Dr Kings Office

The case of the B. family involves parents' concerns with "the terrible twos" and how a pediatrician might address a common behavioral problem in a single visit.

The conclusion is that a useful approach would take into account the unique aspects of the family situation, as well as the parents' past history. The relationship that develops between the parents and the pediatrician as a result of such a consultation would very likely support the parents' ability to gain more insight and better skills.

Parents are often competent to arrive at the resolution of most of their problems when they are provided with the opportunity for extended parent-physician interaction. While the child in the case of the B. family ultimately did well, the discussion of that visit does not imply that this was the only way or even the best way to approach the problem. What it does offer is one way of responding to parents' concerns.

Parents need the opportunity to express their concerns, to discuss their views about the origins of the problem, the contributing factors, and their fears about what might happen if there wasn't any intervention. Our task, as pediatricians, is to consider whether we wish to help parents look at alternative ways of dealing with such a child and, if so, to find out which approach makes sense for the parents concerned.

The problem

Mr. and Mrs. B., came in with their daughter, Suzanne, at twenty six months of age, for a well child exam. I asked, "How are things going?" They replied, "She's going through the terrible twos." I asked, "What do you mean?" This is how Mrs. B. described her daughter:

She is crabby, fussy, she is going through a whining stage. I listen to her whine for half an hour until I'm ready to pull my hair out. She seems unhappy. It baffles me. This whining kid is driving me batty ... I have this thing about candy. My husband sees her upset and says, "A little bit of candy won't hurt." So when I come home, the first thing I hear is, "Candy, candy!" She'll cry for half an hour if I don't give it to her. I don't want to put her upstairs. I feel so frustrated. What am I doing wrong? ... When people see her behaving this way, they say, "What's the matter with her?" I'm mortified. How do I get her to understand that this is not acceptable behavior?

Comment: The problem has been defined. While both parents described the problem, it was Mrs. B. who felt more intensely about it. We also get the feeling that perhaps each parent feels differently about the behavior or, at least, their strategies for dealing with it are different. Furthermore, Mrs. B. sees herself as responsible for her daughter's behavior, as the one who is going to have to find ways of modifying it. She is clearly vulnerable to how her peers regard Suzanne's behavior.

The visit

I went on to ask, "How long has it been going on for?" "Four to five months," they replied. "Is it getting better or worse?", I asked. "It's about the same," they said.

Comment: There is no point making a mountain out of a molehill. If it had just begun a week or two before, particularly in response to some obvious or self-limited incident, I probably would have brushed aside their concern. I would have said that it was quite common at that age and would anticipate that the problem would be resolved before long. It was very evident, however, both by the way Mrs. B. described the problem and by its long-standing nature, that the problem required more clarification.

I then asked, "Who is more concerned?" Mr. B. said, "I regard it as a phase. It bothers my wife more. She gets more upset. I'm more lenient. I tend to be able to listen to it a bit more easily."

Comment: To make a recommendation, one has to be able to understand the problem. To understand the problem, it is important to know who is having trouble coping with the child. On the surface, it appears as if Mrs. B is having most of the difficulty. If so, it is necessary to understand the problem from her perspective before we can offer her guidance and support.

On the other hand, Mr. B. may well be playing an important role, as we shall see. We already know that he is the more lenient of the two parents. Might Mrs. B.'s role be made easier, would she seem less of a "witch," if he took a more active role?

I then asked, "Why does it bother your wife more?" It was apparent that Mrs. B. was well along in a pregnancy which, incidentally, had been unplanned. They had become reconciled to it and were looking forward to the new baby but it had certainly changed some of their immediate life objectives.

Furthermore, Mrs. B. had been severely nauseated during pregnancy. This made it difficult for her, not only in her parental role but also in her professional work as a psychologist which she was trying to maintain throughout her pregnancy. I might add that Suzanne was the second child. There was an older daughter who had no behavior problems.

Comment: It was obvious that this was not simply a problem of a child going through "the terrible twos." There was, in addition, a mother and father working through an unplanned pregnancy with uncomfortable physical symptoms, Mrs. B. trying to cope with an active career, not to mention the responsibilities of caring for an older child. Wouldn't any of us feel overwhelmed?

What about the older child? "Suzanne is more high strung than her (older) sister," the father said. "She never stops from the moment she wakes up!"

Mr. B. said: "She scares her sister. She's such a bully. She's going to be a wild one! I never realized she'd turn out that way!"

Comment: Was Suzanne born this way or was it a function of being the second child, going through a commonly difficult developmental phase, in the midst of some overall family stress? I saw it the latter way. It was good that Mrs. B. had at least derived some feelings of competence from how well she had raised her first child. On the other hand, the contrast between Suzanne and the older sister certainly made it confusing for her mother.

Note also the gradual emergence of labeling with such comments as ..."She's such a bully" or, on another occasion, ..."She's such a con man!" (Mind you, we are talking about a two year old. Yet is this parent any different from the rest of us? When any of us talk about our own children, we can forget about whom we are talking.) In a similar manner, listen to the expectations ..."She's going to be a wild one!"

But we are getting ahead of our story. Did I know what I was dealing with? Was this just a management problem or was I involved with a child with many difficulties? I decided to take an inventory of how the child was functioning.

How was her appetite? "Terrific," they replied.

Was she still on a bottle? It had been discontinued six months before.

Did she have any other habits or fears? "No!," they replied.

How was she physically? Her parents wondered about her ears; she had had a number of earaches.

Friends and relatives had asked about her teething. The teeth were normal on examination.

I asked about Suzanne's sleeping habits. She had begun to climb out of her crib a few months ago, so her parents had put her in a bed. She seemed happy with her bed but she was getting up in the middle of the night two or three times a week and would have to be put back to bed.

Comment: Questions about ears, teeth, and general physical condition are very appropriate. It would be folly to give parents advice about coping with a developmental phase and miss a significant physical problem. Once having satisfied ourselves that Suzanne was in good shape physically, we can go on to helping the parents cope with their child. Incidentally, in my view, teething rarely causes anything in children. At the very least, an overemphasis on teething-related behaviors is often a misplaced concern and may distract parents and doctor from confronting more relevant issues.

