Dr Kings Office

by Howard S. King, MD with Alison Hoppin, MD, Associate Director for Pediatric Services, MGH Weight Center, Linda S. Nikolakopoulos, MS, RD, LDN, Consultant Dietician in Private Practice, and Melinda Strauss, LICSW

“The Centers for Disease Control and Prevention estimates 500,000 people will die next year because of poor diet and physical inactivity.” (Bill Rodgers, in The Boston Globe, April 19, 2004)

Childhood obesity has increased considerably in recent years. About 15% of American children are obese, and an additional 15% are overweight. (1)  “US teens are more likely than those in other countries to eat fast food, snacks and sugary sodas and are more likely to be driven to school and other activities, contributing to a more sedentary lifestyle,” according to the U.S. Maternal and Child Health Bureau.

It should be stated that heredity and biochemical processes such as metabolism play a major role in the development of obesity. While these factors are usually (2) beyond an individual's control, managing daily food consumption presents both choice and challenge for parents and children.

The American Academy of Child Psychiatry recommends changes in eating habits, increased physical activity, diminished television viewing, and addressing family and peer problems and issues of low self-esteem.

Given the epidemic occurrence of obesity and the difficulty in changing habits, what else can pediatricians do to reduce children's vulnerability to this problem, beyond recommending dietary changes and encouraging children to become more active? Are there attitudinal changes we can encourage in the family-child relationship, which might reduce a preoccupation with food?

The focus of this article is to explore the role of the family's relationship with food and its impact on the development of obesity. It is intended to support the pediatrician's efforts to reduce the likelihood of a child developing a lifelong propensity to become overweight.

Family history of weight problems

Parents often ask the pediatrician, “What ‘percentile' is he/she in?” When parents ask that question, it may suggest they're anticipating the likelihood of their child becoming overweight. Pediatricians can be sensitive to that underlying parental fear and use that opportunity to open a discussion. When we help parents put their concerns into words, hopefully, it may diminish the likelihood of parents finding ways, unconsciously, of transforming that fear into a reality.

When parents worry about their child's weight, pediatricians need to take an appropriate, psychologically attuned history. A family history of being overweight, particularly in one or both parents, could be a major contributing factor in children becoming overweight. The history should also include the nutritional status of parents' siblings and grandparents.

It would be helpful to gain some understanding of the etiology of a parent's (or other family member's) weight problem, past or present. If parents are currently overweight or had such a problem in their past, it would be useful to ask them, if they're willing to share such information, what they think might have contributed to this tendency? How old were they when the problem began? Was there any investigation of medical causes for the weight problem? Were there cultural factors, how did being overweight affect their self-esteem, what did they or their parents, in turn, do about it?

Every question, every comment a parent makes about his or her child might possess a deeper meaning. For example, “Could my child be becoming overweight?” may suggest that the parent anticipates, if the child becomes so, that he or she will experience shame because of the stigma of being overweight in our society. In addition, parents may have memories of “shame” in connection with their own development or because becoming overweight emerged in the context of a shameful experience, e.g. the sexual abuse of the parent, at an earlier time in his or her life. These could be “teachable moments” for pediatricians, if they could gain the trust of parents in terms of sharing such memories.

Can we reduce the repetition of obesity from one generation to another?

How do we help parents reduce the possibility of their child inheriting their “weight problem?” How do we help parents establish good boundaries between them and their children, i.e. viewing their children as separate people, able to control their own destiny? If pediatricians provide parents with opportunities to share their personal stories about how and why they, themselves, became overweight, in their own development, parents might more easily assess assumptions they make about their children inheriting weight problems.

Is becoming overweight inherited through genes or could it be “psychogenetic” in origin, i.e. the child becoming aware of how family members approach the process of eating, around the dinner table and, perhaps , gradually internalizing those habits? Genetics plays an important role. However, the family eating environment and the larger cultural environment are influences that are superimposed on any genetic susceptibility for weight gain. Family customs , the family's attitude toward food, and parental expectations are very relevant.

For most people, being overweight is a highly conflicted personal attribute. Most people wish they weren't overweight. But something else is at work if only one person in twenty maintains weight loss from dieting for more than five years.

Despite this discouraging data and the physiological and psychological influences contributing to weight gain, strong motivations to control weight persist . These include concerns about current or long-term health, personal preferences and strong social norms encouraging a thin body habitus, difficulty accomplishing the activities of living, as well as the powerful societal discrimination against individuals with obesity.

