| Site Index |
|
|
         |
|
|
|
|
|
|
|
|
|
|
Shifting
From Traditional to Biopsychosocial Pediatrics |
to pdf >>
Habits are difficult to change. Change is an ordeal. Consider how difficult it is to give up smoking, excessive eating, or taking the time to get sufficient exercise. Pediatricians have the same problem approaching behavioral issues in children. They all have traditional approaches to children or families. Much of the time it is successful. Why bother to change? Prevention in the Context of Managed Care Pediatricians know the preventive tasks that must be pursued. They include everything from immunizations to advocacy of breastfeeding. But, until now, early detection of emotional distress, depression, and mental illness has been, at best, a secondary topic for pediatricians. However, in the new realm of biopsychosocial pediatrics, pediatricians must be the health care system's first "trip-wire," picking up emotional problems in the parent and within the family. By picking up problems earlier and helping with timely referrals, pediatricians can help parents and children as well as society in an important way. Why has insufficient attention been given to this responsibility? Part of the reason may include the lack of training in family systems theory. In addition, personal issues may cause pediatricians to hesitate to address similar issues in medical practice. And, in managed care, time and reimbursement are allocated as though all problems were simple organic disorders. Ironically, managed care could become the driving force for change. There are at least two possibilities to consider for change to occur. Physicians, hospitals, and managed care organizations try hard, often collaboratively, to improve care, reduce costs, and even improve patient satisfaction. Many demands are placed upon physicians to achieve these goals. They work hard to maintain their professional competence and satisfaction, and, sometimes, they feel that the quality of their family life is being compromised. Physicians may even be relieved that mental health has been carved out to designated providers by managed care organizations. Burdened by other tasks, it is as though physicians have chosen not to integrate mental health into the health care model. But there could be a different outcome. By increasing competence in preventive mental health, understanding why certain things happen to children and families could improve. In addition, parents could become partners in the clinician-patient relationship as they gain self-understanding. Results from increased competence might be:
Each patient represents a diagnostic challenge. If guidance and recommendations don't seem to satisfy parents during repeated visits, consider asking where does this "neediness" come from? Ways of Modifying the Pediatrician-Parent Relationship Some families seem to require more office visits than necessary for a specific problem or checkup. This may be because of an unresolved emotional problem. Address these issues directly by helping patients find successful solutions. The following principles are suggested ways of modifying the clinician-patient relationship to achieve these goals. Shift the Focus to the Entire Family Consider focusing not just on the child but also upon the entire family. At every visit, particularly when a parent shares a concern about a child's emotional health, ask: Who is the real patient in this visit? Is something else going on in the family, someone else who needs help? Reconsider the Image of the Parent in the Clinician-Parent Relationship It is helpful to view parents both as storytellers and as teachers. This is a richer way to see them than merely as people who are coming in with problems about their children. What might this changed view accomplish? Pediatricians may be concerned about having the skills and insight to understand the emotional landscape of children and families. By modifying the image of parents, parents may help physicians improve their skills in assessing the child and the family. By engaging parents with respectful listening, not only is their role enhanced with special dignity, they are encouraged to develop a more confident and "activist" self-image. Those attributes can nurture greater feelings of competence in parents and promote more normal development for the child and family. Facilitate the Trajectory of Parental Development Traditionally, pediatricians focus on the biomedical or even psychosocial trajectory of infant development. But such interventions are more effective when parents develop in their own trajectory. Working with parents, pediatricians should ask: "What am I doing to improve their sense of competence and help them become better decision makers, not only in regard to their children but also with their own physical and emotional health?" (See article on Web site on "Developmental Tasks for Successful Parents.")1 Help Parents Develop Healthy Boundaries in Their Relationship with Their Children How can pediatricians help parents view their children as separate people and reduce their tendency to ascribe to their children attributes derived from unresolved conflicts within their own lives? The office visit can be a recurring opportunity to evaluate how the child and the family are doing. Children often remind parents of someone else, themselves, now or in the past, a sibling at some point in time, even their parents or grandparents. In the course of talking about their children, parents may begin to reflect upon other relatives with whom (often unconscious) feelings may be attached. In sharing such feelings, they will gradually see their children as the separate people they really are. Parents worry about their children inheriting family problems such as mental illness, depression, or personality disorders. They can be reassured that such problems need not be passed on from one generation to another. What a parent fears may be passed on, more likely occurred because of someone's emotional impact upon a child. But this parent, supported by the pediatrician, has the capacity to prevent that problem from being passed on to the child. The Child Can Be an Agent for Change In pediatric practice, parents frequently ask for help in understanding and learning how to modify their child's behavior. Pediatricians make suggestions as to how the parents might go about doing that. How does this change if the whole family is viewed as the patient? Understanding the child's behavior requires assessing the status and functioning of all the members of the family system. Rather than merely treating the child, suggest constructive changes to recreate a functional family. When this occurs, the child becomes an agent for change in the family system. Use the Office Visit as a "Corrective Experience" Consider the impact when the family pediatrician finds time to listen to parents with increased curiosity, empathy, and support. As a result of being heard, parents, in turn, may learn to respond similarly to their children: they have a model of how to relate to their children in a more thoughtful way. Be Attentive to "Family Secrets" Family secrets often include mental illness, sexual abuse, depression, suicide, and never-mentioned combat or immigration experiences. In the course of taking a good history, such "secrets" are just below the surface of the parent's narrative, embedded in those seemingly trivial details that are part of every good story. These secrets affect the functioning of children, their parents, and families. Being attentive to these family secrets creates opportunities for constructive intervention. These secrets can be the source of various addictions; thus, it is important to develop an interest in their origins and underpinnings. Be Aware of "Resistance" Resistance to discussing various problems such as alcoholism or family violence is important to consider when taking a family