In addition, we discovered that Suzanne was functioning well in most other aspects of her development. Sleeping is another matter but that will be addressed later on, under Recommendations. The parents and I could turn our collective attention to the issue of the terrible twos in an otherwise physically well, developmentally normal child.

How had they tried to cope with Suzanne up to now, I asked Mrs. B. She replied:

I've read so many books. I've tried everything with her. I put her in her room, saying ..."until you stop your whining ..." On the other hand, I try to be an understanding mother. Nothing seems to make a difference in her attitude. I'm not handling it well. A friend of mine had a child with the same problem. She talked about it with a child psychiatrist. He told my friend that her child needs limits. I tried it with my child. It didn't work. I think I'm being consistent, though.

Comment: A book is good for background and even, at times, for specific advice. But, given bright parents who are dealing simultaneously with a variety of issues, a book, by itself, is often insufficient. Most of us need to reach out to another person who objectively and empathically can help one talk and fully share one's thoughts and feelings. We may learn from the experience of others but, essentially, we all write our own book.

Furthermore, how do we cope with our mixed feelings about the child, her behavior and the methods of coping with it? It is good to be flexible in dealing with children but is that what this parent is doing? Is she reflecting her own temporary insecurity, her attitude towards herself and her husband, or perhaps feelings derived from how she herself was raised?

What else can we learn from listening to Mrs. B.?:

I know it has something to do with me. Suzanne does well with the sitter. She's very strict with Suzanne. But when I come home at night, everything explodes!

Comment: We know a lot already. This child is going through a phase that is frequently difficult. Otherwise, she is functioning well. The parents are trying to cope with a pregnancy, dual careers, divergent attitudes about approaching this child. It is Mrs. B. who is in the most pain about the problem, who is trying to figure out why it's happening and what to do about it. While Mr. B. will appreciate all suggestions from me, it will be with his wife that an alliance needs to be formed.

By her statement that, "It has something to do with me!", parents and pediatrician are beginning to move into a climate of bringing about change. It is not a matter of who should feel guilty. That is irrelevant. It is a matter of trying to help the vulnerable parental figure in the parent-child relationship understand the roots of the problem. We can then help that individual rediscover his or her own coping capacity.

While there might be many more questions one could ask, there is one that might be especially useful. I ask it to help me understand if there is any other reason why these parents might be frustrated or intimidated in dealing with their child over and above the factors cited. I might ask them, "Does this child remind you of anybody else in the family?" Or, put another way, "Do you worry about what is going to happen in the future?"

How did the parents answer these questions?

Mrs. B: "I worry about it becoming a habit of hers if she doesn't get her own way ... She scares her sister, she's such a bully, she'll be a wild one ..."

"Like who?," I asked.

“Well, I have a younger sister with a terrible temperament . It scares the heck out of me. She's the black sheep of the family. She was married at sixteen and she is already divorced. She has such a negative disposition. I wonder if it is hereditary."

Comment: In my opinion, it is not hereditary. Mrs. B. and her husband are very different from Mrs. B.'s parents and their personalities. Her parents had a difficult marriage with stressful life circumstances. Her sister's personality was possibly an unfortunate adaptation to that relationship.

Unfortunately, parents often worry that traits such as those demonstrated by Mrs. B.'s sister might be hereditary. In the absence of any current family problems, these traits, when passed on to the next generation, are more likely a result of a self-fulfilling prophecy. In contrast, Mrs. B. had a strong marital relationship with much love and mutual support. It is common in dealing with our own children to forget the many sources of strength in our current family life.

Parent-Doctor interaction

It would be unrealistic for one visit to result in the disappearance of "the terrible twos" in Suzanne. Nevertheless, I would suggest that as a result of this brief visit much useful information was shared and the process of resolution was initiated. Looking back, what had been accomplished in this single encounter?

1. Sharing the problem

Most important, the problem has been aired and, in particular, a whole host of feelings have been shared. Parents need the time to talk about an issue, to express their ambivalent feelings about the child, and begin to chip away at their feelings of guilt. If we don't give parents the opportunity to discuss these unnecessary guilt feelings, they may be inhibited from being spontaneous and decisive with their child.

2. The reassurance of normalcy

We can be quite honest with these parents about how common this phase is, that other equally competent parents have experienced it, and that it will come to an end before long. It will be helped by the passage of time, the increasing use of language, the mastery of toilet training and, occasionally, the child's own experience with nursery school or day care. This assumes, of course, that there are no chronic aggravating issues at work.

3. Looking at aggravating factors

Suzanne's parents were able to discuss those issues which might have exacerbated the problem. In this case, they included the unplanned pregnancy, Mrs. B.'s physical symptoms and dual careers. In addition, Mrs. B. struggles with guilt for working while she is mothering, guilt that can be reinforced by culture and society. There are, of course, no quick ways of resolving these conflicts and multiple demands. On the other hand, The B.’s are potentially as competent as other parents in being able to arrive at a reasonable resolution of these issues. What it takes is the chance to talk about it, to share the confusion, the tension, the ambivalence. Doing so can be very helpful.

4. Eliminating physical factors

Parents need to focus on the major contributing factors. Reassuring them that the child is in good physical health, that the ears are normal, that she is not teething -- all that can be helpful. They can direct their attention to those aspects of their family that they are quite capable of doing something about.

5. Emphasizing strengths and past achievements

It is easy to become so preoccupied with a child's negative behavior that parents forget how many positive things they have already accomplished with their child. We need to remind them how basically normal their child is. By taking an inventory of what they and their child have mastered, we can help parents regain a more positive perspective.

6. Rediscovering the child's individuality

Through constructive discussions, we can help parents evaluate other potentially contributing factors, for example, how the child might end up or whom the child might resemble. By reassuring parents that the resemblance is only skin deep, that hereditary issues are interesting to talk about but unrealistic in terms of expectations, parents can be helped to individualize their children and see them in a more positive light.

