Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

Many of us remember that during the 1940s, when radio was still in its prime, one of the most popular features was John J. Anthony. He met with problem families on his program; after hearing both sides, discussing their problems, and moderating, he would pronounce his verdict. Usually the antagonists accepted his opinion and left apparently pleased, satisfied, and convinced that Solomon had spoken.

Mr. Anthony had no real psychologic training. He was a bright advertising man with a deep ana sincere voice - a man who had a money-making idea and pursued it avidly.

One day I asked a worldfamous psychoanalyst what he thought of Mr. Anthony. I was surprised by his answer. "You know," he said, "I believe he does a fairly good job, for he has sympathy and understanding - and he listens to people."

I never forgot his opinion, and I realized then, as Fm sure most practicing pediatricians realize today, that if parents and children have confidence in us and in our knowledge and sincerity - and if we can give them adequate rime - we can prevent and even successfully treat many behavior problems.

Most of us have developed a real interest in our new role of family adviser, with our knowledge of child development and an understanding of the emotional needs of children. Some of us have realized that we are neargods in our directing and molding of the lives of our young patients during the most important years of their emotional development. And some pediatricians who realize their vital importance in the lives of so many boys and girls have taken special courses in child development or child psychiatry - and have even undergone psychoanalysis - to be assured that they were not injecting their own inhibitions, compulsions, or biases in the guidance of parents and children.

We all realize that preventing and treating behavior disorders is far more difficult than the prevention and treatment of most clinical diseases. We know that a certain few of the problems of behavior are due to some physical cause. Among these are such conditions as measles encephalitis, hypothyroidism, phenylketonuria, and possibly, for lack of a better etiology, the condition known as "mild cerebral dysfunction."

The vast majority of behavior problems are related to the myriad of environmental factors that, working together - or possibly not working together - mold the personality of the human being.

We do know a number of very important facts, however. One is that the early years of a child's life are the most important in his emotional development. And we do know that good parenting during the early years of life is essential for optimal emotional development.

It has been estimated that over 50 per cent of urban children have some form of personality problems or behavior difficulty. I do not know the figure for rural areas, but I assume it is also high.

All of us practicing pediatricians can attest to the numerous behavior problems in the average pediatrie population. Hyperactive children, sleep problems, temper tantrums, habit spasms, disobedience, lying, school problems, enuresis, encopresis, eating problems, aggressive children, shy children, and many more evidences of behavior difficulties are frequent complaints in every pediatric practice.

The great majority of these problems are not deep-seated, and the constructive relief of these complaints can usually be directed by the capable, welltrained, and thoughtful pediatrician.

There is little question that, with few exceptions, errors or defects in parenting are responsible for the mass of behavior problems in children and adolescents. As I think back on my own experience, the following parental factors immediately…

Many of us remember that during the 1940s, when radio was still in its prime, one of the most popular features was John J. Anthony. He met with problem families on his program; after hearing both sides, discussing their problems, and moderating, he would pronounce his verdict. Usually the antagonists accepted his opinion and left apparently pleased, satisfied, and convinced that Solomon had spoken.

Mr. Anthony had no real psychologic training. He was a bright advertising man with a deep ana sincere voice - a man who had a money-making idea and pursued it avidly.

One day I asked a worldfamous psychoanalyst what he thought of Mr. Anthony. I was surprised by his answer. "You know," he said, "I believe he does a fairly good job, for he has sympathy and understanding - and he listens to people."

I never forgot his opinion, and I realized then, as Fm sure most practicing pediatricians realize today, that if parents and children have confidence in us and in our knowledge and sincerity - and if we can give them adequate rime - we can prevent and even successfully treat many behavior problems.

Most of us have developed a real interest in our new role of family adviser, with our knowledge of child development and an understanding of the emotional needs of children. Some of us have realized that we are neargods in our directing and molding of the lives of our young patients during the most important years of their emotional development. And some pediatricians who realize their vital importance in the lives of so many boys and girls have taken special courses in child development or child psychiatry - and have even undergone psychoanalysis - to be assured that they were not injecting their own inhibitions, compulsions, or biases in the guidance of parents and children.

We all realize that preventing and treating behavior disorders is far more difficult than the prevention and treatment of most clinical diseases. We know that a certain few of the problems of behavior are due to some physical cause. Among these are such conditions as measles encephalitis, hypothyroidism, phenylketonuria, and possibly, for lack of a better etiology, the condition known as "mild cerebral dysfunction."

The vast majority of behavior problems are related to the myriad of environmental factors that, working together - or possibly not working together - mold the personality of the human being.

We do know a number of very important facts, however. One is that the early years of a child's life are the most important in his emotional development. And we do know that good parenting during the early years of life is essential for optimal emotional development.

It has been estimated that over 50 per cent of urban children have some form of personality problems or behavior difficulty. I do not know the figure for rural areas, but I assume it is also high.

All of us practicing pediatricians can attest to the numerous behavior problems in the average pediatrie population. Hyperactive children, sleep problems, temper tantrums, habit spasms, disobedience, lying, school problems, enuresis, encopresis, eating problems, aggressive children, shy children, and many more evidences of behavior difficulties are frequent complaints in every pediatric practice.

The great majority of these problems are not deep-seated, and the constructive relief of these complaints can usually be directed by the capable, welltrained, and thoughtful pediatrician.

There is little question that, with few exceptions, errors or defects in parenting are responsible for the mass of behavior problems in children and adolescents. As I think back on my own experience, the following parental factors immediately come to mind.

* Knowing very iittle of die normal stages of child development.

* Lack of adequate interest in a child or attention to the child.

* Upset or broken homes.

* Favoritism.

* Too harsh and unremitting discipline.

* Lack of sufficient authority.

