Dr Kings Office

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.

Prenatal visits

Parents are often encouraged to meet one or more pediatricians a month or two before they deliver their new baby.

Don’t expect universal support for the concept of a prenatal visit. One parent said that her brother belittled the idea of talking to a physician before her baby was born. He said, "It's how he handles your kid, not how he talks to you!"

Who is the patient? Is it the infant? He or she is not even born yet! Why meet? The fact that you and the parents are meeting makes a number of crucial statements.

Who is the patient?

Surprisingly, this is a basic question throughout the child's growth and development. Parents come in, appropriately, with a list of questions. But when they express concern about their baby, about whom are they really concerned? The questions may seem to be about their infant but, oftentimes, may reflect a different agenda. For example, they may disagree about the management of a particular problem, or the child may remind them either of themselves or some other relative in their current or past family. The questions may also reflect some insecurity with their decision-making or with themselves as to whether they will be competent parents.

Our challenge is to figure out what the real issue is and then, in an alliance with the parents, help them bring their concern to the surface. Helping parents helps children. We need to keep the family in focus at all times.

Forming a relationship

The mother-to-be has had periodic exams with her obstetrician. But now, delivery is imminent. Who will help her cope after her baby is born? As one mother put it, "It all seems so unreal!" The prenatal visit can be a bridge not only to working with a new professional but also to preparing for parenthood.

Parents often bring a long list of questions to the prenatal visit, including: "What are your attitudes about breast feeding?" "How do you feel about circumcision?" "What should I do if there is an emergency?" "How do you feel about silly questions?"

It is not just what we answer, it is how we answer that is crucial. Do we give parents adequate time, do we listen in a way that suggests we are addressing their unconscious concerns, are we listening with empathy, will we help them become competent decision-makers? Most important, do we enjoy listening to their "story"?

Being able to ask "silly questions" is a common concern of parents. With anxiety, and almost apologetically, they want to know how receptive we will be to their various questions. They ask, "Do you have someone in your office who can handle trivial questions?"

I urge them to ask anything. Behind every such question there is a parent who has good reason to be concerned, based on past experience. Or, there is a parent who was raised in an environment that may have demeaned her judgment and competence.

Not only should we attempt answer their questions with thoroughness and compassion. We should also try to make their experience with the "authority figure" of a physician a corrective experience, one in which they feel increasingly competent to trust their own judgment.

Spending sufficient time answering questions will not only be helpful to parents but also helps the child and family grow to their fullest potential.

The prenatal visit can also provide clues, ahead of time, for when we might anticipate a relationship problem with a parent. One mother said, "My husband comes from a family of doctors. He is always looking for a scientific explanation. He can be pushy ... abrasive. But sometimes it is very helpful." Such information helps us to meet the needs of parents and gets communication on the right track from the beginning.

Commitment to prevention

We convey a message when we ask about the parents' history, family history and prenatal fears. The underlying message is, "How can I help parents become competent, how can I help them prevent those problems they are concerned about from happening?

At the same time, we need to be sure that we are functioning within the parents' expectations. Do they want us to help them that way? Will they feel supported or will they feel threatened by a physician who cares about their personal and family functioning?

Trigger questions

You are familiar with the standard prenatal visit, and with the kinds of questions that you routinely ask.

How you ask and what you ask about during the prenatal visit makes a statement of your intentions, and you are able to observe how comfortable parents might be with a relationship that explores psychological issues. Thus, asking a question with a preamble like, "May I ask you if ... " gives parents the opportunity to accept or decline as well as prepare them for situations in the future when they might be asked to reveal how they are feeling, or when there are tensions at home.

Also, asking parents what expectations they have about the role of a pediatrician may be helpful. The thoroughness of the interview, as well as how you follow up areas of concern, will reveal your intentions. One parent noted that "counseling" appeared to be my specialty. I said that while it was, some parents might be uncomfortable with a pediatrician who attempts to explore the emotional side of family functioning. I asked, "How would you feel about it?" She said, "I need emotional guidance. I've never been a parent before. I want someone who will teach us how to manage ..."

The challenge is, "When will a parent's or a pediatrician's question become a 'trigger question,' suggesting that the pediatrician should be alert to some hidden issue?" Here are some examples from my practice:

1. "How old are you and your husband?"

One parent said, "My husband is 48, I am 33."

Why is there such a difference in age? It turned out that this was his second marriage, divorced at 24. What happened? Does it have any implications for this current marriage or their children?