7. Helping parents develop competence

Parents are inundated with all kinds of advice from what they read to that of well-meaning friends. This advice can often be contradictory. Parents can be helped to see that they are capable of formulating responses based on their own perceptions and intuition, and to derive genuine feelings of competence from their own decisions. Discussions with pediatricians should de-emphasize telling them what to do and, rather, focus on helping them arrive at their own insights and decisions.

The "terrible" in the terrible twos: The deeper meaning of words

Mrs. B. was looking forward to the end of the terrible twos. She was also looking forward to the end of a long, unplanned, physically and emotionally difficult pregnancy. It was probably unlikely that she would really feel better about Suzanne until the end of her pregnancy. Supporting her and her husband during that time, reassuring them that this, too, would pass, was tantamount to saying that the terrible twos, one day, would also pass.

Substitute "stressful" or "painful" for "terrible." Who are we to say that this period shouldn't be stressful? Think of what we are asking the child to do, even in the absence of the family stress that the B.'s were experiencing. Suzanne was being asked to develop some control of her free will without the benefit of language and minimal ability to reason. Add to that the fact that her parents see her as "independent" with "a mind of her own." Suzanne must try to cope with a mother who says of herself, "I expect a lot from people."

Parents and their children can have it both ways; the child's free spirit can be preserved and even nurtured. It just doesn't have to be at the expense of parents. Parenting styles are often characterized as either permissive or authoritarian. Neither approach may end up being overly satisfying to the parent or the child. You can encourage parents to create a comfortable style that captures parts of both, perhaps "authoritative," which can be more gratifying to both parent and child, by virtue of its flexibility and mutual respect.

Finally, I suspected that Mr. B. might be more afraid of confrontation than his wife. Superficially, he seemed more easygoing than she. It is possible, however, that the use of candy is something he might have picked up from his own family growing up. Avoid confrontation at all costs -- give the child something to eat! (And making his wife feel doubly guilty to boot!)

There is nothing wrong, of course, with giving your child a sweet as long as you're not doing it to thwart the expression of a feeling. There is nothing wrong with the child having a tantrum. She can cope! So can her dad! And think of what dads might learn as they give their children permission to express negative feelings.

It can make us think back as to how we were raised and why. Our children can teach us something about ourselves, just as we attempt to teach them!

Public faces, private lives

Should you expect more insight from a parent who is a psychologist? We should not, nor should we from a parent who is a psychiatrist, pediatrician, social worker, teacher or nurse. When we are dealing with our own children, we are all in the same boat -- our rational, objective side often gets deferred and the intuitive, gut side comes to the forefront, as well it should in the early years of our children's lives.

Recommendations: Begin with one task

Encourage parents to formulate a small goal and, fortified by success in achieving that, parents may feel competent in other areas of interaction with their child. Thus, I suggested to the parents that they develop a plan for helping Suzanne sleep through the night, initially by insisting that she remain in her own room. What does this accomplish? By so doing, we help parents be more assertive with their child in an appropriate way, and we help parent and child cope with the pain of separation.

Parents begin to feel more competent by making a reasonable demand and sticking to it. The child begins to feel more competent by discovering that she can cope with separation, and everyone becomes a winner. In addition, by getting more rest the parents are better able to cope with the child's demands the next day! They have less fatigue, more flexibility and good humor.

Indeed, once that was accomplished, Mr. and Mrs. B. as well as Suzanne seemed to have a real diminution of tension. The child was already in the process of being trained. Once the sleep problem had been engaged and mastered, the parent-child relationship began to take on an easier tone. The problem regressed briefly after the new baby, a little boy, was born. Once it turned out that he was healthy and began to sleep through the night, Suzanne welcomed the role of the big sister and she, too, slept regularly without interruption.

Finally, a visit like this is not "the end of the story." Rather, it begins a new chapter in family life for the parents and can establish a precedent. The parents can look forward to future opportunities when they can share a concern, share a feeling and, in the context of a mutually respectful relationship, continue to find answers to the new problems that will inevitably emerge.

1. Listening with a "third ear"

   Some pediatricians say they have difficulty putting psychosocial concepts into practice because they lack the expertise to diagnose and treat families' emotional difficulties.

   May I suggest that we don't need special training, beyond our own clinical competence, to provide good help to families in conflict? What is needed is a willingness to listen with a "third ear" -- i.e. hearing not only the parent's general statement but also the language chosen and the feelings, or absence of feelings, accompanying their words.

   A pediatric case study

   Mrs. R. was concerned that her 6 year old daughter, Janet, was becoming "heavy." She came in asking for a diet so that Janet could avoid the painful experience of being overweight that Mrs. R had encountered when she was a child.

   I was puzzled. Janet was in the 50th percentile for height and weight. I asked Mrs. R to enlighten me about her own weight history.

   "I was teased a lot as a child ... I was a butter ball until I was 15 ... If only my parents had helped me ... I'd like her to have better eating habits than I did ... What can I do to help her avoid the problem I had?"

   I asked her to describe Janet's eating habits.

   "When she gets hungry, she turns into an animal! Before anybody gets up, she'll attack the kitchen cabinet and devour a box of crackers. She goes on these binges ... Sometimes she'll hide a piece of bread under her pillow ... Food is an important thing for her ... I've tried not to make a big thing about it."

   In taking the family history, I learned that Mrs. R's grandfather died of cirrhosis, her father had not dealt with his own alcoholism, and her sister was also an alcoholic. When I later pointed out that the words she used to describe her daughter's eating habits were similar to those one might use for an alcoholic, her face registered complete surprise. She had no idea she had used words like "binges" or "hiding under the pillow" in reference to her daughter.

   It turned out that no one in Mrs. R's family had been able to confront how painful alcoholism had been for all of them. In many ways, everyone had sidestepped the issue, but Mrs. R's anxiety and preoccupation about it spread to many unrelated situations, not the least of which was her daughter's eating habits.

   As Mrs. R. was able, over time, to unburden herself of these concerns, the problem gradually resolved itself without a diet imposed by me. Listening with a "third ear" allowed me, as pediatrician for the parent, to be receptive to the subtle message Mrs. R was conveying. I needed to be willing to use my feelings and intuition, as well as intellect, to grasp the essence of what the parent was sharing.

