Pediatric Annals

EDITORIAL 

A Pediatrician's View

Milton I Levine, MD

Abstract

For those of use who have chosen to be practicing pediatricians there is no profession more thrilling and rewarding. Watching and aiding humans develop physically and mentally from infancy to adulthood is a special privilege given to no other branch of medicine.

The pediatrician is of a special breed - a "gentler and kinder" breed. Pediatricians do not seek financial gains: many surveys, the most recent being in 1988, report their income as the lowest of the medical specialties. Rather, their reward is watching children develop and realizing that they are, in part, responsible.

However, as we all know, there are medical and behavioral problems that arise as children grow. The well trained pediatrician is ably equipped to handle almost all of the medical problems with the wide arsenal of antibiotics and modern diagnostic and therapeutic methods available. The behavioral problems that occasionally arise often prove much more difficult to treat and resolve.

It is obvious that the empathetic relationship of a child and pediatrician makes the latter the ideal person to deal with these problems, but several questions come to mind: Is the pediatrician capable of dealing with many of the conditions that occur? And has the pediatrician adequate time to devote to solving the problem?

Certainly the well trained pediatrician is capable of advising and dealing with the great majority of behavioral problems. Among these are sibling rivalry, peer problems, separation anxiety, hyperactivity, and certain learning problems including inattention at school. But the pediatrician must allow sufficient time to devote to the child's situation, which often includes sessions with parents, siblings, and even teachers. Other problems may be more complex and require the care of a skilled psychiatrist or psychologist. These conditions include suicidal attempts, kleptomania, chronic anxiety, cruelty, and severe aggressive behavior.

This very interesting issue of Pediatric Annals, devoted to the severe emotional problems in children, should be of great value to the practicing pediatrician in evaluating the severity of a child's emotional problems. It is under the Guest Editorship of Dr. Christopher H. Hodgman, Associate Professor of Psychiatry and Pediatrics, and Director of the Division of Child and Adolescent Psychiatry of the University of Rochester School of Medicine.

Dr. Hodgman opens the symposium with a discussion of "Common Psychiatric Problems and the Pediatrician." He notes the primary responsibility of the pediatrician is dealing with the behavioral problems of children. He discusses diagnostic methods of psychopathology and recognizes the need for mental health professionals in certain cases, but notes that in many instances "well motivated pediatricians can do as good as job with much less patient resistance."

The first contribution deals with "Childhood Aggressive Behavior" and has been written by Dr. Norman E. Alessi, Director of the Diagnostic and Research Unit of the Child and Adolescent Psychiatric Hospital, University of Michigan Hospitals; and by Dr. John Wittekindt, Attending Physician at the same institution.

Aggressive behavior is observed by all pediatricians at some time in many of their patients during the years of development. This is especially prevalent in younger children and in most cases lessens greatly as they grow into adolescence. However, as the authors describe, there are certain children who continue to maintain attitudes of hostility, quarreling, and combatí veness. The various theories of etiology are described, including certain biological theories. An evaluation of the aggressive behavior of the individual child is then described, followed by a discussion of the various strategies for therapy.

The following article discusses the serious problem of dealing with depression in children and adolescents. The article on "Pediatric Management of Depression" is contributed by Dr. Elizabeth B. Weller, Professor of…

For those of use who have chosen to be practicing pediatricians there is no profession more thrilling and rewarding. Watching and aiding humans develop physically and mentally from infancy to adulthood is a special privilege given to no other branch of medicine.

The pediatrician is of a special breed - a "gentler and kinder" breed. Pediatricians do not seek financial gains: many surveys, the most recent being in 1988, report their income as the lowest of the medical specialties. Rather, their reward is watching children develop and realizing that they are, in part, responsible.

However, as we all know, there are medical and behavioral problems that arise as children grow. The well trained pediatrician is ably equipped to handle almost all of the medical problems with the wide arsenal of antibiotics and modern diagnostic and therapeutic methods available. The behavioral problems that occasionally arise often prove much more difficult to treat and resolve.

It is obvious that the empathetic relationship of a child and pediatrician makes the latter the ideal person to deal with these problems, but several questions come to mind: Is the pediatrician capable of dealing with many of the conditions that occur? And has the pediatrician adequate time to devote to solving the problem?

Certainly the well trained pediatrician is capable of advising and dealing with the great majority of behavioral problems. Among these are sibling rivalry, peer problems, separation anxiety, hyperactivity, and certain learning problems including inattention at school. But the pediatrician must allow sufficient time to devote to the child's situation, which often includes sessions with parents, siblings, and even teachers. Other problems may be more complex and require the care of a skilled psychiatrist or psychologist. These conditions include suicidal attempts, kleptomania, chronic anxiety, cruelty, and severe aggressive behavior.

This very interesting issue of Pediatric Annals, devoted to the severe emotional problems in children, should be of great value to the practicing pediatrician in evaluating the severity of a child's emotional problems. It is under the Guest Editorship of Dr. Christopher H. Hodgman, Associate Professor of Psychiatry and Pediatrics, and Director of the Division of Child and Adolescent Psychiatry of the University of Rochester School of Medicine.