Given that most dietary recommendations fail, might that imply that when we manage such patients, we may be giving insufficient attention to the family history and the family system? Parental modeling is a critical influence on the development of a child's behavior. For example, family-based behavioral counseling demonstrated significant improvement in obesity in a ten-year follow up. (3)

The child as an agent for change in the family

It is difficult to manage the overweight child without seeing him or her in the context of a family system. In that context, the child could become an agent for change. The parent, by definition, is the primary mediator of change, and a family-based effort is , accordingly, both appropriate and necessary.

Discussing the overweight child with the pediatrician can provide the parent with a unique opportunity to reflect back upon the parent's own history of how she or he became overweight or even obese. Dr. Vincent Felitti (of the department of preventive medicine at Kaiser-Permanente) speculates that obesity may sometimes have a “protective” function, when it developed as a response to some unresolved conflict, early in life, e.g. sexual abuse. Some experts feel that this is rare (except in morbid obesity), although it could become a trigger for becoming overweight.

The parent's own struggle with weight or ambivalent relationship with food can strongly influence his or her approach towards the child's weight. That's why it's important to understand the meaning and natural history of the parent's weight problem. The child's struggle with weight could present parents with a wonderful opportunity for the parents themselves to reassess their long-standing problem. The pediatrician can help the child by helping the parent.

Weight problems or obesity in children is a family problem. Even if the parent is no longer overweight, and it seems to be no longer an issue for the parent, it is necessary to understand how the parent's weight problem came to be , as well as how it was managed. This would be not only helpful to the child, but would also promote the parent's long-term health.

Family stressors may contribute to childhood obesity

Does a family history of alcoholism or drug abuse play a role in the predisposition to obesity and other eating problems, e.g. anorexia? If some anorectic children have parents or grandparents who were alcoholic, shouldn't we also inquire about a family history of alcoholism and drug addiction when we evaluate overweight or obese children? Similarly, can we successfully address weight problems or obesity in children without acknowledging the problem of nicotine dependence in a parent or even a grandparent?

Other stressors such as family chaos or the lack of nurturing role models could be significant factors in understanding a child's obesity.

Can parental management of some infantile “habits” predispose a child to a tendency to becoming overweight?

What are the consequences of parents' fears that they will contribute to a child's insecurity in the first year of life?

Many parents believe their mission is to prevent their children from ever being unhappy or sad. Even in the absence of a physical illness (e.g. infection, gastro-esophageal reflux, allergy to some food or failure to gain weight), it is difficult for many parents to ever allow their child to cry. Parents' self-doubts about their ability to nurture their child can lead to difficulties setting limits.

In some populations, parents prefer their young child to be overweight. It makes them feel like better parents because they feel it demonstrates they have adequately fed their child. (4)

Most infants can give up 2 am feedings by two months of age and are able to sleep, approximately from 7 pm to 6 or 7 am, by four months of age. If parents can help children achieve such a schedule, doing so might make it less likely that a child would be predisposed to associate feeding as the only way to feel comforted. But that isn't easy, if parents are currently under stress or experienced serious deprivations in their own development. Such parents find it difficult not to give their child that extra feeding beyond the time that it is necessary.

The idea that the child requires the bottle, breast or pacifier “for security,” beyond the time when most children usually give it up (by one to one and a half years of age), could result in the child becoming dependent upon it as a source of comfort.

A common belief that teething causes irritability and pain in young infants can undermine a parent's resolve not to respond to a crying child at night. But many infants appear to erupt new teeth in the absence of obvious pain or irritability. On the other hand, other infants seem to be irritable for which “teething” is blamed, despite no obvious alteration in the appearance of the gums. In fact, some may have real pathology (e.g. an earache) even though a relative or a professional may have ascribed the symptoms to “teething.”

The pediatrician can help by checking for physiological causes of irritability and, if none is found, by reassuring the parents that some irritability in the sleepy infant is common and usually does not indicate hunger. If given a little time, the child can often return to sleep and develop more mature and independent sleep habits.

Whatever the reason for the persistent use of these transitional objects, the challenge for pediatricians is how to encourage parental self-efficacy along with their ability to set limits. We should always be thinking of how we can help parents learn how to set limits and raise a healthy growing child, without needing to overfeed, as a way of proving their efficacy to themselves.

Barriers to following advice

Most parents, if a pediatrician suggests giving up the bottle or discontinue getting up with a child at night, can usually follow through with those tasks, except in the following circumstances:

•  If the pediatrician suggests doing so for inappropriate reasons, at an inappropriate time, or in a controlling manner.

•  If parents are experiencing some ongoing stress, which make it difficult for them to help the child cope with the loss of this transitional subject. In that case, it is important for us to ask if they would be comfortable sharing what is currently going on, emotionally, with the family.

•  Perhaps this task has a "double meaning," e.g. parents may be having difficulty giving up their own nicotine or food dependency and he or she may (unconsciously) identify with the child's sense of frustration. Or there may be a family history of an addiction, e.g. alcohol dependency. In such cases, it would help the parent (and, ultimately, the child) if we could inquire about such issues, in a gentle and compassionate manner.

