For more than 20 years, behavior, developmental, and psychosocial problems have been the "new morbidity" of pediatrie practice. While pediatricians have a long history of helping families deal with behavioral and psychosocial problems, identifying and treating these problems have been an ongoing challenge to the busy primary care physician. With new constraints from managed care organizations restricting referrals and time, managing children with behavioral and psychosocial problems is a greater challenge now than ever before.
Children's psychosocial problems can be hard to treat even in the context of well-functioning families. Pediatricians are increasingly taking on the job of helping children whose parents themselves have major emotional and behavioral problems. Children living in homes where there is domestic violence, substance abuse, child abuse, or serious emotional illness require special attention to treat, or hopefully prevent, emotional and behavioral problems of their own. The number of children potentially in need of such attention is daunting. Ten to 20% of adults have an episode of major depression at least once in their lifetimes; as many as 10% to 15% of new mothers have a serious episode of depression in the first year of their children's lives,1 and 50% of mothers of children younger than 5 years rate themselves as significantly depressed. An estimated 2 million children are reported to be abused per year, most by their primary caregivers.2 While many of these reports are unsubstantiated, the actual number of abused children is estimated to be about 1.4 million or 3% of the population younger than 18 years. There is also a large overlap between child abuse and domestic violence. An estimated 40% to 70% of children accompanying their mothers to shelters for battered women have themselves been abused.3 Among fatal cases of child abuse, estimates of the proportion of mothers who experienced domestic violence range from 40% to 60%.4
Though troubled homes vary in many ways, they tend to share several elements that put children at risk of serious social and emotional problems.5 Parents in these homes tend to focus less attention on children, and what attention they do give is often negative in tone. Parents are relatively unavailable to help their children with some of the major developmental tasks of childhood, such as learning how to solve social problems, to achieve a degree of self-awareness and awareness of the needs of others, and to regulate one's own emotions and behavior. Children are left more on their own emotionally, and often come - sometimes with the explicit help of their parents - to feel responsible for their parents' problems and well-being. The results are rates of depression, school failure, substance use, and other risky behaviors several times higher than what would be expected if the children came from healthier homes. Some children will immediately suffer from psychological or behavioral problems (such as post-traumatic stress disorder), whereas others will appear initially asymptomatic. There may be outcomes, so-called "sleeper" effects, which manifest themselves at a later point in the child's life.
Given the wide variation of outcomes of abused children and the high risk for psychosocial problems, it could be argued that mental health professionals should be given the responsibility of managing these children. However, there are many more children affected or at risk than child mental health professionals trained to treat them; and, more often than not, referral to these professionals may be limited by the managed care organization or the family's willingness to be referred. Case managers may also argue that it is not clear if preventive intervention by mental health professionals makes a difference for asymptomatic children, though studies have shown positive effects for children of depressed parents.6 For the above reasons, any pediatrician may find himself or herself as the professional responsible for monitoring and treating an abused child or the child of an emotionally ill parent.
The goal of this article is to demonstrate that the primary care physician actually is in a good position to identify and manage problems that may appear in children from troubled households. By synthesizing strategies and techniques that pediatricians already use to identify and treat behavior problems, and combining them with specific knowledge of which problems are common and some specific interventions, the primary care physician can successfully help many of these children and their families.
A few general principles can serve as a point of departure for thinking about evaluation, monitoring, and treatment:
* Children in troubled families frequently don't share what would be an outside observer's perspective on what is happening in their homes. Children readily assume responsibility for their parents' problems and are often fearful of talking about them because they think they will be blamed or separated from their families.
* The parenting problems in troubled homes come in many varieties but often fall into a few major categories: the parents' emotional unavailability, leading to a lack of support and social and emotional teaching; the parents' lack of monitoring, increasing children's sense of insecurity and increasing chances for exposure to dangerous adults, peers, and behaviors; and negative and irritable attention directed at children, often associated with ineffective and yet harsh disciplinary measures.
* Children's temperaments and environments often combine to either ameliorate or exacerbate the home environment. Children who are naturally more adaptive are less bothered by parental problems, are less likely to blame themselves, and are more likely to find supportive relationships outside the home. Children who are naturally shyer or more irritable are more likely to personalize parental problems or respond to them in ways that make the situation worse.
* Child and parent problems fluctuate over time, often in conjunction with major steps in the child's development or changing demands on the family's resources. Families can be helped to anticipate these fluctuations and catch them early, before there are serious consequences.
