CEHL:

Shifting from Traditional to Psychosocial Pediatrics

by Howard S. King, MD

July 2002

Some families come to your office more often than is required for a specific problem or checkup. At such times, they may be dealing, consciously or unconsciously, with some unresolved emotional problem. For that patient or parent you may be able to find better ways of helping them articulate such feelings and yearnings for help. You may be able to help them discover more successful solutions.

Shift your focus to the entire family

Consider focusing not just on the child but also on the entire family. At every visit, particularly when a parent shares with you a concern about a child's emotional health, think about asking yourself, "Who is the real patient?" Is it the child in front of you, or is there something else going on in the family, someone else who needs help?

Shift your view of the parent in the doctor-parent relationship

It is helpful to view parents both as "story tellers" and teachers. It is a richer way to see them rather than as people who are only bringing in problems about their children. What might you accomplish by this changed view?

As a pediatrician, you may be anxious that you haven't the skills to understand what is going on, emotionally, with children and families. By making this change in how you view parents, you may find them helping you to improve your skill in assessing the child and the family.

You may also discover that you accomplish something else. By engaging parents with respectful listening, you may enhance their role with dignity as well as encourage them to develop a more confident and "activist" self-image. These attributes can nurture greater feelings of competence in parents and help achieve your goal of promoting more normal development for the child and family.

Facilitate the trajectory of parental development

It is traditional for pediatricians to focus on the trajectory of infant development. But such interventions are more effective when you also assist parents in their own trajectory.

As you work with parents, you might ask yourself, "What am I doing to improve their sense of competence and to help them become better decision-makers, not only in regard to their children but also with their own physical and emotional health?”

Help parents develop healthy boundaries in their relationship with their children

How might you help parents view their children as separate people? How can you reduce the tendency for them to invest their children with attributes derived from unresolved conflicts within their own lives?

You may be able to do so, in part, by using the office visit as an opportunity to evaluate how the child and the family are doing.

You may also wish to discuss the issue of "inheritance." Parents worry about their children inheriting problems such as mental illness, depression, or personality disorders. You can often reassure them that such problems need not be passed on, particularly if you help parents look at what that experience meant in their own development.

Become aware of the child as an "agent for change"

In pediatric practice, parents frequently ask for help in understanding and learning how to modify their child's behavior. We, in turn, make suggestions as to how the parents might go about doing that.

But what happens if we consider that it is not just the child but rather the whole family that is, potentially, our patient? In that case, as we attempt to understand the child's behavior, we may feel it of value to assess the status and functioning of all the members of the family system.

The end result may be that, rather than merely trying to do something with the child, we may be able to suggest ways of bringing about constructive change in the functioning of other members of the family including the parents.

What has happened? The child, by virtue of some behavioral issue, has functioned as an "agent for change" in the family system by motivating the parent to seek help from the pediatrician.

Redefine prevention in the context of managed care

Most of us know the preventive tasks pediatricians usually take on for themselves. They include everything from immunizations to advocacy for breast feeding. But, up to now, early detection of mental health problems such as mental illness and depression has been, at best, a secondary topic for pediatricians. It is important to emphasize that we are talking as much, if not more, about parents as we are about children. The pediatrician may be the health care system’s first “trip wire” in picking up emotional issues in the parent and within the family.

By picking up such problems earlier and helping the family with a timely referral, you may be able to help both parents and children, as well as society, in an important way.

Why have we given insufficient attention to this responsibility? Part of it may include lack of training in family systems theory. In addition, personal issues may make us hesitate to address similar ones in our medical practice. And, in managed care, the child is viewed as our only patient, so that time and reimbursement are allocated accordingly.

Ironically, the worst curse of managed care, capitation, may become the driving force for change. There are two possibilities. One is that medicine will increasingly deteriorate as physicians end up seeing more and more patients in less and less time as they struggle to survive, professionally and financially.

They may even be relieved if mental health is carved out, putting that burden on a group of designated providers. By so doing, it is as if we have chosen not to integrate that portion of health care within the existing model.

But there are more optimistic possibilities that may come about from increasing your competence in preventive mental health:


You might be able to reduce mental health costs through earlier and shorter interventions, as well as reducing the costs that result from delays in diagnosis, costly testing, and needless procedures.

You might even reduce demands for seemingly fruitless office visits which could be disguised pleas for help.

You might also help parents become better decision-makers in regard to their overall health, and help them become partners in reducing health care costs.


Finally, a frequently criticized attribute of managed care by physicians is what they regard as a sense of entitlement that patients bring to the doctor-patient relationship.

Might we look at it differently? Can we see it as an opportunity? Each of these patients represents a diagnostic challenge. If your guidance and recommendations do not satisfy parents during repeated visits, why not ask yourself (and ultimately them), where does the parents’ "neediness" come from? If you do, you may be astonished by your discoveries.

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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.