When confronted with problems relating to difficult parenting, the practicing pediatrician may face a dilemma - a choice between providing personal counseling and referring the patient and family for more formal psychotherapeutic intervention. The previous articles in this issue have described various examples of difficult and abnormal parenting and the role of the pediatrician in the management of these and similar problems, many of which arise from deficiencies in parent-child interaction. In this article we shall examine the referral dilemma from the points of view of the pediatrician, the family, and the agency or professional receiving the referral. When, how, and why should the family be referred for evaluation and counsel?
The timing of a referral for formal counseling depends in large part on the very basic philosophy of practice under which the pediatrician operates. Experience, training,1 time commitment, priorities, personal values, and sociocultural background determine the degree and intensity of the pediatrician's concern with the psychosocial problems encountered by his patients and their families.
Comfort and interest in the management of psychosocial problems are derived from professional and personal experience. Friedman,2 in discussing the management of adolescent conversion symptoms, states that most primary-care physicians are reluctant to treat such patients, yet experience suggests that most of these patients may be appropriately managed by the physicians to whom they first come for help. Friedman further points out that the reluctance may be based on little interest, lack of appropriate training and experience, and the financial factors to be considered in providing psychotherapy in a practice setting "geared to traditional medical care."
Many pediatricians cultivate a small group of mental health consultants from their community to whom they can tum when they need advice concerning a particular situation or problem. Pediatricians who are most effective in working with psychosocial problems and who are most effective in accomplishing successful mental health referrals use their community contacts well. The contact person can assist the pediatrician in finding an appropriate resource for emotional support for the family and in effecting a successful referral to that resource, be it an agency or an individual professional. In addition, these pediatricians make good use of their long, continuing relationships with the families under their care when mental health referral appears indicated. A warm, trusting relationship allows openness and frankness, which improve the chances of a successful referral.
Some pediatricians are concerned about losing or alienating parents if they suggest that a child's problem is, or even may be, psychologic. They find that it is easier for most parents to accept physical rather than psychologic or dysfunctional explanations, with their attendant stigma.
Goffman,3 in discussing this problem, describes three types of stigma: (1) physical deformities; (2) character disorders, such as weak will, lack of self-control, rigidity, and dishonesty; and (3) racial, national, and religious stigmas. The character disorders - such as mental disorder, dishonesty, addiction, and even homosexuality - become stigmas only when they are labeled as such by authorities. It is sometimes the label that becomes a lifelong burden.
Stigmatization may be an underlying cause, but it is often used as a rationalization for failure to refer or to accept referral. Cost, lack of availability of appropriate services, and lack of confidence in psychologic treatment or mental health professionals most often deter pediatricians from referring. Parents are often deterred by cost, inaccessibility and inconvenience, fear of the encounter, and poor referral. In our own experience, families are often relieved when they are finally referred for mental health consultation and treatment.
Problems derived from abnormal parenting or difficulties in the parent-child relationship do not lend themselves well to the medical model, which emphasizes relatively immediate diagnosis and treatment based on rapid resolution of the symptoms or disease process. The pediatrician does not as easily derive the satisfaction of cure and closure with a case of behavior disorder, child neglect, or adolescent depression as he does from the treatment of a urinary tract infection or the effective long-term management of a seizure disorder. Lack of adequate and appropriate gratification, therefore, represents another disincentive to the pediatrician's involvement in the multiplicity oí problems of abnormal parenting with which he is confronted in daily practice.
The question of involvement, therefore, is basic to the dilemma of referral. Regardless of the degree of personal involvement in management, however, an awareness of the ramifications of parenting problems is essential in pediatric practice.4 Early in the pediatrician's contact with a family, there may be indications of behavioral or developmental problems, or parental coping difficulties, that could call for consultation with a mental health or developmental professional for psychologic and developmental testing or evaluation and treatment. The mental health referral is often made, however, as a last resort and often only when physical causes are "ruled out." This "either-or" duality is unfortunate and interferes with optimal problem solving, which requires concurrent consideration of the biologic, psychologic, and social components of disease and disability. The pediatrician who chooses a position of minimal involvement may err by overlooking or dismissing the severity of complaints. A referral may be considered when problems are recognized; but it may be made too early or abruptly after initial contact, without adequate preparation.
