by Howard S. King, MD
When you wonder if a child's problem might be affected by emotions and events in the family, you may choose to do a pediatric psychosocial consultation with the parents, or make a referral to a child psychiatrist, psychologist or clinical social worker. The following suggestions are offered to those pediatricians who wish to increase their competence in regard to psychosocial issues of children.
During a routine or acute visit, you may have asked the parents if they wish to discuss a problem further. One or both of them have agreed to return for a meeting with you. You may consider it worthwhile to point out that, in the course of discussing their child's problem, it might be helpful to your assessment if they were willing to talk about themselves and their own development. You suggest that it may shed some light on their child's problem (it almost always does.)
At the beginning of the meeting, you may ask, "What would you like to accomplish today? What do you hope to leave with?" Even though the interview may roam far and wide, it is worth reminding parents that the focus of this consultation is to better understand the child's problem you and they are attempting to solve.
You may wish to review the issue of confidentiality with them. It is usually not a concern for parents. Still, your sensitivity to this may suggest to them that the issues to be raised are different from those usually discussed. It is a sign of respect for them. It may also reduce their resistance in regard to sharing painful memories.
As you gain confidence that spending as long as an hour with a parent can be a productive experience, it is worth letting them know that you may possibly need to take that long to discuss their concerns. It will be quite contrary to their usual expectations about the typical pediatric visit.
You explore the details around the presenting symptom. These may include, "Did the onset coincide with some event?" "How long has the symptom been going on for?" "What do you think precipitated it?" "When does it occur?"
There are several questions that may assist parents in becoming more analytical about the problem, to help them begin to share feelings, and even to develop a more active stance. They include:
Asking these questions may, if they are willing, open up new avenues of understanding about the family or extended families, past or present. It may provide you with a broader and relevant perspective, particularly when parents disagree with each other about the answers.
Depending upon the child's age, it is often helpful to assess the child's general functioning. It is useful to ask if the parents have current physical concerns or fears about their child, for example, a difficult pregnancy or delivery, some type of allergy, or an "inability to focus" which might remind them of a relative "who has ADD."
We can spend a great deal of time with a family, even discovering painful areas in a parent's or a family's life experience. But if, at the end, parents tell us that the child's difficulty was really due to some physical problem, we may have wasted their time and ours unless we addressed that issue first or, at least, simultaneously.
They may be unaware that they are worried about some physical issue. It may come out only with time. Still, even in an era of managed care, it is cost effective to rule out physical problems first. Even if it requires consultations and testing to put their mind at ease, anything that might diminish their ambivalence about causality is worth considering.
For example, pediatricians may perfunctorily reassure parents about "the stomach pain," "the headache, "the hyperactivity." But if parents are focused on physical issues, it is better to resolve them before we engage in a psychosocial exploration. It is helpful to think of physical problems first, even if they seem to have no rational basis, in order to keep them from becoming a distraction against the free flow of ideas and feelings. Once we have addressed physical issues, we and the parents can move on to emotional issues with greater freedom.
In summary, inquire about:
In regard to other developmental problems, for example, a toddler with a sleep difficulty, you might consider asking, "Does he have any eating problems, is he still on a bottle and/or pacifier?" "Are there tantrums?" And, at any age, "Does he have any habits or fears?"
In order to understand the child's behavior it is important to ask how the child is doing with siblings, parents, and peers. Beyond gaining insights about those relationships, parents need to feel that you are taking their problem seriously. You do so by leaving no stone unturned when taking a comprehensive history.
Sleep problems may be of particular concern, in part because they are so common. They also have implications for the issue of separation, parental fears, and the associations parents may have with their own past. For example, did they have sleep problems themselves when they were growing up, was there a history of domestic violence in their homes making bedtime a frightening event, did they sleep with one of their parents possibly because of marital difficulties?
It is useful to get details. When does the problem occur? Is it when the child is going to bed at night, does the child keep coming into parents' bed, is she getting up early, does he sleep with anyone, what have the parents done?
Exploring sleep problems may reveal relevant information about the present situation, as well as the dynamics between the parents, and their past history. Furthermore, if you can help them in just this one area, it may provide benefits in regard to other aspects of the child's functioning.
Discussing sleep problems may also help parents acquire feelings of mastery and success. You may be able to confront their fear that something they could do, like setting limits, might be harmful to their child. It would be a great opportunity for you and parents to reflect on how that idea became established in their thinking, and a chance for you to support their healthy instincts about solving the problem.
In regard to sleep problems, helping children say goodbye to their parents at night has additional benefits:
Coping with loss - It helps children, at an early age, to begin to cope (appropriately) with loss. It helps them see, at least at night, that they will be OK on their own and that they can survive. That is an idea that will be increasingly important throughout their childhood and, particularly, as they become adults.
The concept of mourning - As parents struggle to help children cope with loss and separation at night, parents may discover that they themselves have not mastered the developmental task of mourning. Helping their children deal with nighttime issues may help them discover why they were vulnerable as a result of their own earlier life experience. They may learn how it may have impeded their own development and self image.
Developing healthy boundaries - Discussion about sleep, separation, and the parents' role facilitates the development of healthy boundaries between the child and parent, which are crucial for the emotional development of both.
If the child is of school age, does he have any problems there? Does she separate easily? How is he doing cognitively? How does she relate to her teacher? How does he interact with classmates?
An adequate assessment of the child requires assessing the family. The child's problem is often reflective of a family problem, and helping the child may end up helping the family. Obtaining a good family history is necessary for successful intervention in regard to a child's emotional problem.
How are they doing, individually and as a couple? What are their ages, how is their health, how are their jobs? Are they satisfied with their occupations? Do they feel conflicted between work and their parental responsibilities?
How long have they been married and whether (and why) the child was conceived before marriage?