    

    

2. The unseen visitor to pediatric practice

Many of the children we see with emotional or developmental problems may have parents who are "adult children of alcoholics" (ACOA). Alcoholism in one or more grandparents of our pediatric patients is an unseen but influential visitor to pediatric practice.


Who are ACOA parents?

What do we mean by ACOA parents? I am referring to those parents who grew up in families where their own parents were victims of the disease of alcoholism, which may leave a lasting effect on their parenting styles.

Consider alcohol abuse history

How often, in the average day, do we ask ourselves:

"What's wrong with this parent? Why doesn't she understand what is going on?"

"Why does he have such a hard time making decisions? Why does he seem so insecure?"

"What is the reason for her child's low self-esteem?"

A typical history of an ACOA parent

Many parents describe a childhood history similar to this one:

"My sisters and I worried every day about how serious the drinking would become, how much screaming and hitting would take place. Would it ever come to an end? We never knew what would happen the next moment. There was constant tension. We all felt embarrassed that it was somehow our fault. We felt like orphans."

The frequency of alcoholism in family histories

The story above can be recognized by millions of children who live with an alcoholic parent, and by parents in your practice who grew up in similar households. If the average pediatrician meets 16 parents in a typical day, two of them might be such ACOA parents.

What is the emotional inheritance of ACOA parents?

"Adult children of alcoholics guess at what normal behavior is."

They often "lie when it would be just as easy to tell the truth."

They "judge themselves without mercy."

They "have difficulty with intimate relationships."

They "usually feel they are different from other people." They can be "super-responsible or super-irresponsible."

(from Janet Woititz, Adult Children of Alcoholics, 1983)

ACOA parents and the pediatrician

Consider the burden this inheritance must be for a parent who wants to have normal relationships -- with a spouse, with a child, or with a pediatrician who might be unaware of the coping styles of the ACOA parent. Think about what must be going on in the minds of such parents when you give seemingly self-evident advice about child-rearing practice. How do you think such parents respond to you when, at best, they can only guess at what a normal family life is like?

At the time when the ACOA parents in your practice were children, the problem of alcoholism was "the family secret." The rule was never to share the secret with outsiders in order to "protect the good name of the family." Think of what it must be like for parents who struggle with sharing the secret with you, a trusted professional but an "outsider" nonetheless.

What can you, as a pediatrician, offer to such parents?

When pediatricians sit down with parents to figure out whether their child has a behavior problem and why, it is important to remember that there may be "an elephant in the room." What I am referring to is a family secret which may be playing a significant role in the development of the child's problem. Family secrets loom large and occupy much space in the emotional life of the family, but may never be acknowledged, like the metaphorical elephant that everyone must accommodate, at great inconvenience, but no one ever mentions.

One of the most important "family secrets" that I have come upon is the past (or present) history of alcoholism in one or more members of the family. We have already acknowledged that many feelings may be associated with the history of such a secret in a family member. They may include feelings of shame, guilt, anger, or fear.

If you can help parents acknowledge such a history and its significance, in the context of a caring professional relationship, parents will have made a significant first step not only in understanding their child's problem but also in beginning to resolve it.

If knowing about alcoholism history is potentially so important, how might you discover it? Of course, you might simply ask! But there are also indirect ways of exploring alcoholism history.

For example, you might ask why a child's grandparent died when he or she did, particularly at a relatively young age.

A parent's parents might be divorced. You might ask, "Why?" and the parent might reply, "My father was abusive to my mother ... He was an alcoholic."

A parent might reveal that one of his or her siblings had a "drug problem." You might ask if anyone else had a problem of "addiction," at which point the parent might say, "My father was an alcoholic ..."

A parent's sister might have been "anorectic." Because you are aware of an association between that condition and a family history of alcoholism, you might ask if that was the case.

Perhaps a parent might reveal that she became pregnant as a teenager. You might ask, "What happened?" She might reply "I was drinking at the time."

In short, finding out if there is a family history of alcoholism may come out in the course of taking a family history, and by skillful listening. On the other hand, if a parent seems overly distraught about certain habits in his or her child, e.g. persistent thumb sucking, nail biting, or prolonged use of a pacifier, that also may be an opening to obtaining a family history of alcoholism.

I have often observed associations between a child's minor, but problematic, behavior with the behavior of an older alcoholic relative. The alcoholism may have left a legacy of anxiety which may become expressed in parents' exaggerated concerns about the minor behavioral issues of their children.

In summary, you should assume that a family history of alcoholism may exist in any parent with whom you work. Think of eliciting such a history if the timing is appropriate and if parents give you permission to inquire. You might consider encouraging the parent to share feelings about what it was like to grow up in such an environment. It will require time and compassion on your part.

When you do discuss these sensitive issues, you create a model of listening between two adults (assuming that there are "healthy boundaries" between you and the parent) that can serve as a corrective experience. In turn, the parent may then be able to use this experience in interactions with her spouse, her child, and even her own parents as she struggles to undo the effects of past experience.

When to refer

Sometimes in the course of discussing a family history in a matter-of-fact way, the parent may begin to look like she or he is undergoing some very painful memories.

I would encourage pediatricians not to be afraid to ask further, but to proceed slowly and compassionately. It is worth asking, periodically, "Do you mind if I ask you...,?" "Is this OK what I am asking you ...,?" "Would you like to talk about this another time with me or another person?"

Despite your skillful interviewing, you may sometimes feel like you are on the verge of opening up Pandora's Box. You may think that the parent is about to share things she or he has never brought up before. If the parent feels great trust in you and you have confidence in yourself, you may wish to discuss it on another occasion. On the other hand, you may conclude it would be more appropriate to refer the parent to a mental health counselor. The parent should feel that you are doing so out of respect for his or her pain, and that you feel counseling would be helpful for the parent.

The ideal outcome

If you can offer this corrective experience, it is possible that such parents may, in time, give up the useless task of always trying to "rescue" the people they love, whether it be their parents or their own children. Preferably, they will encourage both to take responsibility for their actions.

If pediatricians could play such a role, they might help ACOA parents interrupt a family pattern of addiction and dysfunctionality. Their children, when they become adults, and particularly when they become parents, might be better able to get in touch with past memories and, hopefully, develop healthier relationships and more successful methods of managing life's challenges.

