Pediatricians have long been aware of the great number of emotional problems many of their patients have. We believe that physicians who are providing primary care to children and adolescents are in the best position to diagnose and manage most of the common less severe psychologic, social, and learning problems found in their patients.
The pediatrician has a decided advantage over other mental-health professionals in treating these children, we believe, because he knows the background of the patient, his medical history, and his relationship with other members of his family. Long-term contact with these children and their families often gives the physician significant insights into the causes of mental-health problems and the type of intervention that is most likely to succeed. And the child's capacity to respond to treatment is often enhanced by the sense of trust he or she and the parents feel towards the pediatrician; there is a greater likelihood that the physician's counsel will be heeded and his recommendations complied with.
Sometimes a pediatrician is reluctant to become involved in the psychologic problems of a child or family. It may be because of a sense of personal discomfort in discussing emotional issues or a feeling that he does not have the knowledge to treat emotional problems successfully. We believe that most pediatricians will be able to overcome such a reluctance if they first examine their own feelings and then decide which types of cases they feel most comfortable in managing. Actually, most pediatricians have already acquired a wealth of skills in dealing with emotional problems of their patients, from their experiences even before children's birth in anticipatory guidance of the prospective parents, during early childhood as they make suggestions on behavioral problems, and subsequently as they help the family members handle stress resulting from chronic illness. By refining and directing these skills they already have, pediatricians can become effective counselors for children with emotional problems.
SOME USEFUL SOURCES
Familiarity with some of the literature on child development will help the pediatrician who plans to do a considerable amount of counseling. As with physical medicine, psychologic interventions are based not on the physician's personal history (such as his or her own child-rearing experiences), but on the science of behavioral medicine - that is, a theoretic framework rooted firmly in the behavioral sciences. All pediatricians are familiar with the developmental milestones in early life. When they are assessing a given child's behavior as he grows older, such works as Piaget's1 can be useful in predicting the sequence of stages through which most children pass as they develop their intellectual skills. B. F. Skinner's works on behavior modification2*4 as well as those of others5"7 may also be helpful in suggesting ways in which difficult or troublesome symptoms can be managed.
Erikson's Childhood and Society6 will be useful to pediatricians in providing a framework to aid understanding of the different factors affecting the mental health of children and to plan effective intervention. Erik son stresses the importance of biologic, psychologic, and social factors in the mental health of every child. He has formulated the essential task or critical area to be mastered by the child in each stage of his development. A familiarity with each stage and with the signs that it has successfully been mastered will be helpful to the pediatrician in assessing the mental health of his patients.
Intervention in the emotional conflict of a child, of course, entails intervention in the complete family system. The child's problem cannot be diagnosed and treated effectively and efficiently unless his parents and siblings are also considered.* Parents, in addition to contributing characteristics and tendencies genetically, constandy influence both growth and development of their children through daily messages - subtle and otherwise - about the world in general and their own norms, values, and expectations in particular. While it is true that children have always grown up in families, there are some major differences between how children were reared in the past and how many of them are being reared today.
Family mobility has separated generations from the support and assistance they had come to expect from each other. Employment of both parents now means that assistance often is sought from babysitters or child-care centers. The pediatrician faces additional stressful issues as he sees single parents, divorced couples or stepparents, foster or adopted children, or teenaged parents. In relating to these situations the physician must support the family's child-rearing practices, at the same time remolding and guiding its efforts.
The pediatrician should also be aware of the cultural, religious, and educational influences on the child and family. Involvement in his community school system, as a parent, school-board member, community leader, or provider of care, will expand the pediatrician's knowledge base and expose him to values and norms affecting his patients that he might not otherwise become aware of. Often the first symptoms of emotional problems in children are manifested in difficulties in functioning at school. Parents will frequently initiate contact with a physician because teachers or school officials have encouraged them to obtain medical assessment and advice. When this happens, the pediatrician may be able to intervene when a behavioral problem is still in its early stages, reducing the possibility that referral to a psychiatrist or other mental-health professional will be necessary.