The pediatrician who chooses to provide emotional support and long-term counseling to patients and families may be faced with a decision at the other extreme of the referral dilemma - i.e., how far to go with counseling before making a referral. This decision should be based on the factors that determined the pediatrician's basic involvement - i.e., comfort, interest, values, and degree of expertise - in addition to factors that are primarily patient related.
The severity of the problem is certainly a major factor in determining referral. Threatened or attempted suicide and obvious psychotic symptoms would demand expeditious referral. Motivation and insight are criteria that characterize a successful psychotherapeutic relationship; certainly, families that recognize their emotional needs and disability and ask for help should be referred.
Some primary-care physicians have decided to include a mental health professional -usually a psychologist, social worker, or mental health nurse consultant - on their office team. This mental health professional participates in the behavioral, developmental, and psychosocial evaluation of patients and often carries out short-term therapy within the office or clinic setting. An example of brief family therapy in a pediatric setting has been described by Augenbraun, Reid, and Friedman.5
Once the decision to refer has been made by the pediatrician, preparation of the patient and the family for the referral in a stepwise fashion will enhance acceptance and help to ensure success. The following advice of Novello6 may prove helpful. He suggests that the referring physician (1) be optimistic, (2) listen to the client's reaction (usually resistance), (3) allay the patient's fears, (4) educate the patient about the relationship between mind and body, (5) obtain a release of information from the patient, and (6) keep in touch with the family after referral. Of course, the referring physician should call and discuss the referral with the mental health professional beforehand. Friedman and Selesnick,7 in an article on the psychosomatic aspects of asthma, outlined the critical indications for a psychiatric referral of asthmatic and eczematous children: (1) the family with deep-seated conflicts or severe psychopathology; (2) the family in which there is a great resentment of the child, either because of the illness or for other reasons; (3) the child with a personality disorder or neurotic symptoms that may or may not be secondary to his illness; and (4) the family that uses the physical symptoms as a device for its own neurotic needs. Additional indications are (5) the family that is hurting and really asking for help; (6) the family in which psychologic problems are significantly interfering with medical care; and (7) the family in which there are any psychotic-like reactions, including suicide attempts and drug overdoses.
Friedman and Selesnick addressed certain dynamic points that pediatricians and other physicians should keep in mind once the decision to refer has been made:
1. The physician should not utilize the referral as an expression of his own anger or frustration towards the family. The mental health professional is an additional resource, not a punishment for recalcitrant parents.
2. The physician should not conceal the identity of the mental health professional with such euphemisms as "nerve doctor" but should be open and direct in giving his reasons for the referral. He can state directly that the family's problems are such that they require the attention of a specialist whose primary concern is with emotional difficulties.
3. The physician should be careful not to overrate the efficacy of the psychiatric or psychologic interview, since the parents may then invest it with a great deal of magical expectation. They are bound to be frustrated, and this may interfere with subsequent planning for psychotherapy.
4. The physician should give the parents some indication of the nature of a mental health or psychiatric consultation. The parents should be prepared to discuss intimate questions and the concerns that are interfering with the gratifying course of family life.
5. The physician should be careful to inform the parents that when they accept the psychologic treatment, they will not be forgotten by him. Parents are reassured to know that the physician maintains active responsibility for the medical management of the child. They can then view the referral as part of a team approach in helping their child, rather than as the shunting of a difficult case from one doctor's office to another. Many pediatricians find that a family interview before referral helps to get the entire family ready for the referral and makes success more likely.
A youngster or an adolescent may balk at referral and refuse to cooperate. Optimal handling of the referral as discussed will minimize this problem. Often the referring physician can use his past relationships with the child or adolescent to encourage compliance. The family approach makes it easier for many youngsters to accept referral. Up to this point, we have been concerned with what happened within the referring facility; but once the referral has been made, serious negative consequences may arise because of poor communication between the helping agencies.
Early in the development of child psychiatry, the major emphasis was on resolving the child's emotional problems. The child was in some significant ways disturbing adults in his environment. These adults were usually parents, teachers, or sociolegal authorities. The child was the problem, and the treatment resources represented by medicine, social service, psychology, and the courts focused on the child to find the factors within him that caused the disturbing behavior and tried to correct them.8 The model of one-to-one psychotherapy that had been utilized with adults was modified and applied to individual children. The work that was done with the parents was considered to be for the sake of the child and as a means of helping the parents relate to the psychotherapeutic work being done with their child. With this model in mind, child-guidance clinics were developed to handle children - not families -with their emotional problems.