2. "How long have you been married?"

One parent said, "Five years." Was there any special reason why they took five years to start a family? "I wasn't sure I wanted to have a child ... I see myself as a selfish person. Would I want to give up my freedom? ... I have my own business ... [whereas] my mother was a 'sixties' person. She stayed at home, taking care of me and my siblings."

She is sharing her ambivalence. I praise her for her openness. I suggest that she may feel this way periodically, not to feel guilty for having such feelings, and that she can feel comfortable expressing them with me. I support the idea that, over time, she will be able to meet both her maternal and professional needs.

3. I am asked, "How do you feel about breast-feeding? Will you be supportive?"

One mother said, "I'm not sure that I want to breast-feed even though my husband is lobbying for it. He thinks it is a great idea. I'm not sure I'll like it." I tell her that I'll support her whatever she decides. She shouldn't feel guilty, however, whatever happens.

4. What kind of support system does she have in place?

Where do her parents live? If she is married, where do her in-laws live? Will they be supportive?

One mother replied that one of her parents lived locally, the other lived overseas. "Are they divorced?" She replied, "My parents were divorced when I was six years old. My father was abusing my mother at the time. I started living with my mother until my father kidnapped me when I was seven!" This same mother slept with her baby after the child was born. Her husband was concerned that she might be reenacting what had happened to her when she was young.

Another parent noted his in-laws were going to be living with them after the baby was born. He was worried that it would take them some time to regain their privacy.

Still another mother commented that both sets of grandparents live in another state, and she asked if I would be available to help her cope.

5. "Do you have any fears about this new baby?"

"My husband has gripes about what happened to him growing up ... He blames his father for a lot of things ... He still has a lot of 'stuff' ...I worry how he will relate to our new baby. Especially since we know it is going to be a boy ..."

I tell her that there is bad news and good news. The bad news is that it is understandable she is worried that history might repeat itself. But the good news is that if we are alert, we can intercede. Furthermore, if her husband gets involved in parenting, he may discover that he has "a second chance." As he becomes more aware of his feelings he may be able to share what it was like growing up with his dad, learn more about his father's background and, perhaps, come to terms with these old grievances.

Another parent says, "My brother is schizophrenic. He appeared normal until he was sixteen years old." Will she worry if her little boy is shy at six or if he seems transiently moody at a later age? Will she be concerned about leaving him to go to work because she might predispose him to some long range problem?

Another parent was concerned that her child might inherit her husband's amblyopia, and she asked if I would be able to pick up this condition early enough.

6. The contract

One parent introduced this topic by discussing a group practice she had interviewed prior to her coming to see me. She noted, "I was told I might have a different doctor each time. I worry about there not being continuity of care."

This gave me an opportunity to talk about what my practice was like, but I also encouraged her to let the group practice know how important continuity of care was for her. Continuity of care would seem to be a crucial issue in a pediatric practice which has as its goals enhancing the competence of parents and attempting to prevent emotional difficulties in children and families.

I also suggested that our ultimate goal is to help parents become good decision-makers. Thus, while some situations (like a high fever or injury) might require an immediate response on my part, our goal should be to help parents figure out why they were concerned about a particular issue. Our task is then to support them with finding a way to achieve their goals.

7. The issue of separation

A parent was planning to go back to work when her infant was six weeks of age. She intended to breast feed until that time. "Should I give him a bottle before that?" "Why?" "I'm afraid it will be a tough transition ... I worry that he won't take a bottle." "Then what?" "I won't be able to go back to work!"

I suggested that while it might be a little difficult for her infant, it would be harder for her. She was going back to work, primarily for financial reasons. I felt it might be helpful for her to anticipate the sadness she might feel when she went back. I said she would work it out and her husband and I could help her when the time came. I also encouraged her that her infant would take a bottle when she set her mind to it.

It was important, however, to consider reviewing her and her husband's past history to be sure there were no hidden issues which might make her more vulnerable to the issue of separation. If there was, it might be useful to differentiate those situations from the present where the parents seemed to be functioning in a normal way and appeared capable of healthy adaptation.

8. What plans do they have for child care?

If parents don't bring this up, it is important to do so, not only to understand what kind of arrangements they have made but also how they feel about it.

One parent said, "I heard that infants pick up a lot of colds. Is there any way you can prevent that?" This same parent was also trying to cope with her in-laws who felt she should be staying at home with her child. They would say to her, "We got along without a lot of luxuries ... Are you sure you need to work?"