As the pediatrician makes the transition from his usual role to that of a counselor, he should develop increasing awareness of his use of his "self as a role model, as a helping person. He must be careful to speak in language that his patients will understand and eliminate the use of medical jargon and technical details. Short sentences are useful, as well as asking the patient to summarize his perception of the physician's instructions or directions, so that important advice is not "lost in translation." One should never assume that the person understands what has been said: most patients, regardless of educational level or degree of sophistication, often will not disagree or admit confusion. One should also use nonverbal body language that implies empathy and support, such as direct eye contact, open arm position, and facial expression that reflects what is being said.
A decision should be made in advance regarding the amount of office time that will be allocated to counseling and how fees will be handled. Finally, the pediatrician should consider the types of cases he would feel comfortable in working with and which he would refer to another resource.
At this point the pediatrician must decide what is the best direction for him to take. Which intervention technique should be used? Will he see the entire family, either together or separately, or just the identified problem child? The remainder of this article will discuss several different modes of treatment that have been useful in minimizing emotional reactions of children - behavior modification, natural and logical consequences, and problemsolving skills.
Behavioral modification is the name given to a set of applied procedures that can be used to help a child change his behavior and develop more socially acceptable adaptations to stresses in his life. Since the child's behaviors are usually a reaction to parental demands and thus represent - to a large extent - learned behavior, various techniques of behavior modification can be used to play an important role in treatment.
One method of behavioral modification we believe will be particularly useful to the pediatrician is that developed by B. F. Skinner.2 He realized that the vast majority of human behaviors are learned and developed as a result of a person's experiences in interacting with people and forces in his environment - primarily other human beings who reward, punish, or ignore his actions. Both desirable and undesirable behaviors can be learned as well as unlearned, as the child is conditioned by positive and negative reinforcements.3
There are essentially four ways in which the adult can influence and modify behavior.5 First, the adult can shape or teach a child a brand-new behavior that he has never engaged in before. Second, the adult can increase or strengthen a behavior that is believed to be good or pleasing but that the child does not reveal often enough. Third, the adult can decrease or weaken a behavior that is felt to be undesirable and occurs too frequently. Finally, the adult can maintain or continue the current level of behavior.
The first step the parent must take before attempting to modify the behavior of a child is to define and describe the exact behavior the child is exhibiting that is objectionable. It is important to think precisely about the behavior that one sees and hears. "Mark has been a bad boy" is not a very precise or adequate description of undesirable behavior. The listener does not know what led to the statement. As is often the case, Mark himself may not know which of his behaviors led to that evaluation. "Mark left home without asking permission, and then he played with matches" does describe specifically what behaviors created the problem.
After observing exactly what the child does and how often he does it, the parent can decide whether the behavior must be decreased or increased in frequency. Before any intervention, the parent must measure or count the frequency of behaviors. While this sounds tedious, often the parent will realize that the misbehavior occurs less frequently than stated. In addition, the older child can monitor his own behavior on a wall chart that can give him control and immediate feedback. A simple wall chart is shown in Figure 1 .
As an example of how this can be used in practice, consider what is happening in the Smith family. A great deal of tension exists, centered around nine-year-old John's refusal to take care of his belongings and his stubborn, angry reactions when nagged to do so by his parents. Rather than continually questioning him and yelling at him to do this, his parents would do better to provide a wall chart with the days of the week along the side and the tasks to be completed across the top. This can provide the youngster and the parents with a clear record of the activities. After the child has finished the task, he, or the parents, can check off the appropriate square.
Figure 1. Wall chart that can be used in behavioral modification to encourage performance of daily chores.
Sometimes, the simple act of counting and recording the behavior helps to move the behavior in a more positive direction. Often, however, the adult needs to provide more systematic reinforcement if the child is to modify his behavior. The basic principle underlying positive reinforcement is the immediate rewarding of correct performance. It is always important to include a verbal reinforcer - encouragement, recognition, or praise - along with the tangible reward. This provides the child with additional reinforcement and sets the stage for withdrawing the candy, toys, or other artificial reinforcers later.
