As the frequency and complications of major childhood disease diminish, emotional and behavioral problems emerge as more pressing concerns for families. The proliferation of literature dealing with emotional health and child-parent relationships (e.g., Gordon's Parent Effectiveness Training1 and Brazelton's2'4 and GinottV books) attests to the high level of interest in the subject. Parents seek help from a variety of mental-health advisers of widely divergent training and philosophy - no one group of therapists holds the exclusive "contract" for psychologic therapy in our society. However, a large majority continue to look to their physician for counseling and guidance.6
Practicing pediatricians represent one appropriate group of specialists to deal with behavior problems of children. The practice of pediatrics has increasingly become an outpatient specialty, as disease patterns have changed, therapeutic efficacy improved, and preventive measures become more refined. Furthermore, pediatricians have the unique opportunity to follow children through rapidly changing developmental and emotional-growth stages (weaning, toilet training, separation from parents, introduction and progression through formal learning processes, coping with sexual changes of adolescence).
This longitudinal care allows the pediatrician to develop a comfortable rapport with parents and children. Parental reaction to the child's illnesses, physical and emotional growth, and emotional strengths and weaknesses can all be observed over time. The utilization of pediatric nurse practitioners is a major development of the past decade that may afford the pediatrician more available time in which to counsel parents with respect to developmental problems.
Certainly there are a number of challenges for the behavioral pediatrician who wishes to incorporate his skills into community practice - problems that have not always been identified during formal residency and fellowship training. The behavioral pediatrician must acquaint himself with resources in his community that can support him in his work. Adequate supervision is essential so that the frustrations commonly encountered in this relatively new area of practice can be addressed and his continued professional growth can be encouraged. The pediatrician must consider changes with respect to his office setting, appointment times, and fees. Techniques for initial diagnostic evaluation, followup, and referral need to be developed. The purpose of this article is to discuss these practical issues in more detail and to suggest strategies that may be employed in establishing a new practice of behavioral pediatrics.
The experience of one of the authors (G. P.), who works in a 22-physician multispecialty practice in a rural area, may be illustrative of the types of problems encountered. The Pediatric Department in the Exeter Clinic, Exeter, N.H., includes four pediatricians (three full-time and one part-time) and two nurse-practitioners. The nurse-practitioners spend most of their time administering care to well children and to follow-up visits for acute illness.
The presence of nurse-practitioners has decreased demands on the pediatrician so that more time can be spent with ill children, and with brief counseling on developmental issues (when to begin toilet training, feeding problems, sleep problems). This counseling is done by both pediatricians and nursepractitioners.
All pediatricians in the practice schedule conference appointments (usually 20 to 30 minutes) for more complicated problems, including behavior problems. The author, because of his subspecialty training (a two-year fellowship in behavioral pediatrics) sees more behavior problems and has more frequent visits.
Referrals come from (1) parents concerned about specific behavior problems who call and request help, (2) schools in the area, (3) other physicians in the clinic and physicians outside the clinic, and (4) the pediatrician's own well-child population.
During well-child visits the parents are encouraged to discuss concerns that are not strictly medical. When questions concerning potentially complicated behavior problems arise (e.g., enuresis, encopresis, stealing), parents are told that these are important and that the answers require more time than is available at the present visit. They are requested to schedule a conference appointment to more fully explore their concerns.
MENTAL-HEALTH PROBLEMS IN RURAL PEDIATRIC PRACTICE DURING A 12-MONTH PERIOD
The scope of problems presented by 80 patients referred or- identified within the practice during the past year is given in Table 1. The three patients thought to be psychotic (two adolescents and one child) were referred to psychiatrists for evaluation and treatment. Referrals were also made for the patients with attention-deficit disorders, learning disabilities, or mental subnormality. A complete neurodevelopmental assessment, testing for learning disabilities, and intellectual testing are beyond the scope of the services offered by the practice. Of these 80 patients, approximately one-third continue to be seen on a regular basis. Appointments vary from once a week to once a month or every two months.
Typical of the behavior problems seen in the practice is the following:
James, a six-year-old, was brought to the office by his mother because of fears he experienced earlier in attending nursery school. The parents initially dealt with these fears by withdrawing the child from nursery school. However, when the child reached six, school attendance was mandatory, although James continued to resist going to school. The parents sought help at this time.