* Impaired parents are often ineffective or reluctant advocates for themselves and for their children. They often need help identifying needs and getting an appropriate response from schools, agencies, and the health care system.
HELPING CHILDREN AND PARENTS GAIN PERSPECTIVE
A truism in health care of all kinds is that it is hard to help with problems when they are secrets or the source of shame. Studies find consistently that children and adults decide not to disclose their problems to physicians because they think the physician is uninterested or fear the response to the disclosure.7 Studies also find consistently that patients want to be asked about their problems and respond to a combination of direct, but tactful and empathetic, questions.8 Pediatricians should have some strategy for detecting behavior problems in all children. Approaches vary from asking the parents open-ended questions ("What's [child's name] doing these days?" or "Do you have any concerns about [child's name]'s behavior?"), to more specific "trigger" questions,9 to using preprinted checklists of behavior symptoms such as the Pediatrie Symptom Checklist or the Child Behavior Checklist. Similar questions can be directed toward finding out about the emotional health of adults in the home.10
As the situation becomes clearer, the conversation can be tactfully turned toward how well the family works together and who is available to participate in finding solutions. As an example, concerns about child behavior and maternal mood often appear in a different light when it is suddenly understood that they both take place in the setting of domestic violence.
PARENTING PROBLEMS: TREATMENT AND COMPENSATORY STEPS
Pediatricians have an opportunity not shared by teachers, coaches, or even day care providers to observe the interactions of parents and children. Although we know that child, family, and adult behaviors vary enormously with setting, we can be reasonably certain that problem interactions in our offices are likely to occur elsewhere, even if a smooth office visit says less about how things might be at home.11 Parents vary in their receptivity to offers of advice about how to interact with their children. Like most of us, they resent being cast in the role of villain and listen best when advice comes in response to their own stated needs or questions. The long-term relationship of pediatrie care is ideal for establishing a therapeutic alliance with parents and finding a way to empathize with their concerns, all the while keeping the child's interests in mind as well. A frequently effective strategy is to acknowledge the parent's stresses and burdens, which legitimizes parental disclosure of low mood and distress. Once these burdens can be seen as proximal causes of the parenting problems, rather than the parent being an inherently bad or misguided person, changes in strategy are easier to discuss. Parents may also need an opportunity to speak out of the earshot of their children. Many, if they are in some form of treatment elsewhere, will welcome a request to collaborate with their primary care physician or therapist. Often, even a brief conversation with the parent's provider will help provide perspective. At best, it can help the pediatrician maintain a focus on the child while allowing the parent's provider to better focus treatment on family- and parent -related issues.
Sometimes, however, parents are reluctant or unable to modify their behavior in the short term, or we worry that the likelihood of a relapse is high. In those cases, we can try to create opportunities to compensate.6'12 The main goal is to provide children with opportunities for successful interactions with peers and other adults. These opportunities start in the medical office, modeling respectful interactions for parent and child and making sure that the child's input is solicited and acknowledged. Encouraging or making suggestions for school, after school, work activities, or planned time with supportive adults from the family, the religious community, or the neighborhood will often be helpful in itself. If these suggestions don't work or are rejected, the subsequent discussion may reveal much about the logistical, attitudinal, or relational problems that stand in the way of children's healthy development. In addition, skills groups held at a school or mental health center may be able to strengthen some undeveloped areas of social development.
After-school and sports programs have the advantage of improving monitoring when parents are incapable; the greater degree of structured time and exposure to positive adult role models can help keep children from identifying with youngsters and adults who are already engaged in maladaptive activities. Older children can also be educated about their parents' difficulties. Without putting children in a position of caring for their parents, we can help them understand that they are not to blame for their parents' difficulties not can they contiol changes in their parents' moods or behavior. We can brainstorm with children and parents about how both can try to avoid conflict at times when parental functioning takes a dip.
Pediatricians can also often play a key role in helping schools avoid the re-abuse of children from troubled homes by explaining - within the limits of confidentiality and parental consent - what issues may be motivating a child's interactional style and specifically how the school can make a compensatory response. Unfortunately, children from troubled homes are often mistrustful of adults, preoccupied with their own concerns, and capable of transferring their anger and disappointment with their parents to "safer" targets, such as teachers and peers. Unless educators are aware of this possible reason for the child's behavior, their responses may be as punitive and demeaning as those in the child's home.