Reinforcers should be something in which the child is actively interested. Allowing him a limited choice often works well. Experience with many children under varied situations has led to the realization that certain parental actions or certain types of events are frequently effective reinforcers. Words of praise, recognition, attention, candy or popcorn, opportunities to observe certain events, opportunities to participate in valued activities, are examples of effective reinforcers.
Negative reinforcement or punishment should be used only in very limited situations. When the child's safety is in jeopardy, punishment may be entirely appropriate to ensure the child's welfare. Punishment also may be necessary when the desirable behavior cannot compete with the undesirable behavior. Consider, for example, what happens when the child does not come home right from school even though he has been told to do so. The undesirable behavior of not coming home is positively reinforced by the pleasure he experiences in playing with his friends. That activity is a more powerful reinforcer than the desire of pleasing his parents by coming home to do his chores. In such a situation it may be necessary to punish him when he does not come home, and also to reward him when he does, if the desired goal is to be obtained.
Punishment should not be used often. This is a concept many parents find difficult to accept. You should help them understand that repeated negative attention may generate further misbehavior as a means of gaining more attention. It does not eliminate the child's desire to engage in behaviors the parents find objectionable. And punishment is usually humiliating to the child. It may encourage him to lie or teach him that he must find a way not to get caught the next time. Finally, if physical punishment is used, it becomes a model to the child for aggressive behavior of his own, imitating the aggressive behavior of his parent.
To eliminate problem behavior, it is better to use extinction rather than punishment. This means withholding of a reinforcer that has previously been received contingent on a behavior. When a behavior is ignored, it will decrease in strength and eventually disappear. To stop a child from acting in a particular way, one may arrange conditions so he receives no "payoff** following the undesired behavior. For example, four-year-old Paula would throw a temper tantrum when not given a cookie. By completely ignoring the crying, foot stamping, and yelling, her parents were able to extinguish the temper tantrum. Because other people in the situation deliberately or unintentionally reinforce the undesirable behavior, one must frequently involve them - grandparents, playmates, siblings - to terminate all sources of reinforcement. In Paula's case, her brothers and sisters were also asked to ignore her. To achieve extinction, all reinforcement of undesirable behavior must cease.
The misbehavior may temporarily increase as the child "tries harder" at doing what used to work. This is called extinction burst. Parents must be warned that this may occur and must be urged to be consistent throughout the intervention period. The first two weeks of implementing a plan is often stressful, but it is also the most crucial. The parents become discouraged during this period. They may give up the program entirely. The physician can enhance success by a brief telephone call to check on the progress and reinforce the parents.
Behavioral modification has been useful in treating children with a wide variety of problems - for example, enuresis, masturbation, school truancy, or excessive sibling rivalry. It is most effective when it is planned joindy with the child and his family . Close monitoring and support by the pediatrician will be necessary during the early stages to ensure that the parents consistently apply the necessary principles. Patterson's Living with Children7 is a useful source for further information about how to use this approach.
A second, theoretically different approach to behavioral modification is based on Alfred Adler's theories of individual psychology.* Adler emphasized the interpersonal nature of the individual's problems and believed family relationships could be improved through mutual respect and acceptance of personal responsibility by each member of the family. We find it useful when working with both parents and one or more children joindy. It is helpful in resolving problems stemming from routine living, such as lack of order, lack of cooperation, or poor interpersonal actions.
According to Adler, all behavior is purposive. The purpose of most children's actions is to gain social acceptance and a feeling of belonging. A child who feels socially accepted recognizes that his family is devoted to him, likes him, and has confidence in him. He feels, "These are my people and I want to help them." At the same time he feels, "1 am an OK person; I like myself, and I can do things for myself and for others." This child will work towards the good of the whole family. The same attitudes will later determine his role and behavior in society. An encouraged child who has faith in himself and in others holds cooperation as a goal of behavior.
A misbehaving child, however, mistakenly seeks to gain social acceptance in unacceptable ways. This discouraged child, who feels unfairly treated, whether because of overindulgence or overrepression and punishment, refuses to cooperate. Instead of pursuing useful goals, he may seek useless ones. Dreikurs and Soltz10 categorized these useless goals as
1. Desire for excessive attention: wanting to keep everyone busy with him, requesting special services, clowning, being a nuisance.