Helping parents work out their ambivalence about working, evaluate the positive or negative feedback they get from people around them, diminish guilt, feel they will be competent to manage -- are important tasks for the pediatrician.

9. Reassurance about physical problems.

One father was worried his child might inherit his serious allergy problem. A mother worked in a potentially hazardous industry. "Do you think my child might be predisposed to some type of abnormality?" We need to be prepared to help parents get specific information about such issues.

10. Potential feeding problems

One parent asked about adding cereal to a bottle. "They say it helps a child sleep through the night." I suggested that she consider not doing that. I did acknowledge that sleep problems are a common concern during the first year of life. But, regardless of the etiology, I attempted to convey that hunger was rarely a contributing factor.

I said I would help them manage any sleep problems that might emerge, and also tried to have them reconsider the tendency to use food or extra feedings to cope with pain or stress.

11. Reassurance about family issues

One parent said, "All of us had horrible colic. My mother said, 'We never slept.' Do you think I'll have the same problems with my infant?"

Another parent called herself "the worrying type." She seemed very anxious. It turned out that her mother had tuberculosis and was hospitalized for a year shortly after she was born. She, in turn, was placed with her aunt during her first year of life. One could hardly be surprised that she expected the worst. But, by linking up with a counselor and talking about that experience, along with continued support, she turned out to be a very effective mother.

Finally, one parent mentioned that she grew up in an alcoholic family. She was worried about her brother who seemed to be treating his child the way she and her brother were treated by their abusive father. She asked, "How do you help a sibling change his ways?"

12. The role of fathers

Fathers usually come in for the prenatal visit. At that time, I encourage them to either accompany the mother to the periodic checkups or even come in by themselves. I believe that mothers are helped to get in touch with their feelings and memories as they get involved with the evolving development of their infant. Fathers, who have a harder time with this in our culture, deserve the same opportunity to do so. Reflecting back and forth over time may give them that chance whenever they bring up concerns about their young infant.

It is worth reminding the father that even if the mother is not concerned about a particular issue, he can call you himself. This is not meant to demean the mother's judgment but rather to help him be comfortable with expressing his own fears and anxieties. One father asked, "When should I call?" I said, "Whenever you need to!" "I'm afraid I'll go overboard"" I said, "I'm not worried. You'll gain more and more confidence over time. If you don't, it's my job to help you figure out why."

13. Finally, "What should I read?"

This is a common question at the prenatal visit.

While I encourage parents to read anything they think would be helpful, I try to make a few points:

I urge them to be skeptical about everything they read. I want them to trust their own intuition and judgment.

I suggest that within each of them is their own "book." They will write this "book" over time as they listen to their own questions, raise issues, and filter back answers through their own senses. If they can do that, the confidence that may result from mastering current issues will be available to them in future situations.

I pass out a booklet of my own at the prenatal visit. While it has much useful information, I tell them the most useful item is in the title, "Parents Have Rights Too!" The message I want to convey is that parents have to consider their own needs simultaneously with responding to those of their infant. Giving parents permission to consider themselves can validate their ambivalence and help them carry on with the inevitable sacrifices that being a parent requires.

Pediatricians can make significant contributions to preventive mental health for children and families. As much as we already do, we could do even more in the areas of addiction, mental illness, and family dysfunction.

Our professional self-image

What has kept us from doing so? In part, we may underestimate our capacity to be effective "agents for change." We may only see ourselves as taking care of "little people," overlooking that the family system  requires equal concern. It is also possible that we may be unaware of how effective we could be by being more attentive to parental concerns.

The cost of not spending time

The result may be that we end up doing less in the area of preventive mental health than we might, possibly depriving families of crucial intervention. By missing such opportunities, society and insurers may end up spending more financial resources because of delayed recognition of such problems.

The benefits of spending time

In pediatric practice, time and thoughtful listening are the tools for change. If we spent more time listening to how families struggle to cope, we might reduce the frequency of drug abuse and mental illness.

By listening to families tell their stories, pediatricians may unearth "family secrets," such as incest, child abuse, or alcoholism. At the same time parents are raising their children, they may unknowingly be repeating much of their own life, including harmful behavior they experienced as a child.

If we pediatricians attempted to listen more effectively (with our own "third ear"), particularly at times of transition or change, we might uncover subtle pathology. What would happen if we did? We might have the opportunity to encourage the capacity for change in how parents view their children.

