CEHL:

Strategies for Intervention

by Howard S. King, MD

July 2002

How can you find ways of helping parents within the time constraints of pediatric practice? How can you enhance your effectiveness but still be efficient in doing your work? How do you use your "third ear" to listen to the family story?

Use the office visit as a "corrective experience"

Consider the impact when you, the family pediatrician, find the time to listen to parents with increased curiosity, empathy, and support. As a result of your listening, parents, in turn, may learn to act in a similar way with their children.

Be attentive to "family secrets"

If you remain unaware of traumatic experiences in the history of parents with whom you work, you may miss opportunities for constructive intervention. Be on the lookout for the impact of family secrets upon the functioning of your patients, parents and families.

Develop an interest in the addictions. Go beyond coping with "Joe Camel" or screening for alcohol and drug dependencies in teenage patients. There is the opportunity to understand children of parents who grew up in dysfunctional families, particularly those referred to as "adult children of alcoholics." Family secrets can also include mental illness and depression.

Think about family secrets when confronted with parents who always seem to be making demands, anxious parents who ask endless questions, or parents who are constantly negative in their outlook about their child.

Be aware of "resistance"

You may become aware of a family's resistance to discuss problems or reveal secrets when you inquire about a family history of alcoholism, or when you attempt to determine if there is any domestic violence in the family. You may feel frustrated if you sense parents are not forthcoming about such matters.

How might you overcome such resistance?

Let parents know, explicitly, of your interest in their family history, either at the beginning of your relationship or when you sit down and talk with them about their child's problem.

Invite them to tell you their story. When they do, look for things that may be meaningful in helping you look "below the surface." For example:

If the child's grandparents are living in separate locations, why? What happened? Or if a grandparent died at a young age, what was the cause? How old was the child's parent at the time? What was the impact upon the parent?

Were there any previous pregnancies? This might lead to a discussion of teenage experiences and the circumstances around them. Or were either of the parents previously married? What happened?

Do the parents differ in their attitude and approach to discipline? What do they think accounts for that?

Always be on the lookout for potential problems. Don't wait for parents to raise issues. For example, think about asking routinely if the child has any habits or fears. Are there any sleep problems? How is the child doing at school?

If you detect a problem, you might consider asking the parents to come in at another time to discuss it. If they choose not to, that is up to them. But take note of it. What you are doing, in a non-judgmental way, is making them responsible for choosing not to do so.

Even though parents decide not to go into the problem at this time, you have still accomplished something. You may have set in motion a process of reflection that they will take away from the visit. They now have an awareness of your interest. Perhaps on a later visit, they may be willing to discuss it further.

Look for "associations"

Be aware of possible associations related to the child's behavior in your conversation with parents. For example, they may start out talking about their child's use of a pacifier. Some of your colleagues might ask them why they think their child "needs" it? They might say, "He needs it for support!" A pediatrician might then ask, "Why does he need it for support?" And on it goes. You might ask them if any of their nieces or nephews use a pacifier? What happened with the parents, themselves, when they were young? Were they, or a sibling, dependent upon a pacifier or their thumb? Why do they think they were? You may have arrived at an interesting but also, perhaps, controversial turning point in your conversation.

At this point, you might choose to move on to a discussion of other "oral issues" in their family of origin. Did anyone (including grandparents) smoke, or were there some ongoing stresses in their family of origin? You may wish to go slow in digressing in your interviews, in this way. It needs to feel natural to you before you ask about these issues.

Pediatricians need to be creative in their attempts to overcome resistance. In short, search for associations between the child's behavior and the actions and personalities of other family members, past or present.

Listen for the "overdetermined quality" in the parents' description of the child's behavior

You may also overcome resistance by being sensitive to an "overdetermined quality" in parents’ description of the child's behavior. What do I mean by that? The parents’ words may seem more applicable to that of an adult than that of a child, for example, when they talk about their four month old and say, "He has a terrible temper."

Be aware that parents vary in their "psychological mindedness"

You wish that parents would welcome your interest, perhaps even be grateful. But some issues may be too painful for them to acknowledge when you bring them up. In fact, however gentle you may be, they may be so uncomfortable, that they may switch to another pediatrician. That is the price, however rare, you may have to pay when you ask about emotional issues in the child or family.

Even if they do switch, their view of their child may never be the same. They will know, on some level, perhaps with their next doctor, that if they raise such an issue, there is the possibility of a deeper explanation. So, even if the next pediatrician suggests medication, they may also now be aware that there is another approach.