2. Desire for power: trying to show everyone that he will not do what is asked.
3. Desire for revenge: manifested through disobethence, delinquency, or other misbehavior.
4. Feelings of inadequacy, manifested by "playing the baby," acting as though worthless, incapable, or hopeless.
Thus, a child may be misbehaving to get attention or to demonstrate his power or as a revenge tactic, which says in effect, "I can hurt you by not doing what you ask." Or it may be a manifestation of inadequacy , which purports to say: "It's not my fault; I just can't stop doing it." Usually the child is not precisely aware of what he wants to achieve by his misbehavior. A mother or father, however, can easily tell which goal the child is seeking. The parent accomplishes this by examining his or her own feelings in reaction to it.
For example, if the mother feels annoyed or smothered by her child's requests, the child's goal is probably to gain attention. If she feels anger or resentment, his goal is likely to be to obtain power. If she feels hurt and upset, his goal may well be to get revenge. If she feels helpless when confronted by her child's apparent inabilities, the child's goal is probably defensive - i.e., assuming an inadequacy that is not really present.
In most cases, parents feel exactly what the child intends them to feel. Particular emotions are felt in disturbing situations because the interaction has triggered them. When parents continue to react only in response to their feelings, they help the child to obtain his goal. That is why it is so necessary for parents to clarify what their feelings really are. Once they have some understanding of what their child's needs are, they can take constructive action to meet them and avoid inappropriate reactions.
Corrective procedures. The behaviors outlined above - and the emotions they evoke in parents - suggest that there are procedures the parents can employ to correct their child's behavior. You may find these suggestions helpful in counseling parents of children with behavior problems:
Excessive desire for attention. Tell the parents to ignore misbehaving children when they believe the behavior indicates a desire for excessive attention. Attention should be given at pleasant times, when the child is not making an overt bid for it. The parents must come to realize that punishing, scolding, and giving in to the child's wishes are all forms of attention that will serve to perpetuate negative behavior.
Power. Recognize and admit that the child does have power. The parent should withdraw, or at least not engage in conflict. Act, but do not talk. Be willing, at a later, calmer time, to negotiate as many issues as possible. Redirect the child's efforts into constructive behaviors. This can be accomplished by enlisting the child's cooperation, appealing for his help, and giving him responsibility.
Revenge. Avoid punishment and retaliation. Urge the whole family to encourage the child. Support his efforts to have friends. Do not become hurt or show the child that you are hurt. The parents must learn to recognize and change their own behavior patterns so they will not respond to old provocations. Depending on the seriousness of the child's misbehavior, the pediatrician may want to recommend individual counseling for the child to help him deal more effectively with his feelings.
Feelings of inadequacy. Encourage the child. Remember that any improvement may take a long time. Show faith in the child's ability. Provide opportunities for the child to accomplish things in areas in which you know he can succeed. Work on strengthening areas of deficiency.
Natural consequences as reinforcers. Rather than punishing or rewarding the child's behavior, parents may use natural or logical consequences to counteract the child's attempts to reach the various goals of misbehavior. The essence of natural consequences is to let the child learn from his own behavior. When this occurs, the child experiences the unpleasant results of his own actions. Parents must be alert to prevent any possibility of serious harm to the child. Certainly he cannot be permitted to fall out of a window or eat poisonous substances! Parents may inform a child once of the natural consequences of a specific behavior. If they keep reminding him, they are likely to be either giving him unwarranted attention or punishing him by nagging.
A mother may complain, for example, that her son is a poor eater and that she has to nag to get him to eat. She is encouraged to stop nagging and to allow him to learn by experience. The following morning, her son rushes out to play without having eaten his breakfast. Several hours later, he is famished. He is experiencing the natural consequences of not having eaten breakfast. She does not give him food until lunch time.
Logical consequences can be used as reinforcement, too. Here the result is more or less arranged by the adult, rather than being a matter of letting nature take its course. Essentially the "punishment (the consequence) fits the crime*' and evolves from the misbehavior. For logical consequences to be effective, both the parents and the child must have an understanding of what is expected from the child and what will happen if the child does not perform as expected.