* Being too demanding or too permissive or indulgent,

* Setting standards too high for the child to attain.

* Child abuse.

A careful history can usually reveal one or more of these factors that might have been responsible for a child's behavior problem.

One must not assume, however, that all behavior problems can be treated successfully by pediatricians. When the underlying conditions are too deep or too serious, as in cases of anorexia nervosa or attempted suicide in adolescents, the child should receive treatment by a capable psychiatrist.

Occasionally parents will ask an opinion concerning some specific treatment of which they have read or heard. These include the method used by the Institute for the Achievement of Human Potential in Philadelphia, treatment by hypervitamins, or the elimination of food additives. Relief by the first method has been disproved by the medical community. The other two methods are still without controlled scientific evidence of their efficacy.

This issue of Pediatric Annals - the second on the subject of parenting - is once again under the guest editorship of Dr. David Belais Friedman, Professor of Pediatrics at the University of Southern California, and Hershel K. Swinger, Professor of Special Education at the California State University.

It reviews many of the behavior disorders caused by defective parenting and emphasizes the part pediatricians may play in diagnosing the underlying causes of the problems and in their treatment as well.

The first article, on "Syndromes of Deficits in Parenting," is by Dr. John B. Reinhart, director of the Division of Behavioral Sciences at the Children's Hospital of Pittsburgh. This is an interesting and important article and opens the symposium with a problem that must be recognized but is beyond the ability of a pediatrician to treat by himself. The deficits in parenting that account so much for the rejection, deprivation, and abuse of children are deep-seated and, as has been demonstrated in recent years, are usually related to the parents' own backgrounds: they themselves were deprived and abused.

Dr. Reinhart believes that we should change our attitudes that all men and women should have children and that those who reject parenthood are either "queer" or selfish. People who do not want children should not be induced to have them, for many of these children would be rejected, deprived, or abused. To quote a very wise woman, who chances to be my mother-in-law, speaking of a certain childless couple: "The children they didn't have are very lucky."

Dr. Reinhart further emphasizes the difficulty in treating parents with these deep-seated deficits. He points out that there is no treatment that is easy, quickly effective, and longlasting. He urges the pediatrician, for his part, to show toleration and sympathy for these parents and to try to be helpful rather than punitive.

The next contribution, "Parenting the Child With a Behavior Disorder," offers an approach for the pediatrician that maintains the parents* cooperation and treats the family as a whole. It was written by Dr. Randall M. Foster, chief of the ChildAdolescent Inpatient Psychiatric Services of the University of Southern California. The approach, according to Dr. Foster, succeeds in so many cases because the pediatrician focuses not on what the parents have done to cause the behavior problem but on what they have not done to overcome it. A plan of approach is specified, one that is contrived to change the parents' attitude towards their child's supposed inability to behave properly and, at the same time, to build the child's self-image. As an example, parents are warned against criticizing by referring to a child's misbehavior with such phrases as "Why must you be so bad?" "Why can't you behave?" "Why can't you learn?" The article organizes the pediatrician's approach in relieving many of the common behavior problems.

The article that follows, "Parenting the Adolescent," is by Dr. Frank S. Williams, associate director of family and child psychiatry at the Cedars-Sinai Medical Center in Los Angeles. Dr. Williams emphasizes that the pediatrician is ideally suited to advise and treat the child during this usually turbulent period. The pediatrician has usually been the one person in whom the adolescent has full confidence and whom he will accept most readily as a counselor and confidant. The balance between necessary direction by the family and the development of self-dependence by the growing teenager is discussed, as is the need for the child to develop an individual identity during this period.

The next contribution to the symposium is on "Parenting the Handicapped Child," by Jane W. Kessler, Ph.D., director of the Mental Development Center, Case Western Reserve University, Cleveland. This is a superb article covering an area that is understood by very few pediatricians. Dr. Kessler starts with the birth of the handicapped child - the parents' shock and disbelief and depression - and the pediatrician's attitude towards the birth as well. She emphasizes the extra support needed by the parents in the months and years that follow, as well as the need by the pediatrician to become more expert in the particular handicap so he can readily identify the normal and special needs of the individual child. This is the best article that I have ever read on this subject. Every pediatrician will gain a great deal of valuable information by reading it carefully.

The next article - "The Warm Line: A Telephone Counseling Service for Parents," by Helen Reid, M.S.W. - presents an unusual approach to the problems of parents during the first five years of life. The Warm Line is a free answering service, run by trained health professionals, established as an aid to pediatricians. The typical behavior problems covered are sleep problems, head banging, temper tantrums, eating problems, toileting problems, and biting and attacking other children. The counselors can spend 45 minutes with each caller - somewhat more than most pediatricians can spend at each interview. The Warm Line works closely with pediatricians and child psychiatrists and presents a model of aid for parents that might be followed in many areas of the United States.

The final article approaches a problem of much importance to pediatricians - when to send children for specialized mental health treatment.

It is by Mr. Swinger and Dr. Alan P. Sandler, director of ambulatory diagnostic services at the University of Southern California. The authors agree that most children with behavior problems can be treated successfully by an experienced pediatrician. The question is, When, how, and why should a child be referred for psychiatric help? Of course, the severity of the problem is the major factor in determining referral. The authors emphasize that the pediatrician should inform the parents, when they accept psychologic or psychiatric treatment, that they will not be forgotten by him.

There is much to be learned by all pediatricians in reading the up-to-date material that is presented in this issue of PEDIATRIC ANNALS.

In Appreciation

PEDIATRIC ANNALS wishes to thank the many hundreds of our readers who filed in and returned the questionnaire on hypertension. The answers will soon be tabulated, and the results will be reported in a future issue of the magazine.

M.LL

10.3928/0090-4481-19771001-03

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