•  The parent may remember having experienced difficulty giving up a bottle, thumb, or pacifier when he or she was younger.

Parental guilt about allowing their children to cry can be another barrier to setting healthy limits. Sometimes it may just be the lack of awareness of what children are capable of mastering at such an age. Assuming pediatricians have eliminated the aforementioned medical factors (illness, allergy, failure to gain weight), pediatricians should consider reassuring parents that their children don't require endless support. (If parents feel otherwise, consider exploring why they feel that way.)

But, to be successful, pediatricians must evaluate how the parents are doing. It might mean acknowledging parents' (often mothers') ambivalence about working during the child's first few years of life. Parents may need help not identifying the child as mirroring their own past or present feelings, e.g. of being abandoned. If a mother had some degree of postpartum depression or recalls having had trouble sleeping through the night during her own development, it could be difficult for her to facilitate the child's mastery of this developmental stage.

What should a pediatrician's response be to these observations?

Should we just tell parents “what to do?” Wouldn't a better response be, “Let's figure out where there is a problem and decide what you want to do or why it might be hard for you to do so?” (This line of patient-focused questioning draws from motivational interviewing, which is increasingly used as a strategy for counseling in obesity.)

The challenge for pediatricians is how to discuss the issue of weight, with parents, in a sensitive and non-judgmental way. By using icebreaker questions, we may be able to help parents gain insight into their own motivations and issues, as well as open up a healthy discussion about weight:

•  “Whom does he/she remind you of?” “Why do you think so?” “Tell me about that person.” “What was his/her experience?”

•  How is the parent doing? Is she having, or has she ever had, a postpartum depression?

•  Does the parent recall having feelings of abandonment/sleep problems as a child?

•  What was the parent's relationship with food when he/she was growing up? How did their parents' attitude affect that relationship (e.g. “clean plate club,” the use of food as a reward, withholding food as a punishment or for dieting)?

•  What is a typical day of eating like for the family, e.g. are there structured meals or do members of the family just ‘pick' throughout the day?

A pediatrician's personal experience with food or weight management may affect his or her perspective

There are many management issues for pediatricians, which are straightforward and often just need one solution. They include, for example, the treatment of pneumonia or meningitis.

On the other hand, helping parents manage some developmental tasks has special meaning for all pediatricians, at one time or another. It could be something with which they, themselves, are in conflict with in their role as parents, or something that acquired particular significance in their own development. The consequence may be that we'd like to help parents make the best decision, for them, but our own feelings or our need to be in control may get in the way of helping parents decide what is best for them.

For example, physicians who have struggled with weight may impose their own experience on that patient. On the other hand, if they've never struggled with their weight, they may have a distorted perspective, silently assuming that it should be equally easy for everyone to make healthy choices. In such situations, it may be worth discussing our conflict or frustration with a seemingly “resistant parent” with one of our peers and see if we, ourselves, can overcome our difficulty helping parents master this task.

We want to avoid parents saying to us, “Doc, I tried what you suggested , but it didn't work ” (which could be their way of saying, “I don't think you understood why this was difficult for me”). It should be just the opposite. The goal of client-focused counseling is to help patients identify, within themselves , the barriers that might be inhibiting change.

There are various developmental tasks for which there is no absolute answer. In such instances, one could say to a parent, “If it were my child, I might do this.” Or, it might be preferable to say, “Most parents accomplish this task by a certain age … but you may have a very good reason for delaying the mastery of this task. Perhaps you could share with me your thinking about this.”

It is worth remembering that children who don't seem to cooperate with their parents' best intentions may be teaching their parents something (about the parents' own background). Similarly, the parent who doesn't follow through with our suggestions may be teaching us something about how we've approached some issue with the family (and about our own background).

And a word about “exercise”

It's important for every parent and child to identify and participate in a physical activity that they enjoy. Consider exploring family patterns of exercise and help parents to suggest changes that support an increase in physical activity, such as setting limits on TV time for the whole family.