Suppose, for example, that Bobby is screaming and yelling in the living room, where his mother and father are reading. Father says once, "If you can't be quiet, go to your room." Father now has an understanding with Bobby: If you are quiet, you may remain; if not, you must go. Bobby continues to make noise, and father says firmly but without anger, "Go to your room. Come back when you can behave yourself."
The child is always given a choice, and parents must not show anger, for this would turn into punishment. The following statements are illustrative of the techniques of logical consequences:
"If you don't behave yourself at the restaurant, I will take you home."
"If you fight in the car, I will stop driving and we will be late."
"If you are slow getting dressed in the morning, you will have to finish dressing on the school bus."
Some parents frequently find themselves arguing with a child with the hope of persuading him to stop unwanted behavior. They do not realize that ignoring or withdrawing from a child's misbehavior is a better way than talking. Removing themselves to another room gives the message: "When I don't like what you do, I go away from you."
When withdrawal is used as a training technique, the parents must be careful to indicate that they are fleeing not from the child but, rather, from his behavior. Parents often wonder why withdrawal is so effective. It is effective because a child's behavior is purposive, at either a conscious or an unconscious level. If the child consciously or unconsciously wants to get the adult involved against the adult's will and the adult responds by punishing the child, the child will have succeeded in reaching his goal. If, on the other hand, the adult refuses to play the game but simply vanishes, the child is frustrated in reaching the goal of forcing the adult to pay attention to him because of his bad behavior. And, once frustrated, he is not as likely to try the same thing again.
The Adlerian model is useful and effective in modifying a child's behavior up to about the age of 10. As adolescence nears, however, children begin seeking more control over their own lives and asking for independence. In this age period the pediatrician-counselor will want to intervene somewhat differently and suggest courses of action in which the adolescent can actively participate.
Counseling the adolescent, individually or with his family, usually requires a different level of understanding on the part of the pediatrician. The initial contact, by the parent or teenager, may be precipitated by a "crisis" situation - e.g., running away, suspected pregnancy, drug experimentation. Often this "crisis" is a one-time-only experience that is merely a symptom of the real problem. Uncovering the underlying problem may entail clarification, increasing communication, objective observation, and sincere support of both the teenager and his parents. The question of confidentiality may concern a teenager worried about being embarrassed by disclosure of his actions or being punished for them. The pediatrician should explore this with the adolescent when he suspects it is a problem to him, and do so in such a way as will be reassuring. Often in such cases the teenager actually wants his parents to know what is happening in his life. The pediatrician might tell him, for example, that he can keep confidential any information that the adolescent gives him except only when a situation would cause harm to the patient or someone else. And if, in his judgment, such a situation were about to occur, he could assist the adolescent in disclosing the information and working on a solution.
The problem-solving model is a useful tool for the pediatrician to use, individually or with the entire family. In preparing to use this approach, it is helpful to see both the adolescent and his parents alone and conjointly, first to get an initial understanding of the problem and then to joindy generate solutions. The six steps to follow in implementing the problem-solving approach are shown in the accompanying box.
The following case history indicates how the problem-solving approach works out in practice.
Mrs. Smith brought Barbara, 15, into the office, requesting a referral to a child psychiatrist. Barbara had just been brought home by the police after having run away from home for the first time. The physician talked first individually with each and then jointly.
Both Barbara and her mother felt there were problems to work on but could not agree on what they were (Step 1). After much discussion, it was seen that Barbara's grades were getting worse, she was going out on several school nights, and Mrs. Smith was asking her to stay home on weekends to make up work (Step 2). In fact, the runaway incident was sparked by a failing test grade and Barbara's fear of punishment by her mother.
Barbara and her mother agreed that she could study longer, not go out so often, drop afterschool activities, ask for progress reports from teachers, or drop a few classes (Step 3). Each suggestion was discussed by the three participants (Step 4). Barbara felt she could get better grades if she stayed home more and if she had classmates over to study with her. Mother agreed to cut down on study time required on weekends (Step 5). After three weeks, Barbara and her mother returned to the office. Her grades had stabilized, and Mrs. Smith's attendance at PTA meetings reassured her Barbara was making an attempt to bring up her grades, which encouraged her mother to let up pressure at home (Step 6).