The challenge

But how do we harness time in the service of these goals? Given all the tasks for which we are responsible, particularly in an era of managed care, how can we use time in a way that is practical for us, financially? When a parent raises a troublesome problem over the phone or in the context of a routine well child visit, what can we do?

Sometimes, we can consider asking a few questions that might help us determine if the child is in difficulty or, alternatively, is doing well with many strengths. If the latter is the case, we can reassure the parent that nothing further needs to be done at this time.

Most of the time, however, it is difficult to be certain. Then what? One possibility is to invite the parent or parents to come back at a quiet time of the week (it could be a weekend, evening, or designated afternoon). The important thing is that it be at a time when you won't be interrupted by another patient, secretary, the phone or other distraction. If the parent perceives our mind is elsewhere, our effectiveness is diminished.

A second, equally alternative is to consider referring parents to a trusted colleague who is a psychologist, child psychiatrist, or clinical social worker. We should not underestimate the value of a pediatrician briefly assessing a parent's degree of concern and, sensing that some exploration would be valuable, helping to expedite a referral in a supportive, non-stigmatizing way. It has been wisely said that "half of therapy is preparation for therapy." (Dr. Leston Havens) If pediatricians could accomplish that, they would be making a great contribution to the mental health of the child and the family.

The parents' response

If we do encourage parents to come in to talk, they may be delighted (although anxious) and pleased that we would be willing to give them time. Or, they may suddenly decide that the problem is not so serious and decide to wait. At such times, there can be what is sometimes called "a flight into health" and the child seems to get magically better. (Anything rather than discuss the problem with the doctor!) Or, finally, the parents may consider that the problem is serious enough to accept a referral to a psychologist, clinical social worker, or child psychiatrist, rather than return to meet with you.

By our taking the problem seriously, parents are obligated to decide whether they are serious themselves. We may have already saved ourselves time by asking parents to decide whether they want to continue complaining (thinking that we won't pick up on it), or whether they want to roll up their sleeves and begin to work on the problem.

How much time would it take?

Suppose the parents take us up on the offer of a return visit. How much time would it take? If we chose to, we could help parents describe the problem, its history, contributing factors, their feelings about it, and what to do about it in 45 minutes to an hour. We will become more skillful with time and practice, but if it is a definitive and thorough evaluation, it could take as long as an hour.

That seems like a long time. I would propose, however, that if we do this once in a child's development, that is often all it takes to start solving problems in the child's life, and thus the family's life. It may not cure the problem but, at least, we and the parents will begin to understand what is going on. From that standpoint, that hour is really very short and, potentially, very productive.

Helping parents be in control

For me, it is helpful to ask parents at the beginning, "What would you like to gain from this meeting?" Not only does it keep the meeting focused and productive, but it also helps parents feel empowered and in control. It is not the pediatrician's visit, it is theirs. They are the decision-makers. As we help them become active, we may be helping them gain control over their lives and affect their child's behavior in positive ways.

What have we accomplished?

What have we accomplished in that hour, besides our own understanding of the problem, if we have done it right?

1. The family may have begun to unburden themselves regarding the problem.
   
2. They are grateful that we have taken them seriously and not suggested, without discussion, that the child will outgrow the problem.
   
3. They have begun to be reflective about the problem. By inviting them to talk to us, they begin to think differently about this child, what the behavior could mean, what their worst fears are, what they think could be the cause.
   
4. Finally, we and the family have begun to formulate a plan and share expectations.

Reimbursement for the return visit

Do the medical insurers care about what has been accomplished? Do they value what we have done? Several local insurers have pledged to reimburse pediatricians for spending this time, with the following stipulations:

1. That the time spent was actually provided
   
2. That we did a thorough evaluation
   
3. That we follow up by reevaluating, with the parent, how the child and family are doing over time

Outcomes

Oftentimes, just one meeting may clear the air. At that point, we may be able to reassure parents that the child is basically fine, the problem is transient, that it can be explained by a situational factor, and no further exploration is needed. Alternatively, we may discover with them that the problem is serious and warrants further assessment by a mental health professional.

A reevaluation may be required from time to time as the child moves through different developmental stages. It doesn't mean that the first evaluation was inadequate. It may just mean that some things become apparent only over time as the child confronts subsequent developmental stages. Nevertheless, we can build upon our earlier evaluation and take advantage of insights gained from that initial assessment.

Pediatricians sometimes think they will be "starting from scratch" if they address the mental health issues of children. They don’t realize how much they are already doing that can help them  in this area.