Bill Rodgers (a four-time winner of the Boston Marathon) has written the following:

“Changing the dietary habits of children is a primary concern, because during childhood we form eating habits that last through our lifetime. But telling kids to eat healthy foods because staying slim will help prevent diabetes, heart disease, or cancer later in life will not work. For every parent who replaces candy or cookies with apples at dessert time, there will be a contraband stockpile of candy waiting in the child's closet when dinnertime is over …”

“The most effective way to attack obesity is to get people involved in a sport or physical activity … that burns calories and makes them feel good while they're doing it … “

“People change eating habits only after they start to lose weight and feel better about themselves through running or other sports and physical activities. They become more attuned to their bodies, and realize it's going to be a lot harder to achieve their goal – finishing a 5k race, winning a dance contest, or being the best player on their soccer team – if they don't watch what they eat. Even kids who become interested in a sport like soccer are more likely to choose an apple over a cookie if they know it will help them excel at their chosen physical activity …” (The Boston Globe, April 19, 2004)

Referral for nutritional education

The disease of obesity is clearly multi-factorial. Each component must be addressed individually, by the respective team member responsible for providing the care, in order to appropriately and most effectively treat this disease. The pediatrician and dietitian are integral members of this team, with a psychologist or clinical social worker possibly becoming involved when warranted.

How does one decide upon a good dietitian? A dietitian working primarily with obesity and obesity in children would be the primary candidate. Advice from friends or professionals may be helpful, but the American Dietetic Association provides a Nationwide Nutrition Network, www.eatright.org , which is a national referral service.

The following information would be useful, prior to referring a child to a dietitian:

•  Current height and weight, along with a copy of the growth chart

•  Lab work, including hemoglobin, total cholesterol and blood lipids

•  History of chronic conditions, including diabetes, metabolic disorders, etc.

•  Family history of coronary artery disease, hypertension, diabetes mellitus, elevated cholesterol levels, eating disorders, alcohol or substance abuse

Summary of recommendations for discussion with parents

•  When parents worry about their child becoming overweight, find out if there is a relative with whom the child might be identified – parent, grandparent, aunt or uncle.

•  If such a relative had a weight problem, how and when did it develop, and what are the parents' perceptions of why the problem developed?

•  Is there a significant family secret that a parent would be willing to share - alcoholism, eating disorder, or addiction?

•  Do the parents believe this particular child has “a weight problem?” Do they convey this to the child?

•  How do they think the problem developed?

•  Did the child have difficulty mastering earlier developmental stages, e.g. sleeping through the night, giving up the bottle, breast, and/or pacifier?

•  What is the parents' “worst fear” regarding this particular child?

•  Do they have other worries about this child?

•  How are the parents doing – individually, in their interpersonal relationship, with other members of their families, at work, and with their own self-esteem?

•  How is the child doing – socially (in school, friends, activities) and emotionally, including his or her relationship with the family?

•  Do the parents believe some physical problem, e.g. thyroid disorder, is causing the child's weight problem? If they do, check it out early.

What observations are reassuring to me?

•  The child's height and weight percentiles have been consistent over time.

•  The parents don't believe a physical problem is the cause of the child's weight problem.

•  The child seems to be functioning well in every other way.

•  The parents, individually, and as a couple, appear to be doing well.

•  The parents have developed good “boundaries” in regard to their child.

If I can help parents to be relatively open about their own past and about other overweight family members, and also help them to be comfortable talking about unpleasant experiences related to weight that can be addressed by a referral to further professional help, a positive outcome is more likely to happen.

And, if I, as a pediatrician, can make the above observations, I would be relatively optimistic that the child would, over time, master his or her own eating habits and gradually develop a positive self-image. The hoped for outcome would be that the young patient become an adult without a weight problem or serious obesity.

 

Footnotes

•  Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and Trends in Overweight Among US Children and Adolescents, 1999-2000. JAMA, Oct 2002; 288: 1728-1732

•  There is mounting and intriguing evidence that nutrition during gestation and early life can have a permanent effect on an individual's predisposition to obesity (the concept of metabolic programming). Ozanne SE, Hales CN. Lifespan: catch-up growth and obesity in male mice. Nature, 427 (6973): 411-412

•  Epstein LH. Family-based behavioral intervention for obese children. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity, 20 Suppl1: 514-21, 1996

•  Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC. Maternal feeding practices and childhood obesity; a focus group study of low-income mothers. Archives of Pediatrics & Adolescent Medicine, 152(10): 1010-4, 1998

Letter to the Reader

Introduction

A Survivor ’s Story

1. Domestic Violence Is a Major Public Health Problem
2. Is There Agreement as to What Is Meant by “Domestic Violence”?
3. The Impact on the Mother of Screening for Domestic Violence
4. The Impact on the Pediatrician of Screening for Domestic Violence
5. Who Is a Batterer?
6. Who Is the Patient for the Pediatrician?
7. The Impact of Domestic Violence on the Developing Child
8. Helping Children Cope
9. Child Abuse —A Generational Issue
10. The Frequency of Non-Acknowledgement in the Medical Interview
11. Barriers to Problem Recognition and Intervention in the Primary Care Setting
12. Is There a National Mandate to Conduct Screening for Domestic Violence?
13. Preparing the Office
14. How to Conduct Screening
15. Empower, Refer, and Follow Up
16. The Importance of Documentation
17. Overcoming Barriers Through Education
18. Becoming Acquainted with Community Resources
19. Coding Issues
20. Teen Dating Violence
21. Two Perspectives on Surviving Abuse
22. Constraints of the Medical Model
23. Conclusion