Repetitive attempts to resolve hidden conflicts

You may become aware of long-standing emotional conflicts when you are confronted by parents who seem to require repeated testing of their child or multiple referrals for enigmatic conditions. If they are not addressed appropriately in the medical setting, their concerns may keep coming up over and over again in one disguise or another. One by-product of this is increased health care costs without a beneficial outcome.

What is going on here? Within all people reside memories of conflicts from their past. These memories are stored in the dustbin of past experience. Oftentimes, they are able to rework those memories, over time, into a positive outcome.

But, for many parents you see, there may not be such a positive outcome. For some, painful memories persist. If parents could talk about them, they might say, "Why did it happen? Was it my fault? Even if it wasn't, whose fault was it? I can't get over my anger (or sadness or anxiety) that it happened. Maybe some day I'll understand it."

If you stop and think about those puzzling clinical situations as possible repetitive attempts to resolve conflicts, you may conclude that parents are giving you repeated opportunities to focus in on the real issue. That will happen if you give them, and yourself, the time to ask, "What is really going on here?"

Acknowledge personal issues

Pediatricians are aware that parents may have unconscious attitudes towards physicians, reactions that are often a function of how authority figures dealt with them in the past. If you can learn something about that, at the right time, you may be able to subtly incorporate such insights into the doctor-parent relationship without being direct, in order to help families benefit from your advice.

Parents should be encouraged to weigh your advice critically. But they should do so for rational reasons, or when advice conflicts with their intuition, not because someone in their past had a tendency to undermine their decision-making abilities.

But, we, too, have our own unconscious attitudes towards parents, even though that is rarely discussed. The reasons for our own issues could range from the way we were raised to how we get along with our spouses, as well as our satisfaction with our professional role. These experiences may have a profound influence upon us in our reactions to parental needs. Acknowledging and dealing with our personal issues may help insure that our relationship with parents continues to be compassionate and helpful.

Search for strengths

Parents need to set realistic limits upon their child even though it is difficult. They will do so, more easily, when they have developed a mutually respectful alliance with their pediatrician.

This alliance can be enhanced if, in addition to searching for problems, you also help parents recall the many tasks both they and their child have already accomplished. Acknowledging past strengths will help greatly when parents have to confront new problems.

Reframe and validate parents' feelings

These are related ideas. Reframing, or giving new meaning to, their child's behavior is a simple but powerful tool that you may wish to employ, especially during well-child visits. Complimenting parents through their child, and remarking on how much parents are supporting this competent child, may help parents see their child's behavior in a new light.

Likewise, validating how a parent is feeling can be very helpful. For example, you can reassure an anxious parent about something and they may respond, "You mean I'm not crazy?" Or, when a parent tearfully acknowledges the pain of some memories, you can reassure them about the legitimacy of their feelings and their appropriate response.

Enhance the success of the psychological referral

Terms like therapy, counseling and mental illness are still stigmatizing for much of society. Even if parents in your practice are open to a psychological referral, they still need to feel that they are not being "dumped" when you make that referral. In addition, they should be helped to see therapy not as an outcome of doing something wrong but as an opportunity for individual and family growth.

When you make a referral in a positive and supportive way, not only is it more likely to be successful but it will also reduce the professional and financial resources dissipated by unsuccessful referrals.

Help parents feel comfortable in an activist role



Parents often wish we would provide them with specific answers. Indeed, there are many situations when it is appropriate to answer their questions quickly and directly, providing them with our honest opinion about a particular situation.

On the other hand, consider the value of sharing your ideas, even offering parents some alternative ways of understanding and resolving the problem, but doing so in a tentative way. There is value in helping parents feel that they helped you in understanding the problem even as you are conveying to them that they are capable of using their own good judgment to solve their child's problem.

Incidentally, it is important to involve fathers as much as possible. The opportunity for both mother and father to discuss a problem together in the presence of a third, neutral person, may be helpful and quite new for both.

This approach to helping parents learn how to become good decision-makers may be hard for some parents, based on how they were raised. For some, it may be initially difficult to accept such responsibilities. They may want you to tell them what to do. Others may have the opposite difficulty. It may seem threatening for them to lean on you in the service of gradually understanding what is going on. Such parents may need reassurance that this period of dependency is temporary and, ultimately, the responsibility is in their hands.

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Support

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.