Although you may feel you lack the training of a mental health clinician, that seeming deficiency is balanced by your natural intimacy with many mental health concepts. You make use of this knowledge all the time in your work with children and families, often without realizing it.

By reminding yourself of the following attributes of your relationship with parents, you may feel even more confident when you work with families.

The pediatrician as historian

Over time, listening to parents discuss concerns about their children, you can often understand the ways in which certain families may be vulnerable. You may be able to use their history to discover why a particular family member may have evolved to become the representative for the family conflict.

What you hear may seem initially confusing. However, your observations over time will make increasing sense and may suggest potential opportunities for intervention.

The development of trust

It takes time for parents to form a trusting relationship with a therapist. In contrast, family members have usually known you for a long time. If they believe you are willing and able to intervene at the right time, parents may be ready to be engaged, psychologically, when the need arises.

Furthermore, you have developed credibility and trust through previous successful interventions involving illness and physical health problems. The transition to viewing you as an ally for emotional crises may frequently seem very natural to parents.

Crisis intervention

As a pediatrician, you play a unique role as witness to all the developmental stages from birth to adulthood, not to mention the various joys and sorrows to which families are exposed over time. On such occasions, a host of complicated feelings emerges between family members. Relationships change and require new adjustments. With your understanding of the family history, you may be very helpful by suggesting opportunities for more constructive attitudes and choices when they confront such issues.

A reflective attitude

A psychologist studying two groups of children, one with anorexia and one without, speculated that one factor, among others, might account for the difference. She suggested that a characteristic of the parents in the control group was the existence of a "reflective attitude." Those parents seemed to have an introspective but not guilty nature, a striving for healthy dialogue between parent and child. They seemed to be working to understand their children's behavior but not be so preoccupied that they failed to give their children the space and direction they needed to grow as separate human beings.

You use your well-child visits, without realizing it, to encourage this reflective attitude. You ask questions like, "How is your child doing?" "What are you pleased about?" "What are you concerned about?" "What do you think it means?" "How are you doing?" "How are you and your spouse (or partner) doing?" These questions, and others, stimulate parents to reflect, constructively, with you. Such parents, in turn, are often able to adopt a similarly reflective attitude with their child.

Steering the family through a morass of experts

There is the danger that, by asking such questions, parents may wonder if you are being judgmental. Not so. You are merely trying to help them articulate how they feel. You are not just being supportive but are also encouraging them to use their intuition and healthy gut-feelings.

There are many issues about which "experts" write and lecture. The point is that for such issues there are no right answers, only right answers for some people. Your task is to help parents come up with a solution, in a logical way, that reflects their own feelings and what is appropriate for them. Ideally, you are not just helping parents deal with a problem today, but rather with how they and their children cope with problems for the rest of their lives.

One of your objectives, therefore, is to protect parents from feeling guilty as they encounter a variety of experts who tell them that there is only one way of doing things.

The concept of the "right-lower-quadrant"

What do you do when you try to decide if your patient has appendicitis? You start your exam in the left-upper-quadrant and gradually work towards the area of greatest discomfort, i.e. the right-lower-quadrant.

Similarly, when you are dealing with a family in pain, you try to understand what is going on with the family as a whole, what their strengths are as well as what they are worried about. Gradually you discover the real issues. You don’t avoid those issues because you fear you may, temporarily, bring pain or sadness to the surface. If you have the family's permission to do so, your investigation may bring a secret problem to the attention of all concerned and, by so doing, may bring relief.

Searching for strengths

The evaluation of a family problem means exploring the total functioning of a child and his family. Problem areas may be discovered that need attention. But, just as likely, investigation can bring to light many areas of mastery and competence for both the child and parent.

It is important to discover these strengths. Helping parents remember what they have accomplished may give them the esteem and confidence to deal with issues that remain to be resolved.

The child as an agent for change

As parents help their children through the stages of emotional growth, they inevitably encounter experiences which may bring to mind troubling memories and feelings of their own that may have become repressed. Sometimes their coping methods have been successful. Often, however, they have not.

As children go through these different stages, the parents' old adaptations may be disturbed. It can be like when a scab is peeled off, revealing a poorly healed wound. At such times, parents have the opportunity to reexamine such wounds and contemplate how successful, or not, they have been in resolving such hurts. In short, children, without realizing it, give parents a second chance to revisit their past and the opportunity to resolve some of their old problems.