Appendix I:
Domestic Violence Screening Response

Appendix II:
“Do Victims Cost Health Plans More?”Appendix III:Information and Intervention Resources: A Sample Resource List That Can Be Adapted to Local Areas

Pediatrician Quick Reference Guide

References

by Dr. Ranna Parekh
December, 2003

by Dr. Jerome Groopman
December, 2003

Foreword

Both writers and patients share the struggle of putting feelings into words. So, when we discovered a Boston Globe book review that summarized what we hoped our web site might accomplish, it seemed like marvelous good luck.

Dr. Jerome Groopman, in his review of Richard Horton’s book, “Health Wars: On The Global Front Lines of Modern Medicine,” published by the New York Review of Books, takes on the task of reaffirming the culture of health caregivers and argues for solutions as to what is wrong with medicine today.

Groopman is very qualified to champion the enormous contribution of evidence-based medicine alone. He holds the Dina and Raphael Recanati Chair of Medicine at the Harvard Medical School and is Chief of Experimental Medicine at the Beth Israel Deaconess Medical Center, where he established an innovative program in clinical research and clinical care. However, despite the positive outcomes of evidence-based medicine, Groopman suggests the following:

“Modern medicine is ailing … the traditional esteem and authority accorded to health care professionals have been lost, and until these attributes are restored, the commitment of doctors and nurses will continue to whither …”

Groopman highlights Dr. Horton’s assertion that the current emphasis on marvelous science overlooks the soul. In addition to paying attention to disease, a physician must understand his patient’s anguish, his “dis-ease.” These two physicians teach us that, if medicine is to retain its place as society’s chief source of healing, it will require a subtle alchemy of intuition, the narratives of the patient’s life, and time, the most precious commodity of modern medicine.

Groopman closes the review by presenting Horton’s challenge that

“the role of the doctor must be to alleviate dis-ease … to have the quiet humility to listen … to act as the voice of one’s patient through advocacy, … and to take on the opportunity of restoring human dignity, which is the essential fabric of modern medicine.”

The following are excerpts from Dr. Groopman’s review of “Health Wars: On The Global Front Lines of Modern Medicine” by Richard Horton, MD. Comments and subtitles are mine.

- Howard S. King, MD

 

Something is seriously wrong with modern medicine

“Modern medicine is ailing. Something is seriously wrong. This is felt not only by patients, but also by doctors….Yet there is disagreement about the diagnosis of medicine’s malady.…The traditional esteem and authority accorded to health care professionals have been lost, and until these attributes are restored, the commitment of doctors and nurses will continue to wither.” It will require the reaffirmation of the culture of caregivers. What is that culture?

The explosion in scientific information

In reviewing Dr. Horton’s book, Dr. Groopman addresses that question. “Horton’s primary thesis is expressed by a play on the word ‘disease.’ Doctors are trained in medical school and residency to focus squarely on the diseases of their patients. The explosion in scientific information…has made this focus even more sharp and penetrating. While in the past physicians relied heavily on the spoken history of symptoms offered by the sick and their families, and then pursued these clues in the bedside examination…technology now permits the physician largely to skip such time-intensive practices and jump to a CAT scan to visualize the inner anatomy of the patient and to DNA analysis of his tissues to pinpoint what is wrong.”

Yet modern medicine overlooks the need to understand the patient’s anguish

“Horton asserts that this concentration on marvelous science overlooks the soul. In addition to paying attention to disease, he says, a doctor must understand his patient’s anguish, his ‘dis-ease.’

This position, Horton emphasizes, goes against the tide of so-called evidence-based medicine. And evidence-based medicine is all the rage these days, the core of medical school curriculums at our most prestigious institutions. ‘Evidence-based medicine is a movement that aims to quell what its more extreme supporters see as two malevolent attitudes in medicine,’ (Horton) writes. ‘One is that the favored basic science for medicine is done in the laboratory. Respectable medical researchers point themselves toward the bench, not the bedside.…The other attitude concerns the power of and respect for the clinical professor, awarded by virtue of his or her long experience….’

Yet humans are not consistently rational beings, and the physicians who practice medicine and the patients who receive care are both deeply human. Horton shows how powerful the irrational is in our public health, and how feeble ‘evidence’ may be in influencing the salubrity of society.”

Experience is out because it cannot be measured.