In extreme cases, a parent's ability to care for his or her child may cross the clinician's boundary for making a legally required report of suspected abuse or neglect. This difficult step is often made easier if clinicians follow a rough protocol. First, when even vague concerns about abuse or neglect arise, it is useful to reflect a moment and develop some explicit criteria that would signal the need to report in this particular case. For example, one is worried about a pattern of possibly neglectful parenting. The clinician decides that, so far, nothing has happened at a level of severity that would require a report, but that a report would be triggered if it was heard that the child had actually been left unattended in a risky environment. Ideally, the clinician has access to a formal child maltreatment team or to thoughtful colleagues, who can help think about such criteria and help decide when they have been met. Second, reporting is best never used as a threat to get a parent to achieve desired behavior. The threatened act then becomes a punishment rather than a help. It is fair and important to let parents know about the clinician's increasing level of concern, and in many settings it is appropriate, at the outset of treatment, to discuss the parent's experiences with child protective services and his or her concerns about reporting. However, when the criteria for a report have been met, it is usually best for the clinician to simply explain what now needs to be done. Third, except in relatively rare cases, the actual mechanics of reporting should be discussed in advance with the parents to maximize the chance of a good therapeutic outcome. The discussion can include the reasons for the report, hoped for responses from the agency, and the clinician's ongoing, supportive involvement with the family. Although many clinicians offer parents the opportunity to report themselves, reports from professionals are often taken more seriously (also, from a technical point of view, having a parent report does not fulfill the clinician's legal obligation to make a report).
MONITORING ALONG THE COURSE OF CHILD DEVELOPMENT
Children from troubled homes don't universally have problems - many adapt well, at least at the level of being able to carry out critical tasks such as attending school and developing good relationships outside the home. As is the pattern with many emotional problems, however, difficulties can arise even after long periods where all seems well. One theory explaining such "sleeper" effects is that early abuse or emotionally absent parenting leads to alterations in some of the critical developmental tasks faced during childhood (Table 1). These alterations can be compensated by personal or environmental factors at one stage of development but then surface again as problems at another stage, often precipitated by a transition or stress. For example, children may do relatively well in a structured, somewhat sheltered elementary school, but on reaching a large middle school may lack the affective stability or sense of self that is necessary to steer clear of problems and find a new, comfortable peer group. Or, a parent's or friend's illness may reopen attachment issues that had temporarily gone unchallenged. Pediatricians who follow families over time are uniquely placed to either anticipate these challenges or to help families quickly interpret what may be happening so that treatment can be started or shifted as necessary.
HELPING PARENTS BE BETTER ADVOCATES FOR THEMSELVES AND THEIR CHILDREN
Pediatricians usually don't see themselves as having a primary therapeutic relationship with their patients' parents, but, in fact, many pediatrie interventions - from ensuring medication compliance to instituting behavioral plans - work by virtue of the fact that they address parental concerns and emotional needs. Parents with emotional problems or who are victims of violence often are willing to seek help for their children but refuse to seek help for themselves. One reason for this may be that children are extensions of the parental self, and parents are inherently more positive toward people who genuinely care for their children. Troubled parents often antagonize other potential sources of help by being overly demanding or passive. They may avoid sources of help that require tangling with complicated social and school systems because they (often with good reason) fear losing control of the situation or being treated in a demeaning manner. Pediatricians have an opportunity to help parents gain the confidence and skills necessary to find more help by guiding and praising their initial small efforts and by refraining their shortcomings as opportunities for building new skills rather than subjects for blame.
Pediatricians may also not require many new skills in order to help troubled parents. Analyses of the work of experienced psychotherapists find that the interpersonal dimensions of treatment - the ability to establish trust, to generate a feeling of respect, and to work together - are more predictive of successful treatment for depression than mode of therapy or even, in some cases, medication use." Pediatricians don't need to provide a complete treatment, but they can create an atmosphere in which parents feel capable of taking on next needed steps.
Major Developmental Tasks and Resulting Problems in Children of Troubled Parents
BUILDING CARE FOR TROUBLED FAMILIES INTO YOUR PRACTICE
Pediatricians can start caring for troubled families by doing what they do best: helping to optimize a child's physical health and working hard to find any developmental or learning problems that need to be addressed with specific therapies or educational plans. Pediatricians are also experts at monitoring for physical signs of abuse or neglect: injuries, sexually transmitted diseases, shifting patterns of growth, or changes in bowel or bladder habits. As noted above, it is only a small jump from here to being able to ask about behavioral or emotional concerns that could be related to violence.