Children as "agents for change"

ACOA parents often raise child development concerns with their pediatrician because they secretly worry that their child will "inherit" the family illness. Ironically, it is their concerns about their own children, your pediatric patients, that can provide the parents with a second chance to revisit their own past. If you assist them, these parents may be able to start life anew even though their first concern originated with their child!

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.)

"What would you like to accomplish today?"

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.

Confidentiality

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.

The one-hour visit

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.

The chief complaint

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:

1. What do they think is the cause?



2. What have they done about it so far?



3. Is there a difference of opinion between the parents as to what to do?



4. Does the child have other problems?



5. What are their worst fears about the problem if it continues?



6. Whom does the child remind them of?

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.

Physical problems

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:

• The child's past history
  
  
• The pregnancy, labor, and delivery
  
  
• The first year of life -- issues of colic, constipation, feeding, and sleeping
  
  
• Growth and development, delays in walking or talking
  
  
• Toilet training

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?"

The child's relationships

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

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.

Helping children say goodbye

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.

School issues

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?

Other family members

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.

Parents

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

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.

Significant losses for the parent

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:

	Age of occurrence		Cause		Age of parent*
Death of close relative
Serious illness in close relative
Divorce in close relative
Were these losses grieved? If not, why not?

* 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."

Family mental health counseling history

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.

Parents' background

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.

Therapeutic benefits of history taking

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.

A few procedural notes

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.

Follow up

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.

It is your usual busy day. You may even be running behind. But you have a feeling about the way the parent is describing the child that there may be something going on beneath the surface. You should move on to the next patient but you think about inviting the parent to come in again, either by herself or with her husband. How do you go about making that decision? When the parent asks, "Could it (the particular symptom) be abnormal?," what questions might you ask?

"Is anything else going on with the child?"

The problem that has been raised may have greater significance if the child is experiencing difficulties in more than one area of his or her life.

You are tempted to say "it is common for the age." Maybe it is, but hesitate for a moment to avoid reassuring the parent prematurely. The child could be doing the parent a favor by prompting her, through his or her behavior, to bring up the symptom. If the parent discovers a sympathetic ear, she may begin a process of considering whether the particular symptom could have deeper meaning.

Other questions you might ask then or later

• Why does the parent think the symptom is happening now?
  
  
• If there are two parents, what does the other parent think might be the cause of the symptom?
  
  
• Is anything else going on with the family?
  
  
• Have there been any recent losses? By losses, we include recent deaths, serious illness, a parent losing a job, or an impending separation or divorce.
  
  
• If the timing is appropriate, you might ask, "What are your worst fears about your child's problem?" What does the parent think might happen if she did nothing?
  
  
• Does the child remind her of someone? Oftentimes, the parent unconsciously may identify the child's behavior with someone in the parent's own family.
  
  
• What was the parent like at this age?
  
  
• For how long has the symptom been going on? If it exceeds six weeks, there may be greater concern.
  
  
• What has the parent already done to try and make things better?

If you can engage the parent in a dialogue about these issues, there is the possibility that you may gain some deeper understanding of the child's problem.

What can make your intervention successful?

Parents are more likely to be responsive to your questions if they have been concerned for some time. It also helps if the parents have developed a relationship of trust with you, perhaps from your management of a past illness with this child or another sibling.

Think of every visit, especially the "well-child encounter," as an opportunity to reach out to parents regarding the functioning of all the family members, not just the child whose visit it is. In short, you can make each visit, potentially, a family assessment.

When you run out of time

Sometimes parents will bring up a problem directly. Often, they may raise the problem just as they are about to leave.

For example, if you asked at the end of the visit, "Is there anything else I can do?," the parent might reply, " ... not unless you know how to help me with ..." At such times, there are at least two options. One is to be frustrated that they are raising a complicated issue with one foot out the door. The other is not to hesitate to take them up on it! You might suggest that you would be glad to give them time on another day to discuss it with you. It will be interesting to see who might take you up on that.

Coming in another time

The idea of asking parents to come in another time is sometimes alien to pediatricians' thinking. There is something about our style, and perhaps of physicians in general, that leads us to believe we should make decisions in a single encounter. Oftentimes we can. We decide whether the child with a high fever and rapid breathing has pneumonia, or whether the pain in the right-lower quadrant should prompt a work-up for appendicitis.

But behavioral issues require a different approach. You often need a second chance with that symptom. You need to feel less rushed, perhaps at a time of day or week when you don't have to worry about the next patient, or answer 5 or 6 telephone calls. Be good to yourself. Allow yourself the luxury of enough time to ask the parent sufficient questions to make an appropriate assessment. The time you take that once, with a willing parent, could provide you and the parent with insights for years to come.

How do you invite them back?

The next step would be to ask the parent if she or he would like to come in again and discuss the problem. Are they motivated to do so? Do they seem "psychologically- minded?" Many parents may not be ready at that time. Even if they decline doing so, it is worth noting that in your chart.

You might say, "I think it is something you might consider addressing ... But you may have good reasons for not wanting to go into it at this time ... Let me know if you would like to do so at some future time ..."

The issue of confidentiality

It is important to discuss, early on, the confidentiality of discussions regarding behavior and family issues in your practice.

You should consider that behind any emotional problem of the child, there may reside some family secret involving the child, the parent, or some other relative, now or in the past. Accordingly, the parent will be more comfortable sharing such information if, at some point, you make explicit the issue of confidentiality, as well as exceptions to confidentiality such as mandated reporting.

Some parents may prefer a referral

If the parent wishes to address the problem, with whom do they wish to discuss it, at least initially? It could be with you, but it might be that they would be more comfortable discussing it with a mental health counselor. Even if they decide to discuss it with you, and you are ready to do so, consider the possibility that at some point they may prefer someone else, particularly if it involves discussing personal issues.

Parents provide repeated opportunities for intervention

Families provide you with many opportunities over time to address such problems, often because of the human need to bring up distressing conflicts again and again in an attempt to resolve them, in order to feel better. If parents choose not to deal with the problem once, you can anticipate that the problem will surface at some other time, perhaps in some other form. Conversely, just as parents are always striving for resolution, they may try to keep the problem underground if it feels too painful to talk about.