“ ‘In our new quantitative world-view of medicine, experience is “out” because it cannot be measured, packaged, examined, manipulated or tested experimentally or statistically. Experience exists only in the mind. In hierarchies of valid evidence, experience sits at the bottom, the weak associate of scientifically acquired evidence.’ ”

Nevertheless, intuition needs to be a potent factor in diagnosis and treatment …along with the clinical narrative

But, “Horton rejects this trend, and asserts that intuition, how a doctor ‘feels’ about a patient and his condition, needs to be a potent factor in diagnosis and treatment: ‘intuition is about as unscientific as one can get in writing about reliable evidence. But in medicine, in many practical disciplines, intuition is a powerful tool in the right hands.’ ”

In the meantime, “clinical care pivots on narratives, the narratives of the patient’s life, that link his past to his present and that project his future. Such narratives fall outside of statistically analyzed experimental evidence, the evidence that this generation of doctors is taught to primarily invoke when offering options for treatment.”

They both require time, perhaps the most precious commodity in modern medicine …

“To reincorporate narratives into the doctor-patient encounter, and to provide the fertile environment for intuition, requires time, perhaps the most precious commodity in modern medicine. There seems to be scant time afforded to allow a patient to speak in what is often a disconnected and seemingly meandering way, but which can reveal key clues not only about an underlying physical condition but also his beliefs, attitudes, and needs.”

“…it is a person’s beliefs, attitudes, and state of mind that will determine how he readily he follows a treatment regimen and how successfully he can endure an illness.” Horton writes, “It is time for time, and the judgment that it permits…to be taken more seriously. This change is necessary if medicine is to retain its place as society’s chief source of healing. It is by no means certain that it will do so.”

The essential role of human dignity and the humility to listen

Finally, Horton “makes an argument that human dignity should be the essential fabric of modern medicine….‘Medicine is an important lever for restoring human dignity, at the bedsides of the sick….The role of the doctor must be to alleviate dis-ease as well as disease, to have the quiet humility to listen when faced with pervasive anxiety, to have the strength to give sustenance when faced with despair, and to have the confidence to act as the voice of one’s patient…through advocacy, when faced with vulnerability and powerlessness. The restoration of dignity is the end common to all of these endeavors.’ (Italics mine)

‘Amid the many exaggerated scientific claims and harsh political debates that characterize much of modern medicine, this simple idea, so easily overlooked, is the fundamental reason why medicine matters, and why we need to take human dignity a great deal more seriously than we do today.’”

In January 2004, Dr. Groopman will publish “The Anatomy of Hope: How People Prevail in the Face of Illness” (Random House) which explores how hope can change the outcome of illness.

Being a successful parent, raising a happy, healthy child, should be one of the most important and gratifying objectives of adult life.

But the journey isn't an easy one. There are many challenges along the way. You worry about your child's physical problems and how they will be resolved. You also wonder whether your child might develop emotional problems.

Does my child have an emotional problem?

One of the most difficult tasks you may confront is deciding whether your child could have an emotional problem. For example, she or he might be afraid to go to school, be prone to "lying," be abusive to a sibling or have difficulty falling asleep at night.

How do you respond? If you have a spouse or partner, he or she could be someone with whom you can share your concern and arrive at a thoughtful conclusion. Sometimes, however, your spouse or partner may not be able to understand why you are worried. As you try to understand your child's behavior, friends, relatives, or even a child's teacher may be helpful in deciding whether your child might have a problem.

One task is to overcome the natural tendency to deny there is a problem. You may also find it difficult to overcome guilt feelings that you might have contributed to the problem in some way. Friends and relatives, with the best of intentions, may try to reassure you that "it is nothing" or that "your child will outgrow it." Maybe your child will, but you deserve the opportunity to talk about your child and give yourself peace of mind. You may decide to seek counseling.

How does counseling work?

Counseling is a special kind of talking. It means bringing to your awareness feelings you have kept inside for a long time. This dialogue occurs between patients or parents and a professional whom they trust.

A counseling relationship allows you to listen to your own words, and also gives you a way of stepping outside of yourself to see how your way of feeling and thinking about parenting affects how you actually behave toward your child and others in your family. With this new perspective, you may be able to figure out how to solve a long-standing problem in a new, creative way. It also provides you with a choice about how you might wish to respond to similar problems in the future.

Who is there to help me?

Once you overcome those obstacles, what might be your next step? Which professional might help you discuss your fears, decide if there is a problem and choose the kind of help your child and you might need? Whom can you trust?

Your community usually provides a variety of resources. Your child's teacher or school counselor may suggest a child psychologist or psychiatrist, a clinical social worker, a behavioral pediatrician, or a mental health center. These are all excellent resources. Since a psychosocial consultation can be provided by different types of professionals, I have labeled such a person with the general term "counselor."

