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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?
- The family may have begun to unburden
themselves regarding the problem.
- They are grateful that we have taken
them seriously and not suggested, without discussion, that
the child will outgrow the problem.
- 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.
- 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:
- That the time spent was actually provided
- That we did a thorough evaluation
- 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.
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