It is obviously worthwhile trying to intercede as early as possible with the motivated parent. But parents need to confront these issues on their own time table. You may be reluctant to give up addressing the problem now, but they should do so when they are ready, perhaps with someone else.

Some parents dismiss the problem they raised

Sometimes, taking the time to respond to a parent's query may actually lead them to dismiss the problem, saying it is not really that important and they don't need to discuss it now. Even if you feel otherwise, it is wise to give them space and time to reflect on the issue and have them exercise their own initiative on another occasion. Regardless of what they choose to do, you may have set in motion a reflective process, to be revisited at a later time.

How can you find ways of helping parents within the time constraints of pediatric practice? How can you enhance your effectiveness but still be efficient in doing your work? How do you use your "third ear" to listen to the family story?

Use the office visit as a "corrective experience"

Be attentive to "family secrets"

If you remain unaware of traumatic experiences in the history of parents with whom you work, you may miss opportunities for constructive intervention. Be on the lookout for the impact of family secrets upon the functioning of your patients, parents and families.

Develop an interest in the addictions. Go beyond coping with "Joe Camel" or screening for alcohol and drug dependencies in teenage patients. There is the opportunity to understand children of parents who grew up in dysfunctional families, particularly those referred to as "adult children of alcoholics." Family secrets can also include mental illness and depression.

Think about family secrets when confronted with parents who always seem to be making demands, anxious parents who ask endless questions, or parents who are constantly negative in their outlook about their child.

Be aware of "resistance"

You may become aware of a family's resistance to discuss problems or reveal secrets when you inquire about a family history of alcoholism, or when you attempt to determine if there is any domestic violence in the family. You may feel frustrated if you sense parents are not forthcoming about such matters.

How might you overcome such resistance?

Let parents know, explicitly, of your interest in their family history, either at the beginning of your relationship or when you sit down and talk with them about their child's problem.

Invite them to tell you their story. When they do, look for things that may be meaningful in helping you look "below the surface." For example:

If the child's grandparents are living in separate locations, why? 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 any previous pregnancies? This might lead to a discussion of teenage experiences and the circumstances around them. Or were either of the parents previously married? What happened?

Do the parents differ in their attitude and approach to discipline? What do they think accounts for that?

Always be on the lookout for potential problems. Don't wait for parents to raise issues. For example, think about asking routinely if the child has any habits or fears. Are there any sleep problems? How is the child doing at school?

If you detect a problem, you might consider asking the parents to come in at another time to discuss it. If they choose not to, that is up to them. But take note of it. What you are doing, in a non-judgmental way, is making them responsible for choosing not to do so.

Even though parents decide not to go into the problem at this time, you have still accomplished something. You may have set in motion a process of reflection that they will take away from the visit. They now have an awareness of your interest. Perhaps on a later visit, they may be willing to discuss it further.

Look for "associations"

Be aware of possible associations related to the child's behavior in your conversation with parents. For example, they may start out talking about their child's use of a pacifier. Some of your colleagues might ask them why they think their child "needs" it? They might say, "He needs it for support!" A pediatrician might then ask, "Why does he need it for support?" And on it goes. You might ask them if any of their nieces or nephews use a pacifier? 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? You may have arrived at an interesting but also, perhaps, controversial turning point in your conversation.

At this point, you might choose to move on to a discussion of other "oral issues" in their family of origin. Did anyone (including grandparents) smoke, or were there some ongoing stresses in their family of origin? You may wish to go slow in digressing in your interviews, in this way. It needs to feel natural to you before you ask about these issues.

Pediatricians need to be creative in their attempts to overcome resistance. In short, search for associations between the child's behavior and the actions and personalities of other family members, past or present.

Listen for the "overdetermined quality" in the parents' description of the child's behavior

You may also overcome resistance by being sensitive to an "overdetermined quality" in parents’ description of the child's behavior. What do I mean by that? The parents’ words may seem more applicable to that of an adult than that of a child, for example, when they talk about their four month old and say, "He has a terrible temper."

Be aware that parents vary in their "psychological mindedness"

You wish that parents would welcome your interest, perhaps even be grateful. But some issues may be too painful for them to acknowledge when you bring them up. In fact, however gentle you may be, they may be so uncomfortable, that they may switch to another pediatrician. That is the price, however rare, you may have to pay when you ask about emotional issues in the child or family.

Even if they do switch, their view of their child may never be the same. They will know, on some level, perhaps with their next doctor, that if they raise such an issue, there is the possibility of a deeper explanation. So, even if the next pediatrician suggests medication, they may also now be aware that there is another approach.

Repetitive attempts to resolve hidden conflicts

You may become aware of long-standing emotional conflicts when you are confronted by parents who seem to require repeated testing of their child or multiple referrals for enigmatic conditions. If they are not addressed appropriately in the medical setting, their concerns may keep coming up over and over again in one disguise 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. Oftentimes, they are able to rework those memories, over time, into a positive outcome.

But, for many parents you see, 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? Even if it wasn't, 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."

If you stop and think about those puzzling clinical situations as possible repetitive attempts to resolve conflicts, you may conclude that parents are giving you repeated opportunities to focus in on the real issue. That will happen if you give them, and yourself, the time to ask, "What is really going on here?"

Acknowledge personal issues

Pediatricians are aware that parents may have unconscious attitudes towards physicians, reactions that are often a function of how authority figures dealt with them in the past. If you can learn something about that, at the right time, you may be able to subtly incorporate such insights into the doctor-parent relationship without being direct, in order to help families benefit from your advice.

Parents should be encouraged to weigh your advice critically. But they should do so for rational reasons, or when advice conflicts with their intuition, not because someone in their past had a tendency to undermine their decision-making abilities.

But, we, too, have our own unconscious attitudes towards parents, even though that is rarely discussed. The reasons for our own issues could range from the way we were raised to how we get along with our spouses, as well as our satisfaction with our professional role. These experiences may have a profound influence upon us in our reactions to parental needs. Acknowledging and dealing with our personal issues may help insure that our relationship with parents continues to be compassionate and helpful.