But there may be someone else for you to consider: your own pediatrician. Could he or she play a useful role in helping you plan your next steps?

Your pediatrician has known your family over time. He or she has seen your child for regular checkups and has observed your child's growth and development. You may have mentioned, from time to time, worries about other members of your family including issues of health, loss of job, even deaths in the family. Might not the pediatrician be a possible resource, at least initially, to talk with about your child's emotional health?

Pediatricians will vary in how they may respond to your concern. Some may be pleased to help you with the initial assessment. Others may prefer to identify an appropriate resource for you within the community, reassuring you that you are taking a constructive first step.

Remember, seeing a counselor doesn't mean that your child will require therapy. It merely indicates that additional time and expertise is required than is usually available in the routine office visit.

What types of questions do parents ask?

1. Why isn't there a quick answer to my child's problem?
   
   It would be wonderful if there was. Unfortunately, there are no easy answers. Every child is unique. Both family values and history play important roles in how a child grows and develops. It takes time to address the complex threads that create each child's special situation. And, the solution must make sense to you after taking time for careful consideration.
2. Why doesn't the counselor just talk to the child?
   
   That may happen later on . Helping children often starts with helping parents. That may involve understanding how you, as parents, are doing. It may also include understanding how you, yourselves, were raised and something of your own early life experiences.
3. Should one or both parents be present?
   
   Both, if possible. Sometimes each of you may share perceptions about your child that the other may have never been fully aware of, and that exchange of ideas may be as useful as anything that the counselor could suggest.
4. Suppose one parent is reluctant to come?
   
   That is OK. If one parent comes in, shares her or his concerns and gains useful insights, that often has a positive effect on other members of the family.
5. Suppose I have questions before the visit?
   
   Don't hesitate to call the counselor with any questions or concerns before you meet. Such meetings are not meant to be mysterious; the objective is not to find problems. Instead, they are meant to help you and your child become aware of how much you have already accomplished and what you can now do in this challenging area of your child's development.
6. What if I'm not comfortable with the counselor?
   
   Even though the counselor you have chosen may be well-trained and well-intentioned, it is possible that the chemistry between you may seem less than ideal. If you feel you have given it a good try, consider seeking a second opinion. You need to feel comfortable with your choice.

What should parents expect from a counseling experience?

Whoever is the counselor, keep in mind that how they listen to you describe the problem, the questions they ask you to clarify your concerns, and how they go about helping you consider your next steps, should help you take charge of your child's emotional health.

Whatever you and they choose to do, you should feel that you are being listened to in a thoughtful, compassionate way, that you have time to express your concerns, and that you and the counselor are charting a course to begin resolving your child's problem.

The parent as a story teller

Every parent has a family story to tell which may reveal to both you and the counselor what may be at the root of your child's difficulty. The story may be not only about the child but also about your family as a whole. The problem may not only have an immediate history but one that may go back in time, even to several generations. I hope you will feel comfortable sharing that story.

Is the assessment confidential?

You should be reassured that such discussions are absolutely confidential in accordance with the law. Don't hesitate to ask the counselor about confidentiality. Personal information will not be shared with the insurance company or managed care plan. From the standpoint of a pediatrician, the only information that should be disclosed would be that you came in for a consultation, period!

What types of questions might you be asked?

An assessment of your child's behavior problem will be done either by the pediatrician or, more often, by the counselor that he or she recommends. The evaluation of the problem could take as long as an hour in order to get a sense of what is going on. What would represent an adequate assessment?

An evaluation should include a thorough review of your concerns, including when the problem began, whether it coincided with a recent event or if it has been more longstanding. You may be asked what you believe are contributing factors as well as what you have done so far.

If there are two parents, you may be asked if you view the problem similarly or differently, and what each of you think might be the cause.

The counselor will usually ask how your child is doing in a variety of areas, such as eating, sleeping, separation, fears and habits (for example, thumb sucking or nail biting). Depending upon the age of the child, the counselor may ask about the developmental history and how he or she does with discipline, other children or school.

If you have other children, you may be asked how they are doing, and whether there are any marital problems.

You may be asked about your worries for the future if nothing is done about your child's behavior. Sometimes, you may worry that your child may have "inherited" a problem from some other relatives. Or your child may remind you of someone else, particularly a member of your own family.

It may not be easy, but talking with your counselor about those family members who had an impact upon you, talking about the affection and anger that you may have or had toward these individuals, may be helpful. By so doing, you may be able to gradually separate them in your mind from your child, so that you can look upon your child as the separate person he or she really is.