After several appointments it became apparent that James also had other unrealistic fears (fear of the dark, fear of separation, intense fear of being disciplined). Fear of the dark and of separation from family members was also exhibited by James's mother, and counseling for the mother was recommended. She initially resisted seeing a psychiatrist, stating that talking about her anxieties would only intensify them. She agreed to the idea, however, when she was shown that her own anxieties served as a barometer for her child's fears.
James continues to be seen on a supportive basis and now talks about some of his mother's unrealistic fears. He is attending school regularly, although still on occasion exhibiting fears of the dark by resisting going to bed. This case demonstrates the importance of obtaining a complete history not only with respect to the patient's problem but also with respect to related parental concerns and fears.
A second frequent problem concerns somatic symptoms, with no evident organic basis. An example is given below:
Ron's parents consulted the physician because of Ron's frequent headaches. The headaches had been diagnosed as "migraine" but had not responded to appropriate medications. In talking with Ron, we found that the headaches had increased in frequency and intensity since his father had suffered a nearfatal stroke, which left the father severely physically disabled and mentally depressed. Before the stroke, his father had rigidly controlled Ron's behavior and the behavior of everyone in the household. After the stroke, the entire power structure of the household had been altered so that Ron's mother took over all disciplinary responsibility.
Ron was helped to understand that his headaches were related to feelings associated with his father. Although the headaches have now essentially vanished, Ron continues to be seen on a monthly basis for support in dealing with a chronically depressed and dying father.
Different types of problems require different therapeutic approaches: patients with encopresis (as an isolated problem) seem to respond best to behavior-modification programs, as suggested by Levine and Bakow.7 Patients with conversion symptoms respond most favorably to insight-oriented counseling (understanding that fears associated with daily situations may actívate somatic symptoms). Children of families in which there is divorce, violence, or death often respond to supportive counseling sessions in which the physician empathizes with the difficult environmental situation in which the child finds himself.
In all cases, effective therapeutic intervention cannot be achieved until a complete medical and psychosocial history has been obtained. Although this may appear self-evident, particularly if the patient has been previously known to the pediatrician, the initial evaluation is itself an important part of the therapy. The next section will consider some specifics of the diagnostic and therapeutic process.
THE INITIAL DIAGNOSTIC PROCESS
The parents of the patient, whether self-referred or referred from other physicians, should be first seen for an initial brief appointment to discuss (1) the area of concern, (2) the goals of the family for amelioration of the problem, (3) the fee, and (4) the consultant's future plans for evaluation. The presence of both parents is encouraged.
At this visit the parents are allowed to verbalize their concerns about the child or adolescent. If the parents do not volunteer that the referral was suggested by someone else, this should be inquired about, since communication with the referring physician or agency is vital for effective continuous help to be offered. Parental expectations from the consultation should also be discussed. What would the parents like to see happen as a result of their consultation? Little more should be attempted in terms of data gathering at this time.
Near the end of the first visit, the physician's fee must be discussed. The parents should be apprised that the visit fee is determined by the amount of time spent with the patient; they should also be informed that the total number of visits that will be indicated cannot be exactly determined at that time. Talking about fees rarely comes easily to the physician, since during medical training fees are not an issue. Furthermore, since the house officer does not receive direct remuneration for services rendered, he is isolated from the concept that families certainly assess their child's need for care partly in terms of dollars.
All of this changes in the practice situation. An excellent discussion on the subject can be found in Bird's book Talking with Patients,9 which is recommended to all practitioners dealing with patients on a fee-for- service basis. Since the physician's fee is an integral part of the process of comprehensive medical care, such discussion is mandatory in patient-care situations. If the family feels unable to assume the cost of consultation visits, alternatives must be considered, such as referral to agencies charging on a sliding-scale basis.
At the completion of the first visit, the behavioral pediatrician should indicate his plans for future meetings with the patient and his family. Usually, one or two 45-minute appointments for the purpose of evaluating parent and patient concerns need to be scheduled within the next few weeks. Parents should be informed at the outset of the evaluation that eventual referral to a psychiatrist may be necessary, depending on the seriousness of the problem.
During the subsequent evaluation sessions, parents are questioned with respect to (1) emotional strength and weaknesses of their child; (2) medical history, including birth and infancy history, and developmental history (including exploration of behavioral disturbances, such as sleep problems, toilet-training issues, fire setting, stealing, phobias, discipline problems); (3) school history; (4) peer relationships; and (5) parental childhood background (relationships with their own parents and whether their childhoods were considered happy). It may take several visits to accumulate and properly assess this information. Less experienced clinicians often mistakenly assume that they should be able to clearly identify all pertinent issues in a single visit; in fact, a longer evaluation time may be more realistic.