Search for strengths

Parents need to set realistic limits upon their child even though it is difficult. They will do so, more easily, when they have developed a mutually respectful alliance with their pediatrician.

This alliance can be enhanced if, in addition to searching for problems, you also help parents recall the many tasks both 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 that you may wish to employ, especially during well-child visits. Complimenting parents through their child, and remarking on how much parents are supporting this competent child, may help parents see their child's behavior in a new light.

Likewise, validating how a parent is feeling can be very helpful. For example, you can reassure an anxious parent about something and they may respond, "You mean I'm not crazy?" Or, when a parent tearfully acknowledges the pain of some memories, you can reassure them about the legitimacy of their feelings and their appropriate response.

Enhance the success of the psychological referral

Terms like therapy, counseling and mental illness are still stigmatizing for much of society. Even if parents in your practice are open to a psychological referral, they still need to feel that they are not being "dumped" when you make that referral. 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.

When you make a referral in a positive and supportive way, not only is it more likely to be successful but it will also reduce the professional and financial resources dissipated by unsuccessful referrals.

Help parents feel comfortable in an activist role

Parents often wish we would provide them with specific answers. Indeed, there are many situations when it is appropriate to answer their questions quickly and directly, providing them with our honest opinion about a particular situation.

On the other hand, consider the value of sharing your ideas, even offering parents some alternative ways of understanding and resolving the problem, but doing so in a tentative way. There is value in helping parents feel that they helped you in understanding the problem even as you are conveying to them that they are capable of using their own good judgment to solve their child's problem.

Incidentally, it is important to involve fathers as much as 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.

This approach to helping parents learn how to become good decision-makers may be hard for some parents, based on how they were raised. For some, it may be initially difficult to accept such responsibilities. They may want you to tell them what to do. Others may have the opposite difficulty. It may seem threatening for them to lean on you in the service of gradually understanding what is going on. Such parents may need reassurance that this period of dependency is temporary and, ultimately, the responsibility is in their hands.

by Howard S. King, MD with Ruth E. Freeman, MSW

Parents periodically share with us that there has been a death in the family, for example, a grandparent. Ruth Freeman, MSW, Program Director of The Cove Center for Grieving Children, points out that there are many more grieving children in schools and communities than people realize. Children sometimes display symptoms of grief or complicated grief, and yet are diagnosed as anxious, oppositional or hyperactive. In fact, they may not have had the opportunity to express feelings directly about the experience of loss.

Pediatricians should consider that unrecognized grief may be the reason for unexplained, difficult behavior in the child. Increasing our vigilance at times of grief may also provide useful preventive opportunities.

How can we help their young child cope with loss when there is a death in the family?

At such times, we physicians may feel we need to produce quick answers, and may be reluctant to go beyond the specific question when parents ask how they can help their child. As one colleague said, “There is so much pressure within the health care system these days to be brief.” But, when we do that, we may miss opportunities for useful interventions. There are consequences when we are brief in our answers to appropriate questions from families seeking guidance. When we do not assess further, we could end up spending much more time later, if concerns develop into full-blown parenting problems.

What should pediatrician be aware of when there is a death in the family? How can pediatricians engage parents in helping their children develop resilience through the childhood experiences of loss?

Grieving is a family experience

One question we should consider is, “How are the parents doing?” If it was the mother’s mother who died, how is she coping with the death of her mother? Is she grieving appropriately? Perhaps their relationship was complicated, even hostile at times, which might make it more difficult for the child’ mother to cope with the loss.

Or, if the mother is comfortable doing so, we might ask whether she would be interested in talking about how things have been going for her recently. We might ask if she could tell us something about her mother, some of her memories. If that is difficult for her, or for us, we might prefer to make a timely referral to a health care professional or self-help organization for bereavement support.

Such supportive inquiry can help parents identify strong emotions that naturally arise at times of loss. Pediatricians can then help parents to consciously choose how to nurture their children and manage their own stress and grief.

Anniversary reactions

It may be useful to ask parents if they might have experienced a major loss when they were children. Sometimes, a mother who finds it difficult to help her child cope with grief may have memories of being overwhelmed herself when she was a young child. Or a father might recall being unsupported when the death of an important relative was treated as a secret, or his parents might have had a complicated grief reaction of their own.

If the pediatrician or other health professional is able to help the parent talk about those early experiences and memories, it can be very supportive to the parent, and may help them to be more available to the child.

Helping the child talk about the loss

It is worthwhile for parents to let the child express his or her ideas about what happened when a grandparent (or other close relative) died. For example, the child may wonder, if she had been a “better” child, this might not have happened to her grandma. Is the child worried about what might happen to her parents? Might she “lose” them, too?

Such ideas and worries may have less impact on the child’s emotional well being if he or she can talk about them with a parent or other caring adult.

Talking with children about death

Although children think about death differently depending on their age, most young children need adults to keep information concrete and simple, and to tell the truth.

Useful language to use when children ask questions is that “dead” means that the ears don’t hear, the eyes don’t see, the skin doesn’t feel, the nose doesn’t smell, the heart doesn’t beat. Otherwise, it can be very disturbing to think about Grandma’s body in a coffin.

It is best not to use phrases like “Grandma is sleeping” or “We lost Dad” or “Grandpa went to Heaven.” Children take these comments literally, so they may ask literal questions like, “If Grandpa went to Heaven, why doesn’t he come back?” “If we lost her, why don’t we look for her?” Parents’ responses to children’s questions about the permanence of death may be interwoven with their religious beliefs.

Some children will be satisfied with the simple explanation that a beloved relative has died while others may persist with curious or anxious questions about death. The pediatrician can play an important role in explaining to school aged children how the body stops working, for example, using simple terms to explain what happens when a heart is too sick to continue to beat, or what a “stroke” is.

Children’s grieving may show up as irritability or refusal to engage in certain activities associated with the family member. Adults will need to pay attention to children’s grief when it is expressed, even when the timing is inconvenient or when the child’s behavior may be socially inappropriate. The pediatrician can offer guidance and reassurance to families where a child is particularly distressed by a death, immediately or several weeks or months later.