In recent years there has been a movement toward focusing equal attention on the child and his family.9 While it is recognized that a child is referred to a mental health professional or facility because of the anxieties of people close to him, it is still tacitly accepted that these difficulties occur primarily because the child is disturbed. Increasingly, we are recognizing the organic unit of the family, and it is suggested that the disturbance within the child is only one indication of a latent or manifest disturbance within the total family unit. "It is now widely felt that better results are obtainable in psychotherapeutic work with a child when at least the emotionally more significant parent is receiving treatment concomitantly. In most instances, this is carried on at the same clinic and ordinarily by a therapist other than the one seeing the child."8 Although most treatment centers do some conjoint family therapy, they usually utilize the team approach and, in effect, the family is referred to a number of different professionals. This complicates the channels of communication, especially if the pediatrician continues to work with the family.
After the family has been referred, it becomes essential for the health and mental health professionals to clearly define what role each is to take in dealing with the family problems. Of course, the family must know what it can expect from each helping source. Psychologists are often asked "medical questions" that they cannot answer. Frequendy the mental health consultant is asked to "second guess" the physician or to agree with the supposition that the child's problems are actually physical. Conversely, the physician may be asked to agree or disagree with the opinion of the mental health consultant.
The mental professional receiving the referral may draw conclusions about the patient's problems that are different from the referring physician's. Often the patient presents a view of his problems that is somewhat different from those of the referral source. A phone call to the physician clarifies the issues and avoids allowing the family to play one professional against another. Another factor to consider is the opportunity presented to the family for an expression of ambivalence towards the pediatrician or the mental health professional - sometimes overtly and sometimes by subtle distortions and misquotations, none necessarily intentional. The process of resolving the family's ambivalence about referral and psychotherapy should result in a therapeutic experience for the family. A family approach, as well as cooperation between the pediatrician and the mental health consultant, allows the consideration of all factors operative in a child behavior problem or a disturbance in the parent-child relationship. The quality and quantity of reciprocal stimulation, genetic endowment, temperamental differences, interpersonal reactions, social and cultural influences, school experiences, and relationships with peers and peer groups, should be considered and evaluated and the findings utilized in the therapeutic approach.10
1. Rothenberg, M. B. Child psychiatry - pediatrics liaison. J. Am. Acad. OhHd Psychiatry 7 (1968), 492-509
2. Friedman. S. B. Conversion symptoms in adolescents. Pediatr. affi. North Am. 20 (1973), 873-882.
3. Goffman, E. Stigma. Engiewood Cliffs, NJ.: Prentice-Hall, 1963.
4. Chamberlin, R. W. Management of preschool benaver problems. Pediatr. CAn. Worth Am. 2t (1974), 33-47.
5. Augenbraun, B., Reid, H. L., and Friedman, D. B. Brief intervention as a preventive force in disorders of early childhood. Am. J. Orthopsychiatry 37 (1967), 897-702.
6. Novello, J. R. Psychiatric referrals made easier. Resident and Staff Physician (October, 1973), 86-89.
7. Friedman, D. B. , and Selesnick, S. T. Clinical notes on the management of asthma and eczema: When to call the psychiatrist. CAn. Pediatr. 4 (1965), 735-738.
8. Kaplan, M. Problems between a referring source and a child guidance clinic. In Szurek, S. A., and Perlin, I, N. (eds.). The Antisocial Chid, His FamSy and His Community. Palo Alto. Calif.: Science and Behavior Books. 1989, pp. 116-131.
9. Group for the Advancement of Psychiatry, Committee on Child Psychiatry. From Diagnosis to Treatment: An Approach to Treatment Planning tor the Emotionally Disturbed Child. GAP. Report No. 87, September, 1973, pp. 531-537, 547-552.
10. Clemmens, R. L., and Kenny, T. J. Prevention of emotional problems in children: A philosophy for child rearing. Clin. Pediatr. 16 (1977), 122-123.