It should be emphasized to parents during the evaluation that information provided to the physician by their child is confidential. It will not be shared with them unless such information involves possible danger to the child (e.g., suicide) or to others. Parents wishing to divulge confidential material to the physician should be informed that such material may need to be shared with the patient. However, parents should also be told they will receive information on their child's progress. This may be provided by the physician seeing their child or by a related professional (social worker, lay therapist) dealing with parental concerns. The latter approach may be more appropriate when the patient is an adolescent. Adolescents frequently distrust adults and envision their physician as collaborating with parents if regular meetings occur between physician and parents.
Evaluation sessions with the child or adolescent should be nondirective, candid, and nonthreatening. Specifically, effective physician-patient rapport is more readily established if at the beginning the physician honestly shares with the patient the nature of parental concerns. The issue of confidentiality must also be discussed with the patient early in the evaluation process. It should be made clear to the patient that information shared with the physician will not be communicated to the parents unless it is the child's personal wish or, as previously stated, unless such material entails possible danger to self or others.
At the completion of the evaluation sessions, the physician must outline to the patient and parents his future approach to the defined problem. This plan may require brief therapy with the patient alone (20-to-40-minute appointments every week for a one-to-two month period), regular meetings with the family and patient, prolonged weekly therapy with the patient, or referral to another agency or professional. Usually it is not possible to accurately estimate the number of future visits needed. However, families often erroneously assume that chronic emotional problems can be obliterated as quickly as an earache or sore throat, since the consultant may also be their family pediatrician. Therefore, parents and child must appreciate the approximate duration of physician concern if they are to make adequate time and financial arrangements.
Follow-up sessions with parents should take place every four to six weeks. This important step in the communication process must not be ignored. The patient's physician (or related professional) should elicit persistent or new concerns with respect to their child, parental opinions with respect to the child's progress, and parental reaction to continuing behavior problems exhibited by the child at home. The physician should remember to reiterate to the parents his belief that they are doing the best they can to help their child. He should also emphasize both the validity of the child's or adolescent's concerns and the importance of continued professional intervention. Certain follow-up parental visits should include the child. Such visits not only demonstrate to the child that confidentiality of individual sessions is not being breached but also aid the physician in appreciating changes in parent-child interaction - an important index to the effectiveness of ongoing therapy.
Regular communication with referring physicians and agencies is also important: appropriate permission must be obtained from the patient and family for such follow-up. A brief telephone conversation or letter after the patient is initially evaluated should be sent to the referring agency or physician and appropriate contact continued thereafter. Such follow-up serves several purposes: (1) it represents tangible evidence that the patient and family have complied with the referral recommendations; (2) it represents common professional courtesy; (3) it provides the referring agency or physician important information so that a well-informed and integrated approach to the patient and his family is maintained.
Although the pediatrician is often best qualified to treat common behavior problems presented by his patient, there are definite indications for referral to more intensively trained mental-health professionals. These indications will be merely outlined here and are more extensively discussed elsewhere in this issue.
Referral should be considered when the patient's symptoms continue to interfere with daily functioning and activities or when the physician or school feels that there has not been a lessening of the patient's symptoms. School officials can provide valuable information about peer interactions and the effect of the emotional problem on school performance. Referral is, of course, indicated if parents consider that inadequate progress has been made after the agreed-on duration of therapy. Such a decision is frequently a difficult one. Obtaining psychologic tests may be of help in this process, and projective tests in particular may provide an additional valuable indicator of the patient's functioning.
The pediatrician should also consider psychiatric referral when the patient's problem creates uncomfortable feelings in him. Situations related to homosexual issues, seductive adolescent behavior, or adolescent acting-out problems may create feelings that can prevent an objective evaluation and interfere with therapy. It is as unrealistic to assume that a physician can adequately treat all psychologic problems as it is to assume that he can treat all medical ones. Realizing one's own limitations is an important professional attribute.
A third situation in which referral should be considered occurs with the patient or family who is a close social relation or relative of the physician. Dealing with emotional problems of friends' or relatives' children is seldom appropriate. Obtaining intimate personal details of family and sexual functioning is often indicated in the evaluation, and that may jeopardize the social relationship; conversely, failure or hesitancy to obtain appropriate data may jeopardize the therapy.