It is useful to let parents know that children grieve differently from adults. Children may go out to play minutes after hearing about their grandmother’s death, but two months later, a trip to a familiar restaurant may recall a memory that brings the child to tears.

The child and the funeral

What are the parents’ intentions about the funeral? Should they take the child to the cemetery? Increasingly, with appropriate preparation, most parents do. Children can be told what to expect at a funeral and burial, and may have a strong wish either to attend or stay home. If possible, children’s preferences should be taken seriously.

It will be helpful for parents to ask a close relative or family friend, who knows the child well, to be available during the funeral to tend to the child’s needs. For example, the child may want to leave the room, or ask questions, at times when the parents are not emotionally available to the child.

It is important for parents to be able to engage in their own healthy grieving process. The child will not be “hurt” by witnessing the parent “break down,” as long as the child can see that the parent is getting support from other adults, and the child is helped to understand that it is not his or her job to meet the parent’s primary needs for support.

The spouse

While the spouse of a bereaved parent may take on the responsibility for the care and comfort of the bereaved parent and also the children, it may be that the death of an in-law is a significant loss for him or her as well.

The spouse may also experience an anniversary reaction derived from memories of her or his own earlier losses, which might not have been acknowledged at the time. The pediatrician can reach out to both parents at the time of a death in the family, involve both parents in discussion and encourage a dialogue between them.

Coping with loss begins before a death in the family

In early childhood, there are preparatory opportunities for parents and children to accept loss as a normal developmental process. For example, helping children sleep through the night, in their own bed or crib, can be a constructive developmental challenge. Similarly, helping the child give up breast-feeding, the bottle or pacifier may also provide experiences of mastery and resilience related to loss. The same lessons apply to the loss of the child’s favorite toy or the death of a family pet.

Sometimes, these events may come to light when a parent asks the pediatrician about what is “normal.” In fact, the pediatrician has a sensitive task at such times. Our challenge may be to try to understand if there is an underlying worry. The parents may have difficulty helping the child master these tasks because they bring back painful memories from their own childhoods. Allowing parents to share those feelings may make it easier for them to help their children work through loss more successfully.

Unacknowledged grief in the pediatrician

Of course, physicians and other health care professionals also have their own experience with bereavement, and may have unresolved issues with unacknowledged grief. Helping parents and children cope with loss may stir up feelings that can get in the way of reaching out to others. If we become aware of changes in our ways of responding and helping at such times, it may be useful to talk it over with trusted friends or colleagues.

An example occurred with a physician friend who, at age five, was fully aware that his father was undergoing life-threatening surgery, an experience that profoundly affected him and his family. As an adult, he felt that death was always “just around the corner.” A few years after he married, his wife developed a serious although temporary illness.
Shortly after, he began to repetitively lose his keys, wallet and important papers.

In time, he sought professional counseling and came to understand how his wife’s illness had stirred up memories of how anxious he and his family had been when he was five years old, which he had never had the opportunity to talk about. By understanding those connections and sharing those experiences with a compassionate listener, he became more effective in helping patients and families deal with their own experience of loss.

Summary

• If parents ask you how to help their child cope with the death of a grandparent or other close relative, consider the impact of the loss on the parents as well.
• Helping parents cope with loss will benefit the child.
• Encourage parents to talk about the meaning of the loss.
• A parent may be overwhelmed by a current loss because it may bring back memories of a previously unacknowledged loss.
• Remind parents about the importance of providing uninterrupted time for their child to talk about the death of a family member.
• Keep things concrete, simple and truthful when talking about death with the child.
• How children grieve will vary with their age and can be very different from how adults grieve.
• It does not hurt the child to witness a parent grieving and receiving support from other adults.
• The spouse of the bereaved parent may also be experiencing grief, perhaps derived from his or her own previous losses.
• The child’s normal process of growth and development provides opportunities to cope with loss. Pediatricians can help parents to understand the value and significance of such experiences.
• Pediatricians may have their own experiences of unacknowledged grief. Being aware of such experiences may facilitate the pediatrician’s ability to be helpful to patients and families.

Resources

The Hope Program

The Hope Program is a service of the Pediatric Department of Newton-Wellesley Hospital, supporting parents, caregivers and children as they attempt to deal with the death of a loved one. The program also assists pediatricians when a family under their care experiences loss.

A special bag with play and educational materials for children ages four through ten, includes a pamphlet for parents and is available to Hospital services including the emergency department, oncology, pediatrics, etc. It includes an activity book to help children explore their own emotions through creative expression about what happens when someone dies.

The guide for parents advises that “children have the capacity to mourn beginning in infancy,” and goes on to suggest guidelines to help parents respond to their child when he or she is going through the grieving process.

Parents or professionals can contact Lori Stacks at 617-243-6510 to receive Hope Program materials and information.

The Children’s Room

This center for grieving children and teenagers “offers hope and quality of life to bereaved children and those who are part of their lives.” Trained, committed volunteers facilitate groups that meet twice monthly, for children three to eighteen years old and their families.

The Children’s Room is located at 819 Massachusetts Avenue, Arlington, Massachusetts 02466. The telephone number is 781-641-4741.

The Wellness Community

The Wellness Community offers programs to provide support and education for children, ages five through twelve, who have a parent or grandparent with cancer. It is located at the Echo Bridge Office Park, 1039 Chestnut St.,  Newton Upper Falls,  Mass. 02464. The telephone number is 617-332-1919. 

Web sites

The Cove
www.covect.org
Safe Harbors for Grieving Children serves children and families in Connecticut and provides useful online information and guidance, as well as links to children’s bereavement support organizations in other locations. Books for children are recommended, including When Dinosaurs Die: A Guide to Understanding Death by Laurie K. Brown, Children and Grief by William Worden, and Guiding Your Children Through Grief by Mary Ann and James P. Emsweiler, founders of The Cove.

The Centering Corporation
www.centering.org
Offers an extensive catalog of books and materials for children and adults who are coping with many different kinds of loss.

The Dougy Center
www.grievingchild.org
P rovides supportive and educational material on line for children and parents.