Learning some techniques developed by family therapists can also provide an important incremental skill for pediatricians. Learning to observe patterns of communication, eliciting a genogram, managing a discussion with two parents and a child, and other skills can both save time and help move treatment along to new levels.14 Sometimes, the single best intervention is identifying someone in the family, perhaps an uncle or grandparent, who has been supportive but on the periphery and can now take a temporarily more active role - coming to visits and helping the child and parent gain insight and build resources.
Working with troubled families is more comfortable and satisfying if one doesn't feel alone. Few, if any, such families can be helped by a single professional. Even if it were possible, the potential ethical dilemmas, ambiguous situations, and slow pace of progress make it imperative to work, formally or informally, as part of a team. Teams help especially in situations where the clinician feels torn between the needs of parent and child, as, for example, when there are concerns about both child abuse and domestic violence. Teams can also give much needed perspective when, during a long relationship between the family and clinician, the clinician, too, comes to see no way out of the family's problems. Unfortunately, pediatricians must often create the team as they go along or help parents start to draw together a team. The process is infinitely easier if the pediatrician has a directory of local services available for rapid reference. A preliminary list of numbers, names, and addresses to collect is given in Table 2.
Working with some troubled families may require a restructuring of office time. Diagnosis of an ear infection and writing a prescription for an antibiotic is a 10-minute venture, whereas diagnosing aggressive behavior in a 6-year-old and counseling the mother on ways to prevent him from beating up his 3-year-old sister may ultimately take hours. The key is to set time aside and make appointments to discuss particular problems. If a problem has been going on for weeks to months and it is 5:00 on Friday afternoon when a mother says, "by the way ...," the problem will likely still be there if time is set aside for a half-hour or hour visit in the next few weeks. It is important, though, to make sure that there hasn't been some acute crisis that prompts sudden disclosure of an otherwise chronic problem. As noted above, ineffective and too-late communications are hallmarks of troubled families. Most of the time, the problem can wait, but occasionally the question, "do you have any worries that led you to bring the issue up now?" will elicit a reply such as, "his father will be back from a trip this weekend, and the last time Johnny wet the bed his father punched him in the stomach and gave him a black eye."
Telephone Numbers to Have at Your Fingertips Before Working with Troubled Families
Changing behaviors is difficult - it requires patience, practice, and repetition. It is important for each pediatrician to know how he or she will be reimbursed for psychosocial services rendered. As contracts change, it is also important to participate in physician groups that can advocate for humane policies. Depending on the type of practice and the financial arrangements of the pediatrician's office, dealing with behavior problems may also not be very lucrative. Often, pediatricians will not be reimbursed for the amount of time spent with a patient unless a diagnosis can be made. For example, if a child can be given a recognized diagnosis (for example, oppositional defiant disorder), then the pediatrician may be reimbursed for a visit or a referral may be considered justified. But if the child is just aggressive, there is no code for aggressive behavior, and no payment or a lesser payment would be received (however, some insurers will not pay for a visit with particular diagnostic categories - including oppositional defiant disorder - which they feel are not treatable). The recently issued Classification of Child and Adolescent Mental Diagnoses in Primary Care, a joint project of the AAP, APA, and other organizations, offers new opportunities to make discrete diagnoses of behavioral concerns as well as environmental Stressors such as parental emotional problems. Work is currently under way to translate these diagnoses into billing codes that could become reimbursable as they are shown to be being used widely in practice.
Finally, many pediatricians are afraid of dealing with psychosocial problems. Troubled parents are often hostile rather than grateful for our efforts, and, at best, rate of change for amount of effort is often low. Other sources of reluctance stem partially from the time factor ("if I don't bring it up, we don't have to talk about it") and also from lack of training. Only recently has the Residency Review Commission instituted guidelines requiring at least 1 month of training on behavior issues in postgraduate pediatrie programs. To overcome these obstacles, the pediatrician must arrange support from colleagues and face the fear. In some areas, training is available through Collaborative Office Rounds (groups of general pediatricians, behavioral pediatricians, and child psychiatrists sponsored by the federal Maternal and Child Health Bureau) or more formal supervision through postgraduate fellowships.15 Even when they are not curative, the pediatrician's efforts and caring will gradually move the families toward an understanding of their difficulties and acceptance of help, which is likely to make subsequent referrals more successful.16
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10. Kempet KJ. Kelleher KJ. Family psychosocial screening: instruments and techniques. Ambulatory Child Health. 1996;1:325-339.
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Major Developmental Tasks and Resulting Problems in Children of Troubled Parents
Telephone Numbers to Have at Your Fingertips Before Working with Troubled Families