Were either of them previously married and if they were (and if they are comfortable sharing it), what happened?
Siblings - If there are siblings, how are they doing?
Extended family - This includes grandparents, aunts and uncles, nieces and nephews. Do they live nearby? Are there good relationships? Is anyone alienated from the rest?
Losses - Have there been any recent losses, for example, the death of a close friend or relative, the loss of a job, or an unhappy move?
Family secrets can include alcoholism, domestic violence, child abuse, sexual abuse, extramarital relationships, and suicide.
This is vital information. Such issues are rarely disclosed easily and voluntarily, but sometimes you become aware of them when you hear statements like, "He died after an auto accident" or "I don't have anything to do with him" or "She is separated from her husband."
There are at least two ways of asking about family secrets. One method would be to ask about them directly. I prefer, instead, to follow up on the parents' subtle, open-ended comments about why some relative died young (e.g. alcoholism, suicide), why grandparents were divorced when the parent was a teenager (e.g. domestic violence, extramarital relationship), or when a parent wonders why the child is so "reserved" (e.g. family history of mental illness).
Pediatricians will decide which technique is most comfortable for them. The main thing is not to put parents on the defensive, but to take advantage of associations between seemingly random statements and more serious issues that may exist below the surface.
This information is very relevant in understanding the child's symptoms. For example, if the child's sadness or depression mirrors how the parent may be feeling, it is important to find out if a parent is mourning a loss which remains unacknowledged.
It might be useful to have the following family history of loss recorded in the child's history, for both sides of the family:
* Sometimes a child has a symptom that doesn't correspond to any logical reason or current situation at home at school. There may be a deeper reason. For example, if the child is four years old, did something happen when the parent was four? Were the grandparents divorced, did someone die, was the parent abused when the parent was four years old? This issues are referred to as "anniversary reactions."
This includes the child, parents, parents' siblings, and grandparents. Mental health history could be relevant, in terms of helping parents be more comfortable, if you are considering making a referral for counseling. It may be more so if parents worry about the child "inheriting" mental illness.
This would include mother's relationship to maternal grandmother (MGM) and grandfather (MGF); history of abuse; self-esteem as child and adult; sources of guilt; relationship between MGM and MGF; self-esteem of MGM. The same history should be taken for the father.
Obtaining this information can be as much of an art as how one goes about determining the presence and relevance of family secrets. Rather than ask about it directly, there may be alternative opportunities. For example, suppose a six year old patient has a problem and you are told she is named after her grandmother. That could lead you to ask about the grandmother and why she was named for her.
Detailed, thoughtful history taking may begin to solve some of the problems families bring to you every day. The process of taking a history, in and of itself, can have major therapeutic benefits:
Time and attention - What must it be like for the average parent to receive an hour of uninterrupted time to listen to her or his concerns?
The family story - You wonder how you will get to the root of the child's problem. You often will, if you give parents time to "tell their story."
A corrective experience - Many parents come from dysfunctional family relationships where, if they were listened to at all, were listened to with disrespect and often responded to with abuse. You, as a pediatrician, by listening with compassion, curiosity and a willingness to learn, can give them a type of respect they may have never received before.
Sharing of feelings - As part of this interview process, often for the first time in their lives, parents are being permitted to express feelings that could have been either repressed or came out in a distorted fashion. By helping them share feelings, they may be enabled, in turn, to allow their children to express feelings and avoid the need for attention seeking behavior.
Focus on the whole family - Some relatives are self-absorbed, unaware of how intrusive they were in the lives of other family members. By systematically inquiring about those family members, past and present, parents may become better able to look at them more objectively, develop better boundaries, and even mourn the loss of deceased family members. By so doing, they can become more in touch with who they, themselves, are.
Encouragement to become better decision-makers - In the course of parenting, numerous choices have to be made. In the course of your history taking, there will be opportunities for you to help them discover that they have the competence to make good decisions.
History taking is not a methodical process. You may be able to ask some of the questions outlined here, but you may not have time for all, at least in a single meeting. It certainly is not like asking parents to fill out a questionnaire while they wait to be seen by you.
Sometimes, like visiting a foreign town, you may be tempted by something a parent says to follow unanticipated "back alleys." This is referred to as the process of association. If you are a musician, you might think of it as if you were improvising on a familiar melody. It is a potentially rich and interesting way to conduct an interview.
In the minds of parents, some ideas or memories may appear to be bound up in meaningful pairs or chains. These clusters of ideas may reside below the surface of a parent's thinking. It is as if the interview is being conducted, between parent and pediatrician, on both a conscious and unconscious level.
If we respond to these subtle messages and ask about certain issues, doing so gently and tentatively, parents may be able to share thoughts they often would have not shared spontaneously. You may also obtain much useful information about the feelings associated with those memories.
By so doing, you may discover that the child’s behavior problem may reflect some family conflict, that the child may be acting out some issue, e.g. in regard to the parents' marriage, a troubled parent, the parent when she was a child, or the parent's parent who might have been alcoholic or mentally ill.
You will discover many opportunities for intervention as a result of this single meeting. Caution parents to solve one problem at a time. Let them draw strength from a single victory and then take on other issues. Many of these problems have been going on for a long time. It will take time to bring about change. Parents will decide when they are ready to institute change. All you can do is to try and lay out a road map.
Encourage them to call you (or you them) in a week or two. Ask them how they are doing. Praise them for what they have achieved, acknowledge that change is not an easy process.
Finally, consider the appropriateness of a referral to a mental health professional. You may believe you have solved the problem in a single visit, or you may wish to meet with the parents one additional time, but don't miss the opportunity of encouraging them to consider consulting a mental health worker. Such a professional, with your help, may be able to follow up and build upon the good work you have begun with your timely intervention.
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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.