious and warrants further assessment by a mental health professional.
A reevaluation may be required from time to time as the child moves through different developmental stages. It doesn't mean that the first evaluation was inadequate. It may just mean that some things become apparent only over time as the child confronts subsequent developmental stages. Nevertheless, we can build upon our earlier evaluation and take advantage of insights gained from that initial assessment.
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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.