Sometimes there are "family secrets" or worries that may seem related to the development of your child's problem. They may include a family history of alcoholism, abuse or mental illness. Counselors recognize that sharing such concerns may be difficult or painful. Nevertheless because a discussion of the family history can be very important in helping you deal with your child's behavior, I would encourage you to consider passing on such information to the counselor.

There may have been "losses" (for example, a premature death, a serious illness, loss of a job, or a divorce) that you may feel contribute, at least in part, to the development of the problem. You may be encouraged to share those events and how you feel your family may have been affected.

Finally, an assessment should also include a discussion of your child's and your family's strengths and successes.

How can you judge the quality of the outcome?

At the end of such an evaluation by the counselor, you should feel that:

• he or she was genuinely interested in the individuality of your family
• you have not only shared your thoughts and feelings but are also gradually acquiring a feeling of competence in addressing your child's problems
• you have choices in confronting these problems, and you have the capacity for making good decisions

It is worth remembering, however , that such achievements take time.

The visit should broaden your perspective about the family in which you were raised

Of course, the greatest challenge for parents is to help their children become the mature, loving individuals they have the right to become.

But for many reasons, children may remind you of other individuals in your family including your spouse, your parents, as well as yourself or your siblings, in the past or present.

This is normal. Many traits we project upon our children are special, charming, worthy of being passed on. Unfortunately, some of them may not be. In the course of telling your story, you may discover whom you are really describing. Once you do, you may then be able to move on and come to see your own children as the unique children they really are.

The issue of control

Raising children obligates parents to think about how they address the idea of "control" in their own families. Occasionally parents may not agree about how to manage this issue. You may feel vulnerable for one or more reasons.

One or both of your parents might have seemed "out of control" or might have been too controlling. A consequence may be that you may have difficulty giving your own children sufficient guidance or limits for fear of being over-controlling yourself.

Sleep problems

More than 95% of children should be able to sleep through the night by four months of age. On the other hand, some have stated that it is probably the commonest emotional problem of childhood.

When sleep problems are allowed to become a chronic issue, it may say to the child, "You can't cope with loneliness ... You don't have the strength ...You need me to feel secure ..." If that is the case, the challenge is to find out why you believe that to be true.

Alcoholism and mental illness in families

You may worry that alcoholism or mental illness is inherited. It certainly seems as if they are because there is be a higher incidence of such problems in some families compared to others. Your counselor may suggest that such tendencies could be acquired rather than inherited. If that were the case, it raises the possibility that parents and children have a greater potential to become masters of their own destiny.

Managed care and parent counseling

You may believe that pediatricians do not have time for counseling because HMOs do not reimburse pediatricians for such intervention. That seems to be changing. Some HMOs are gradually allowing pediatricians to do so. If you are in any doubt whether your health plan supports this type of intervention, check with them to make sure that this is a covered benefit.

Many pediatricians are aware which health plans support this type of counseling. All that is required is for the pediatrician to state that he or she has spent the requisite time doing so.

Other sources of funding

There are additional sources of financial support that are available to families, depending upon the child's age, the nature and the severity of the problem, as well as the family's financial status.

Resources include early intervention programs for the newborn to three age group including children with developmental or behavioral problems, and Department of Education funds for children with learning disabilities.

If your child is disabled, he or she may be eligible for financial support through Supplemental Security Insurance (SSI). In addition, the state departments of social services, mental health, and retardation may also provide you with support.

Your pediatrician, or the social worker in you community hospital or mental health center, may help you apply for assistance from such agencies and resources.

The child's problem is an opportunity!

While it is painful to confront developmental issues in your children, problems can also be seen as an opportunity to assess how you and your child are doing, and the earlier the better.

As your pediatrician or counselor listens to you, you may discover that the problem has been bubbling under the surface for some time. By reconsidering how your family is doing, you may find ways of constructive intervention that could help your whole family not only address the current problem but also become stronger in the long run.

 

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Dear parents,

We hope this web site will address your present or future concerns about your child’s emotional development.

Our primary goal is to encourage you to bring those concerns early to the attention of your child’s physician. All of us, as parents, need to be comfortable asking for help. By so doing, you will gain the reassurance you deserve or find appropriate guidance and support. You will discover that as a family you have many natural strengths and have already accomplished much in the course of your child’s development. In addition, whatever you achieve now will assist you as you encounter future challenges.

Your pediatrician, family physician, and nurse practitioner have many talents and resources available to them to help you solve your child’s problem. They are there for you at times of crisis and may often be reimbursed by your health plan if they provide such intervention.

You may wish to invite your child’s pediatrician, or your family physician, to visit the doctors’ section of this web site. Between your physician’s knowledge, your determination to succeed, and whatever insights this web site may generate, we are confident that you and your pediatrician will become effective partners in understanding and enhancing your child's development.

Howard King and Melinda Strauss