There may be a variety of potential referral resources in the community. These include psychiatrists in private practice, child-psychiatry clinics (often affiliated with university medical centers), and community mental-health agencies. In many areas, psychiatrists in private practice are few in number and may have long waiting lists; unless the families have excellent third-party insurance coverage, visits may be prohibitively expensive. Childpsychiatry clinics do often charge on a sliding-fee scale, but they, too, may have long waiting lists. In addition, they often will accept patients only from a defined geographic area - and then only for evaluation. Community mental-health agencies offer the advantage of sliding-scale fees and the availability for long-term follow-up, but they often have inadequate medical coverage, so that patients requiring psychotropic medications cannot be adequately followed.
At times, because of temporary lack of referral availability or because of geographic isolation, it may be necessary for the physician to follow the patient who would otherwise be referred. Although not optimal, such a supportive relationship can serve the patient and his family well, and its efficacy should not be minimized.
In all cases where referral is suggested, parental and patient compliance with the referral is improved if that possibility has been mentioned as a contingency early in the evaluation process. The physician must always help families understand that seeing a psychiatric professional does not connote "craziness." After the referral is made, continued physician contact with the family concerning the emotional problem helps assure compliance with visits to the psychiatrist.
Community resources. Establishing rapport with fellow professionals and agencies within a community aids the newly arrived behavioral pediatrician in several ways. By providing "visibility," the pediatrician becomes more quickly known in the community. Availability for meetings with agencies and with other professionals suggests a commitment to the community, and goodwill is established with one's colleagues. Of equal importance, familiarity with community resources also provides the new practitioner with potential referral possibilities for his own difficult patients.
Visibility can be achieved by both seeking out and being ready to accept a role in such activities as parent-education groups, school-centered groups (parent-teacher associations, school health programs), prenatal and postnatal education classes, and well-child clinics. It needs to be kept in mind that many organizations cannot readily provide adequate remuneration for such participation. The benefits of such associations accrue slowly, but with time they may result in increased referrals to the pediatrician. For example, one of the authors was asked to serve as a cofacilitator for a group of parents with developmen tally delayed children. The meeting was held at a special school for such children. As a result, several children from the special school were referred to the pediatrician; he was invited to participate on the boards of directors of several allied agencies and was offered a funded position as medical consultant to the school.
Pediatricians who practice general pediatrics and also spend time seeing patients with emotional problems may face some conflicts in balancing both roles. Usually, patients with emotional problems do not respond to therapeutic intervention as swiftly or as dramatically as do patients with acute medical illnesses. Families, who may have come to expect immediate results from previous medical intervention, may become dissatisfied and even angry when rapid improvement does not occur. Indeed, the pediatrician may himself at times believe he can or should effectively cure any emotional problem. Such unrealistic goals are referred to in psychiatric terms as "rescue fantasies." However, psychiatrists may be better equipped to deal with such rescue fantasies, because the concept is a familiar one and is likely to have been addressed during their training.
The pediatrician may face a related issue soon after establishing a new practice: the inappropriately high expectations of medical colleagues. He may be inundated by referrals from practitioners seeking help for families with long-standing emotional problems. The established practitioners envision their new colleague as a messiah and often convey this feeling to their referred patients. The new practitioner must, therefore, not only cope with unrealistic aims of both the referring doctor and the referred patient but also deal with the patient's possibly irremediable chronic emotional problem. Such an introduction to a pediatric practice can be extremely disheartening, especially if the practitioner has no available empathetic professional support.
For these and other reasons, it is extremely important that the behavioral pediatrician establish a program for his own professional sustenance and growth. He should begin by seeking out other professionals in his geographic area with similar specialty and subspecialty interests. This provides a forum in which to discuss and share concerns with respect to difficult cases.9 It also provides a sense of shared professional empathy for such cases and an appreciation of the range of treatment philosophies utilized by various colleagues. Sharing case material with similarly trained professionals may offer fresh insights into dealing with problems presented by difficult cases. In addition, communication with those caring for patients with similar problems can be a mutually supportive process, important for the physician's professional satisfaction.
Case discussions also reveal the kind of patients with whom the therapist feels most comfortable and the treatment modalities he employs. One subspecialist may have extensive experience with encopretic patients but prefer not to handle patients with anorexia nervosa. Such information is valuable in deciding to whom to refer patients. Treatment-modality preferences of each professional also surface during such discussions. For example, the practitioner becomes aware of whether the professional is analytically or behaviorally oriented, the length of time patients spend in therapy, and whom the subspecialist treats (the patient, the patient and his parents, or the parents alone).
