CEHL:

The Psychosocial Assets of the Pediatrician

by Howard S. King, MD

July 2002

Pediatricians sometimes think they will be "starting from scratch" if they address the mental health issues of children. They don’t realize how much they are already doing that can help them in this area.

Although you may feel you lack the training of a mental health clinician, that seeming deficiency is balanced by your natural intimacy with many mental health concepts. You make use of this knowledge all the time in your work with children and families, often without realizing it.

By reminding yourself of the following attributes of your relationship with parents, you may feel even more confident when you work with families.

The pediatrician as historian

Over time, listening to parents discuss concerns about their children, you can often understand the ways in which certain families may be vulnerable. You may be able to use their history to discover why a particular family member may have evolved to become the representative for the family conflict.

What you hear may seem initially confusing. However, your observations over time will make increasing sense and may suggest potential opportunities for intervention.

The development of trust

It takes time for parents to form a trusting relationship with a therapist. In contrast, family members have usually known you for a long time. If they believe you are willing and able to intervene at the right time, parents may be ready to be engaged, psychologically, when the need arises.

Furthermore, you have developed credibility and trust through previous successful interventions involving illness and physical health problems. The transition to viewing you as an ally for emotional crises may frequently seem very natural to parents.

Crisis intervention

As a pediatrician, you play a unique role as witness to all the developmental stages from birth to adulthood, not to mention the various joys and sorrows to which families are exposed over time. On such occasions, a host of complicated feelings emerges between family members. Relationships change and require new adjustments. With your understanding of the family history, you may be very helpful by suggesting opportunities for more constructive attitudes and choices when they confront such issues.

A reflective attitude

A psychologist studying two groups of children, one with anorexia and one without, speculated that one factor, among others, might account for the difference. She suggested that a characteristic of the parents in the control group was the existence of a "reflective attitude." Those parents seemed to have an introspective but not guilty nature, a striving for healthy dialogue between parent and child. They seemed to be working to understand their children's behavior but not be so preoccupied that they failed to give their children the space and direction they needed to grow as separate human beings.

You use your well-child visits, without realizing it, to encourage this reflective attitude. You ask questions like, "How is your child doing?" "What are you pleased about?" "What are you concerned about?" "What do you think it means?" "How are you doing?" "How are you and your spouse (or partner) doing?" These questions, and others, stimulate parents to reflect, constructively, with you. Such parents, in turn, are often able to adopt a similarly reflective attitude with their child.

Steering the family through a morass of experts

There is the danger that, by asking such questions, parents may wonder if you are being judgmental. Not so. You are merely trying to help them articulate how they feel. You are not just being supportive but are also encouraging them to use their intuition and healthy gut-feelings.

There are many issues about which "experts" write and lecture. The point is that for such issues there are no right answers, only right answers for some people. Your task is to help parents come up with a solution, in a logical way, that reflects their own feelings and what is appropriate for them. Ideally, you are not just helping parents deal with a problem today, but rather with how they and their children cope with problems for the rest of their lives.

One of your objectives, therefore, is to protect parents from feeling guilty as they encounter a variety of experts who tell them that there is only one way of doing things.

The concept of the "right-lower-quadrant"

What do you do when you try to decide if your patient has appendicitis? You start your exam in the left-upper-quadrant and gradually work towards the area of greatest discomfort, i.e. the right-lower-quadrant.

Similarly, when you are dealing with a family in pain, you try to understand what is going on with the family as a whole, what their strengths are as well as what they are worried about. Gradually you discover the real issues. You don’t avoid those issues because you fear you may, temporarily, bring pain or sadness to the surface. If you have the family's permission to do so, your investigation may bring a secret problem to the attention of all concerned and, by so doing, may bring relief.

Searching for strengths

The evaluation of a family problem means exploring the total functioning of a child and his family. Problem areas may be discovered that need attention. But, just as likely, investigation can bring to light many areas of mastery and competence for both the child and parent.

It is important to discover these strengths. Helping parents remember what they have accomplished may give them the esteem and confidence to deal with issues that remain to be resolved.

The child as an agent for change

As parents help their children through the stages of emotional growth, they inevitably encounter experiences which may bring to mind troubling memories and feelings of their own that may have become repressed. Sometimes their coping methods have been successful. Often, however, they have not.

As children go through these different stages, the parents' old adaptations may be disturbed. It can be like when a scab is peeled off, revealing a poorly healed wound. At such times, parents have the opportunity to reexamine such wounds and contemplate how successful, or not, they have been in resolving such hurts. In short, children, without realizing it, give parents a second chance to revisit their past and the opportunity to resolve some of their old problems.