history. Let parents know explicitly the importance of their family history in their child's health or problems. For example, if the child's grandparents don't live together, ask why or 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 previous pregnancies? At what age and what were the circumstances around them? Were either of the parents previously married? What happened? Do the parents differ in their approach to discipline? What do they think accounts for that? Be on the lookout for potential problems. Don't wait for parents to raise issues. For example, routinely ask if the child has any habits or fears? Are there any sleep problems? How is the child doing at school? How are disagreements settled in the home? If a problem arises, offer the parent the opportunity to discuss it at another time. Make the parent responsible for choosing to pursue the problem or not. If they choose not to, a process of reflection has been set in motion and the parent may be willing to discuss the problem later. There is significant value for physicians learning how to take a detailed psychosocial history. As the Web site article on "Taking a History"2 points out, taking such a history may not only be informative but also have a therapeutic value as well. A previsit family and child health questionnaire, completed at home, is a valuable timesaving tool that allows the pediatrician to focus in detail on problem areas. Listening for "Associations" Be aware of possible associations related to the child's behavior. For example, if parents say the child "needs" a pacifier, ask why they think s/he "needs" it? If parents say, "He needs it for support," ask, "Help me understand why he needs it for support?" Ask if any of their nieces or nephews use a pacifier excessively? 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? Delving further into the family history may raise interesting and revealing points. This can reveal other issues in the family history. For example, did anyone (including grandparents) smoke or drink excessively, or were there ongoing stresses in their family of origin? Proceed slowly in digressing in interviews, in this way. It needs to feel natural to ask about these issues. Pediatricians need to be creative in their attempts to overcome resistance. One way of doing so is to search for "associations" between the child's behavior and the actions and personalities of other family members, past or present. Listen for an "Over-Determined Quality" in the Parents' Description of the Child's Behavior Resistance can be overcome by being sensitive to an "over-determined quality" in parents' description of the child's behavior. For example, parents might say their four month old, "... has a terrible temper." It may be useful to ask, "Who does he remind you of?" Be Aware that Parents Vary in Their "Psychological Mindedness" Some feelings or memories may be too painful for parents to acknowledge. Vincent Felitti, MD, as a result of the Adverse Childhood Experiences (ACE) Study,3 strongly feels it is best to obtain comprehensive and sensitive information by a skillfully devised questionnaire. It is important to enter a highly volatile emotional discussion only when you can do so comfortably; otherwise your own discomfort may close down meaningful discussion and convince you it isn't worth doing. Some parents have no desire to discuss such matters. They may not believe it is relevant; it may cause anxiety; or they may be inhibited because of issues of shame or stigma. In these instances, be careful not to press them to do so. It may be easier for them at a later point in the relationship. Repetitive Attempts to Resolve Hidden Conflicts It is important to consider the possibility of hidden emotional conflicts when parents have a need for repeated testing of their child, or multiple referrals for enigmatic conditions. If these requests are not addressed definitively in the medical setting, the concerns may arise repeatedly, in one guise 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. Often, they are able to rework those memories, over time, into a positive outcome. But, for many parents, 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? If not, 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." What escapes notice in pediatrics usually comes back in adult medicine. Acknowledge Personal Issues Pediatricians are aware that parents may have unconscious attitudes towards physicians, because of past experience with authority figures. Insights should be incorporated into the clinician-patient relationship to encourage parents to weigh advice critically and for rational reasons. When advice conflicts with their intuition, the disparity needs discussion. Physicians, too, have their own unconscious reasons for attitudes towards parents. These vary from how they were raised to how they get along with their spouses to satisfaction with their professional role. Those experiences have a profound influence. Recognizing and dealing with these personal issues helps insure that the relationship with parents is compassionate and helpful. Search for Strengths Parents need to set realistic limits upon their child. They can be assisted by recalling the many tasks 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 to employ during well-child visits. By complimenting parents on the support they give this competent child, parents begin to see their child's behavior in a new light. Likewise, validating how a parent feels can be very helpful. Who has not heard the response, "You mean I'm not crazy?" When a parent tearfully acknowledges the pain of past memories, they are reassured that their feelings are legitimate and quite appropriate. Enhance the Success of the Psychological Referral Terms like therapy, counseling, and mental illness are still stigmatizing for much of society. Even if parents are open to a psychological referral, they still need to feel that they are not being "dumped" when being referred. 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. Referrals made in a positive and supportive way are more likely to be successful and will also reduce the professional and financial resources dissipated by unsuccessful referrals. Help Parents Feel Comfortable in an Activist Role Parents often wish for specific answers and there are situations where it is appropriate to answer their questions quickly and directly. There are times, however, when sharing ideas and offering parents alternative ways of understanding and resolving the problem is less definitive. There is value here in helping parents feel that they have successfully conveyed the problem and they are supported in using their own good judgment to solve their child's problem. It is important to involve fathers whenever 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. Helping parents learn how to become good decision makers is hard for some parents. It may be initially difficult for them to accept such responsibilities. They may want to be told what to do. Others may have the opposite difficulty. It may seem threatening for them to rely on others in the course of gradually understanding what is going on. Such parents will need reassurance that this period of dependency is only temporary and ultimately the responsibility is in their hands. Conclusion This approach to parents may seem very different from traditional pediatric practice. The biopsychosocial approach is one that can be mastered over time without much difficulty and can gradually become second nature with repeated practice. Not only will this approach to pediatric care be gratifying, but parents will also discover how competent they can become in raising their children in an emotionally stable and satisfying way. In an era of managed care, the physician, the parent, and even the health system could all be winners. That would indeed be gratifying. References
|
|
|
|
|
|
|
|
|
|
|
 |
|