In addition to these case discussions, the pediatrician should consider seeking regular individual professional supervision, if at all possible. For example, one-hour meetings with a psychologist or psychiatrist every other week, or even once a month, might be scheduled. Such professional support may be invaluable in securing continuing career satisfaction.
Part-time teaching may also provide a source of continuing career satisfaction for the practitioner. This may entail travel to a local medical center half a day a week or every other week to discuss the management of common emotional problems of children and adolescents with nurses, medical students, or house officers. Work with local child-psychiatry societies and pediatric societies as a member of a functioning committee dealing with emotional problems or as a participant in workshops may also serve as a source of professional support and education. Practice-related research (compliance studies, emotional-problem-incidence studies) may provide a continuing professional stimulation and support. Pediatricians specifically trained in dealing with emotional problems are few in number, and research related to emotional problems in pediatric practice has been limited. Research need not require inordinate amounts of time. A recent commentary by Carey10 outlines how research may be incorporated into a practice setting.
Although the exact design and organization of the practice setting will vary with individual physician needs, some thought needs to be given to physical structure of the office, personnel, and time allocation for subspecialty patients. Physical-plant requirements for behavioral counseling may include (1) relatively soundproofed offices, (2) a separate waiting room for teenagers, (3) a playroom for younger children being seen in play therapy, and (4) a physician's office conducive to therapy with teenagers or parents (free of medical equipment and examining tables).
The office personnel who greet patients must be cordial yet efficient. The receptionist's responsibilities may include confirming appointments with patients the day before appointments^ investigating by phone patients who fail to come for appointments, and reiteration of policy to patients with respect to missed appointments. The receptionist and nursing staff are the "gatekeepers" of the practice; an irascible receptionist can be quite destructive to the goodwill of a practice, especially a practice dealing with patients with emotional problems.
Time allocation for behavior-problem patients is an individual decision. Physicians who feel more alert in the morning may choose to see such patients during those hours, since treating patients with emotional problems can be extremely taxing mentally. Patient needs, such as school attendance and parents' work schedules, may interfere with working out this solution easily, but usually compromises can be effected. Parental or patient resistance to therapy can frequently be measured partly by the difficulty in establishing appointment times.
In summary, a health-care system emphasizing ambulatory, comprehensive, and preventive care of children can provide an appropriate setting for the practice of the subspecialty of behavioral pediatrics. There is no dearth of child and adolescent patients with behavioral problems and no paucity of parents with concerns about their children. Dealing with behavioral pediatrics in practice, once the logistics of the practice are established, can be challenging and rewarding. The subspecialty is not without its frustrations, but opportunities to ensure continued professional satisfaction exist. The pediatrician who addresses both somatic and emotional problems of patients offers optimal care to a pediatric population.
1. Gordon, T. Parent Effectiveness Training: The Tested New Way to Raise Responsible Children. New York: Peter Wyden, 1970.
2. Brazelton, T. B. Infants and Mothers: Individual Differences in Development. New York: Delacorte Press, 1969.
3. Brazelton, T. B., Koslowski, B., and Main, M. The origins of reciprocity: the early mother-infant interaction. In Lewis, M., and Rosen· bhim, L. (eds.): The Effects of the Infant on its Caregiver. New York: Wiky Interscience, 1974, pp. 49-77.
4. Brazelton, T. B. Toddlers and Parents. New York: Delacorte Press/ Seymour Lawrence, 1974.
5. Ginott, H. G. Group Psychotherapy with Children. New York: McGraw-Hill Book Company, 1961.
6. American Academy of Pediatrics, Task Force on Pediatric Education. The Future of Pediatric Education. Evanston, 111.: American Academy of Pediatrics, 1978.
7. Levine, M. D., and Bakow, H. Children with encopresis: a study of treatment outcome. Pediatrics 58 (1976), 845-852.
8. Bird, B. Talking with Patients. Second Edition. Philadelphia: I. B. Lippincott Company, 1973.
9. Sumpter, E. A., and Friedman, S. B. Workshop dealing with emotional problems: one method of preventing the "dissatisfied pediatrician syndrome." Clin. Pediatr. 7 (1968), 149.
10. Carey, W. B. On doing research in office practice. Pediatrics 62 (1978), 424-425.
MENTAL-HEALTH PROBLEMS IN RURAL PEDIATRIC PRACTICE DURING A 12-MONTH PERIOD