When parents express thoughts and feelings about their children, their defenses against thinking about themselves may be less rigid than at other times. If you have a good alliance with parents, you can help them clarify such issues. In that sense, the child may do as much for the parent as the parent does for the child.

System theory

It is common, in a well-child visit, that you may end up considering several family members simultaneously. A parent comes in to talk about one child who has a rivalry with another sibling. This may remind parents, in turn, of how they interacted with siblings when they were younger and how their parents dealt with it. So, unlike other physicians, you may be involved, consciously or unconsciously, with systems.

Systems theory as it pertains to families takes into account not only how individual members relate to each other but also how the family as a whole develops and changes over time. Thinking about families this way may help you understand causality in regard to childhood problems, and may even suggest useful ways of intervening.

Parenting, the archetypal way to gain competence

Regardless of how people are raised, regardless of their education or status in work or marriage, all of us are given a fresh start when we become parents. As potential allies to the parent, pediatricians have a great opportunity to help nurture that sense of competence.

The parent who acquires competence in this role can usually master most of the other challenges in life.

The routine office visit as a corrective experience

As a pediatrician, you shouldn't feel you are just a source of information. You are also seen as an authority figure (although maybe less so these days). Regardless of how you present yourself, parents may view you, and respond to you, the way they responded to other authority figures in their past.

How would you characterize the ideal pediatrician-parent relationship? Might it not include patient listening, a non-judgmental attitude, permission for the parent to express a variety of feelings, and an absence of ridicule and condescension? You are always in a position to give advice. You may be most successful, however, when you help parents understand that they have choices and that they can develop a sense of competence in making good decisions.

Furthermore, parents may use the relationship with you as a model for learning and, in turn, a model for how they can listen and intervene constructively with their children.

There are other aspects of the office visit from which parents may gain insight. For example, many of the families you see may have difficulty expressing feelings, and some may tell their child that "big boys don't cry!" But throat swabs are unpleasant, shots do hurt! It may be useful when you give an injection or take a throat culture to say, "It may hurt a little ... It's all right to cry."

Such corrective experiences for children and their parents, however trivial they may seem individually, become increasingly significant in the aggregate, helping both parent and child gain confidence and express feelings.

Working with parents where they're at!

You will be more successful in helping parents manage the emotional growth of their children if you consider starting with where the parents are.

Suppose a parent came in with a four year old child, concerned about tantrums and the child being "out of control." The parent wonders if the child has food allergies or could be hyperactive. You may personally believe that the tantrums are emotional in origin. Your task, then, is how to help the parent consider that possibility and manage the child's behavior from that point of view.

If that is the case, you will have a number of tasks. You may ask yourself (and, ultimately, the parent) why the parent would consider the unlikely possibility of food allergy or hyperactivity. At the same time, you want to convey respect for the parent who has shared that belief. At some point, you will express your own contrary, even though tentative, point of view. Still, consider offering parents the choice (e.g. temporarily exploring food allergy) and leave it to them to follow their own initiative.

Double- and triple-identification

You may be the first person to hear inappropriate labels attached to a child, e.g. the one month old infant who has a "terrible temper" or who is "high-strung." (Is she talking about her spouse or her siblings?) Or you may hear about the six year old with a "binge for crackers" (reminiscent of an alcoholic grandfather?).

You don't know if these things are true unless you think about listening, not only to the parent but also to your own senses as you become aware of an inappropriate label applied to the child. At that point, ask yourself whether the parent is really thinking about some individual either in her present life, or in her past, to whom she is attached by an important unconscious conflict.

In short, you may wish to consider that the child may be identified by the parents with people from the parents' past. How you verify that intuition and how you share it with compassion is another matter, but it is important for you to recognize it.

Combating the self-fulfilling prophecy

How many times have you heard parents say such things as, "I'm going to have a lot of problems with her when she is a teenager" ... or ... "He is a high strung kid!" ... or "He'll never change!"

You will have many opportunities in your pediatric visits to constructively confront parents, at the appropriate moment, when they express such ideas and ask why they contemplate such outcomes.

The longitudinal benefit of psychosocial pediatrics

Pediatricians need to remember that the emotional growth of parents occurs over time. It is an evolutionary process which occurs during the entire span of their children's lives.

Each crisis, each developmental stage of a child, in fact, each child in a family provides parents with opportunities to gain insight and acquire mastery over a variety of unresolved life experiences.

The relationship between you and parents is like a book with many chapters. If you have a collaboration with parents based on trust and mutual respect, the outcome would seem salutary for the child and the family.

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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.