Dr. Hodgman opens the symposium with a discussion of "Common Psychiatric Problems and the Pediatrician." He notes the primary responsibility of the pediatrician is dealing with the behavioral problems of children. He discusses diagnostic methods of psychopathology and recognizes the need for mental health professionals in certain cases, but notes that in many instances "well motivated pediatricians can do as good as job with much less patient resistance."

The first contribution deals with "Childhood Aggressive Behavior" and has been written by Dr. Norman E. Alessi, Director of the Diagnostic and Research Unit of the Child and Adolescent Psychiatric Hospital, University of Michigan Hospitals; and by Dr. John Wittekindt, Attending Physician at the same institution.

Aggressive behavior is observed by all pediatricians at some time in many of their patients during the years of development. This is especially prevalent in younger children and in most cases lessens greatly as they grow into adolescence. However, as the authors describe, there are certain children who continue to maintain attitudes of hostility, quarreling, and combatí veness. The various theories of etiology are described, including certain biological theories. An evaluation of the aggressive behavior of the individual child is then described, followed by a discussion of the various strategies for therapy.

The following article discusses the serious problem of dealing with depression in children and adolescents. The article on "Pediatric Management of Depression" is contributed by Dr. Elizabeth B. Weller, Professor of Psychiatry and Pediatrics, and Director of the Division of Child and Adolescent Psychiatry; and by Dr. Ronald A. Weller, Professor of Psychiatry and Director of Education and Training, Department of Psychiatry. Both are from the Ohio State University, Columbus.

Most of us realize that many children experience minor periods of depression, but we also realize that occasionally major depressive disorders occur. These may prove serious so prompt diagnosis and treatment are urgent. The authors of this important article start by defining the symptoms that could lead to the diagnosis of a serious disorder. But how should we interview these depressed children? For optimal results, should one interview parents, the child, or a combined family group? These questions are posed and answered. It is noted that the differential diagnosis is most important because certain physical conditions can cause or mimic psychiatric symptoms.

This article clearly presents the various methods of treatment, especially in cases of severe depression and when pharmacotherapy is indicated. Modern treatment of major depression is presented as a combination of individual psychotherapy, parent education, and family therapy as well as pharmacotherapy.

The next article discusses the "Pediatric Management of Anxiety Disorders," and is authored by Dr. Richard E. Mattison, Associate Professor of Psychiatry, Pennsylvania State University College of Medicine, Hershey.

Anxiety disorders are not infrequent in the development of children. Pediatricians can usually treat separation anxiety without too much difficulty. Dr. Mattison not only deals with this problem but also discusses other anxieties such as unrealistic concern about such situations as future events, the constant need for reassurance, and a feeling of tension or inability to relax. Other anxieties discussed are simple phobias, where anxieties are provoked by fear of a certain specific object or situation, and obsessive-compulsive disorders. Therapy for these anxieties is carefully covered, including pharmacotherapy and behavioral-cognitive therapy. The latter approach is well described.

The fourth contribution discusses an interesting subject: "Risk Taking Behaviors in the Adolescent Patient." It has been written by Dr. Charles E. Irwin, Associate Professor of Pediatrics and Director of the Division of Adolescent Medicine, Department of Pediatrics, University of California School of Medicine, San Francisco.

Risk taking by adolescents is a well recognized phenomenon. During World War II, late adolescents were sought as aviators because the adolescent has a feeling of invulnerability and lacks imagination for possible danger or even death. Dr. Irwin notes that at present the three prime areas of risk taking among adolescents are sexual activity, substance use, and recreational vehicle use. Adolescents, in their approach to life, cannot conceive of contracting lung cancer from smoking, nor can they realize the dangers of drinking alcohol before driving a car. Risk figures are presented in this article. An interesting section presents risk taking behavior as part of normal adolescent development as a stage in emancipation from the family when the adolescent is seeking adult decisions without having acquired requisite cognitive capabilities.

The final article is most important and valuable. It discusses the "Pediatric Management of Suicide Behavior" and is authored by Dr. Paul D. Trautman, Assistant Professor of Clinical Psychiatry, and by Dr. David Shaffer, Professor of Psychiatry and Pediatrics, and Irving Phillips Professor of Child Psychiatry, Columbia University College of Physicians and Surgeons, New York.

Drs. Trautman and Shaffer introduce their article by emphasizing the frequency of intentional suicide attempts (more than 300,000 per year among children and adolescents). The various methods of attempting suicide are described as well as the relative attempts of the two sexes. The importance of an adequate evaluation of every child attempting suicide is emphasized. The participation of the parents in the interview is noted as essential. This is followed by the important goals of the emergency evaluation such as the need for hospitalization, the efforts to understand the reasons for thought of suicide, whether they be family problems, school failure, depression, conduct disorder, or substance abuse.

The authors note that it is essential to formulate a treatment plan aiming specifically at the various problems that have led to the suicide attempt. The whole family must be involved in this plan. This article should be read by all pediatricians, for suicide attempts are not infrequent among children and adolescents. These are, without question, the most serious emotional problems confronted by pediatricians. Dr. Trautman and Dr. Shaffer are recognized authorities in this important area and their knowledge and advice is most valuable.

10.3928/0090-4481-19890201-04

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