WHEN TO REFER
Each of the models discussed above may be useful to the pediatrician in advising on behavioral problems of childhood and adolescence. There are certain situations, however, that do not lend themselves to these modes of counseling, and referral to more appropriate resources may be necessary. Indications for referral may include a long-standing history of emotional or family problems, a continuation or increased intensity of problems after six to eight counseling sessions, suicidal gestures or attempts, or repeated instances of alcohol or drug abuse.
In cases where the pediatrician does not feel confident in handling certain behavioral problems himself, a variety of referral services are available in the larger communities. Community mentalhealth centers and family-service agencies exist in the large metropolitan areas, staffed by social workers, psychologists, and psychiatrists. They operate with a sliding-scale fee system. Pastoral counseling by trained mental-health professionals is also available in many communities, and some patients may feel more comfortable in this type of setting.
Specialized clinics and agencies in the large cities provide counseling services. Planned Parenthood, for example, will provide counseling in teenage sexuality. Local community centers often provide teenage counseling on alcohol, substance abuse, and family or peer problems. Y.M.C.A.s, Y.M.H.A.s, and Women's Growth Centers often sponsor various types of growth-oriented counseling for older teens and young adults. Local schools often offer many different types of parent-education opportunities.
While such resources exist in hundreds of communities, locating them may take some footwork. Referral networks are sometimes operated by local health and welfare councils or mental-health associations and may be of assistance in such cases. Libraries often have directories of community services. The classified telephone directories in larger cities list social-service agencies under such headings as "Marriage and Family Counselors," "Mental Health Clinics," "Social Service Organizations," and the like.
The pediatrician should have prior contact with a professional mental-health worker before he refers a patient, and he should be given some assurance of the person's qualifications. In referring a patient to a nonphysician who is a mental-health professional, we believe, the pediatrician should inquire about the therapist's educational background, past work experiences that are relevant, the length of time he has been with the agency, whether he is licensed or certified by a recognized board of examiners, and the mode of intervention he chooses to use.6 Personal contact with the mental-health professional will give the pediatrician more confidence in the service the professional will provide his patient and the patient's family than he otherwise might have, as well as afford a means of learning how the intervention is progressing.
Pediatricians have a major role to perform in helping children overcome behavioral problems. They can make their work more effective by expanding their own knowledge of the causes of the majority of behavioral problems in children and adolescents and by becoming aware of the various methods of intervention that have proved successful in managing them.
A great number of behavioral problems can be managed best if recognized and treated early. By expanding his repertoire of intervention skills, the pediatrician can add an important dimension to the services he is able to offer children and their families.
1. Piaget, J. The Origins of Intelligence in Children. New York; W. W. Norton & Company, 1963.
2. Skinner, B. P. The Behavior of Organisms. New York: AppletonCentury -Crofts, 1938.
3. Skinner, B. F. Beyond Freedom and Dignity. New York: Alfred A. Knopf, 1971.
4. Skinner, B. F. Science and Human Behavior. New York: The Macmillan Company, 1953.
5. Bandura. A. Principles of Behavior Modification. New York: Holt, Rinehart and Winston, 1969.
6. Erikson, E. H. Childhood and Society. New York: W. W. Norton & Company, 1950.
7. Patterson, G. R. L. Living with Children. Champaign, 111.: Research Press, 1976.
8. Ansbacher, H., and Ansbacher, R. R. (edt.): The Individual Psychology of Alfred Adler: A Systematic Presentation in Selections from His Writings. New York: Basic Books, 1956.
9. Way, L. Alfred Adler: An Introduction to His Psychology. Baltimore: Penguin Books, 1956.
10. Dreikurs, R., and Soltz, V, Children: The Challenge. New York: Duell. Sloan and Pearce, 1964.
Figure 1. Wall chart that can be used in behavioral modification to encourage performance of daily chores.