When parents express thoughts and feelings about their children, their defenses against thinking about themselves may be less rigid than at other times. If you have a good alliance with parents, you can help them clarify such issues. In that sense, the child may do as much for the parent as the parent does for the child.

System theory

It is common, in a well-child visit, that you may end up considering several family members simultaneously. A parent comes in to talk about one child who has a rivalry with another sibling. This may remind parents, in turn, of how they interacted with siblings when they were younger and how their parents dealt with it. So, unlike other physicians, you may be involved, consciously or unconsciously, with systems.

Systems theory as it pertains to families takes into account not only how individual members relate to each other but also how the family as a whole develops and changes over time. Thinking about families this way may help you understand causality in regard to childhood problems, and may even suggest useful ways of intervening.

Parenting, the archetypal way to gain competence

Regardless of how people are raised, regardless of their education or status in work or marriage, all of us are given a fresh start when we become parents. As potential allies to the parent, pediatricians have a great opportunity to help nurture that sense of competence.

The parent who acquires competence in this role can usually master most of the other challenges in life.

The routine office visit as a corrective experience

As a pediatrician, you shouldn't feel you are just a source of information. You are also seen as an authority figure (although maybe less so these days). Regardless of how you present yourself, parents may view you, and respond to you, the way they responded to other authority figures in their past.

How would you characterize the ideal pediatrician-parent relationship? Might it not include patient listening, a non-judgmental attitude, permission for the parent to express a variety of feelings, and an absence of ridicule and condescension? You are always in a position to give advice. You may be most successful, however, when you help parents understand that they have choices and that they can develop a sense of competence in making good decisions.

Furthermore, parents may use the relationship with you as a model for learning and, in turn, a model for how they can listen and intervene constructively with their children.

There are other aspects of the office visit from which parents may gain insight. For example, many of the families you see may have difficulty expressing feelings, and some may tell their child that "big boys don't cry!" But throat swabs are unpleasant, shots do hurt! It may be useful when you give an injection or take a throat culture to say, "It may hurt a little ... It's all right to cry."

Such corrective experiences for children and their parents, however trivial they may seem individually, become increasingly significant in the aggregate, helping both parent and child gain confidence and express feelings.

Working with parents where they're at!

You will be more successful in helping parents manage the emotional growth of their children if you consider starting with where the parents are.

Suppose a parent came in with a four year old child, concerned about tantrums and the child being "out of control." The parent wonders if the child has food allergies or could be hyperactive. You may personally believe that the tantrums are emotional in origin. Your task, then, is how to help the parent consider that possibility and manage the child's behavior from that point of view.

If that is the case, you will have a number of tasks. You may ask yourself (and, ultimately, the parent) why the parent would consider the unlikely possibility of food allergy or hyperactivity. At the same time, you want to convey respect for the parent who has shared that belief. At some point, you will express your own contrary, even though tentative, point of view. Still, consider offering parents the choice (e.g. temporarily exploring food allergy) and leave it to them to follow their own initiative.

Double- and triple-identification

You may be the first person to hear inappropriate labels attached to a child, e.g. the one month old infant who has a "terrible temper" or who is "high-strung." (Is she talking about her spouse or her siblings?) Or you may hear about the six year old with a "binge for crackers" (reminiscent of an alcoholic grandfather?).

You don't know if these things are true unless you think about listening, not only to the parent but also to your own senses as you become aware of an inappropriate label applied to the child. At that point, ask yourself whether the parent is really thinking about some individual either in her present life, or in her past, to whom she is attached by an important unconscious conflict.

In short, you may wish to consider that the child may be identified by the parents with people from the parents' past. How you verify that intuition and how you share it with compassion is another matter, but it is important for you to recognize it.

Combating the self-fulfilling prophecy

How many times have you heard parents say such things as, "I'm going to have a lot of problems with her when she is a teenager" ... or ... "He is a high strung kid!" ... or "He'll never change!"

You will have many opportunities in your pediatric visits to constructively confront parents, at the appropriate moment, when they express such ideas and ask why they contemplate such outcomes.

The longitudinal benefit of psychosocial pediatrics

Pediatricians need to remember that the emotional growth of parents occurs over time. It is an evolutionary process which occurs during the entire span of their children's lives.

Each crisis, each developmental stage of a child, in fact, each child in a family provides parents with opportunities to gain insight and acquire mastery over a variety of unresolved life experiences.

The relationship between you and parents is like a book with many chapters. If you have a collaboration with parents based on trust and mutual respect, the outcome would seem salutary for the child and the family.