Pediatrician involvement in the emotional
problems of children
Pediatricians have understandable reservations
about involving themselves in evaluating the emotional problems
of children. You wonder if you will be able to find the time
to do it, if you will be reimbursed for the time spent, how
you will do it (most of us were never trained to do this),
and you may be skeptical that parents can be motivated to
work on these issues.
What is the most important question?
Those issues above should be addressed.
But are they the most crucial? For me, the most important
question is, "Do we believe we can change behavior by
empathic listening?"
If you believe you can, you may be halfway
home in helping children and their families understand emotional
problems. The rest is a matter of practice.
What do you do when you don't believe you
can change behavior?
But suppose you don't believe you can change
behavior by empathic listening?
One possibility is to ask yourself why
you may have felt that way up to now.
Perhaps you once tried to get help for
yourself by talking with an empathic listener and it wasn't
successful. Perhaps someone you know once tried to get help
for his or her worries and was unsuccessful. Did you conclude
that the process was a waste of time? You might consider the
possibility that the process just wasn't handled in the right
way.
Perhaps you make intellectual observations
that seem to validate your skepticism. What do I mean by this?
It is the sort of observation that some parents make either
about their child or even about their spouse: "He is
just that way ... He was born that way ... He's just like
his father ... or my brother ... he'll never change!"
I am referring to the conviction of some parents, possibly
even yourself, that some people have inherited a personality
that is resistant to change, so "why even try?"
What do you do if you don't believe you
can change behavior and there is a parent in your office who
is concerned about her child? She might be saying, "He's
out of control!" "He never sleeps through the night!"
"He has these fears!" "He just won't give up
the bottle!" "What do I do about those tantrums?"
"He'll outgrow it!"
Perhaps you have answered, "He'll
outgrow it!" How do you know that? "Experience.
I just know it." Probably, you would be right. Most of
the time the child will outgrow it. But is it possible that
that complaint could be the first step in a pathological process?
How can you come to that conclusion if you don't have a way
to evaluate the complaint rather than just trust your intuition?
Suppose a parent comes into our office
and says, "My child is tired all the time." You
might ask her how long it has been going on and she replies,
"For weeks!" Even if you find nothing on physical
exam, you might consider the possibility of checking a blood
count. Sometimes you might think it a waste of time but, at
least in some cases, wouldn't that be a good beginning?
A parent's concern about a child's emotional
problem deserves further inquiry as it does about a physical
problem. Rather than advise, "He'll outgrow it,"
you may want to consider the possibility that he might not,
just like the child who is "tired all the time."
"A Chorus Line" and listening
to the family story
Then what do you do? It may be useful to
recall the play "A Chorus Line" to help us remember
the importance of individualizing the behavioral issues that
parents report to us about their children. I may use the theme
of that play with parents when they ask me whether they should
take a problem seriously. If you recall the story, you will
remember those wonderful dancers: they looked alike, they
danced in perfect rhythm together. But the body of the play
involved interviewing eight dancers, men and women. Even though
at the end they all looked alike, each of them had a different
story to tell. Most of them ended up fine, but two did not.
How do you decide who will not simply end
up fine? You may be able to by listening to the family story.
I would suggest that that is how to go
about assessing whether the parent should be concerned. Even
if you don't choose to explore further, think about referring
the parent to a professional who will take on that responsibility,
rather than suggest to the parent that "He'll outgrow
it." Again, how do you know unless, like the actor-producer
in "A Chorus Line," you take the time to ask and
then listen to their story?
Opening questions
Examples of quick questions you might ask
as the parent has one foot out the door, or when your secretary
calls on the intercom to say "You're running behind,"
include:
What are your worst fears? (about this
situation) or
Whom does he remind you of?
Even if you don't have the time to digest
the answer, it may start the parent reflecting about the problem.
The next time you see her, she may have begun to think about
it more deeply and may be willing to engage you about her
concerns. Even with limited office time it is possible to
open a conversation that can eventually lead to a clearer
understanding of the child's problems for both parent and
physician.
This is the "pediatric advantage:”
you see families over and over again. In the process of catching
a few minutes with them now and then, you can gradually introduce
the idea of setting aside time to talk about long-standing
problems.
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