I have learned many things during my afternoon continuity clinics. Most children come in with no issues or problems on their list (it always says well child check). Yet, there have been countless times when I have put on my white coat, entered the room, introduced myself, asked if there were any issues that they wished to discuss, and quickly found myself wading through situations that I never could have envisioned before entering residency. Many times these questions are physical in nature, "What's that thing on her Hp?," or "He's been constipated for seven years." More often than not, however, these issues are psychosocial, "Why is he ifc biting his brother's stomach?." (If you were wondering, these inquiries are not authorial license, but represent real comments made in the context of clinic visits.)
As I first began to encounter these issues, I was tempted to try to extend the visit as long as it took to get these problems out into the open and at least on the road to resolution. But as my schedule became busier and more patients came to each clinic, I found myself up against a wall. I simply could not have explored all of these issues in the time available and I began to see for myself what is and what will continue to be a problem for office pediatricians. In the 10 to 15 minutes that pediatricians have to see each patient, these issues can barely be touched on, let alone covered in depth. This is the reason child and adolescent psychiatry has a critical role to play in the future of general pediatrics.
In an ideal world, patients would visit one individual who could deal with all problems that they could possibly present. To be able to have the knowledge, time, and resources to treat fully everything from diabetes and leukemia to depression and obsessive-compulsive disorder would be a tremendous gift. But in reality it is unrealistic and often the best that we can do for our patients is to know when a problem is beyond our capabilities. This seems easier, however, when the issue is physical.
With mental health concerns, the situation is often many times more complex. Not only must we evaluate the patient, but also aspects of his or her social environment. The parents' response to the child's issues frequently plays a greater role in diagnosis and treatment than with many other pediatric problems. Decisions require sorting through information from several sources and the same thought process applies to nearly every diagnosis. In addition to active investigation, we must also know how to address mental health problems.
One of the first things that I learned in my clinical training was to think about and look for everything that made sense in a given situation. If I wasn't considering all of the possibilities, I wouldn't find a solution, no matter the quality of my medical history and physical examination. This rule of evaluation applies to child mental health care as well. Even in the short time pediatricians have with each child in die office setting, we can still entertain the possibility that our patient has a mental health issue pertinent to the presenting complaint. This vigilance alone can make a difference. In some cases the problem is obvious, as in the previously noted case in which a child's mother complained to me diat her son was impossible to discipline and that he routinely attempted to injure his brother by biting him. Of course, in most instances the interventions are more subtle.
The events of 9/1 1 and the subsequent fallout from that tragedy brought media attention to the emotional adjustment of children. This reinforced the role of the pediatrician in the primary identification of psychiatric distress.
It also becomes vital to have active relationships with practicing child and adolescent psychiatrists, psychologists, and social workers in the community. The reason for this is simple: all of our observations are worth very little if we have nothing to offer in the way of treatment. We can either learn how to handle a variety of basic psychiatric disorders or identify referral sources that can specifically diagnose and treat these conditions. With heightened awareness of psychiatric conditions comes a responsibility to know what to do next and to maintain active relationships with mental health professionals.
Do these issues apply to subspecialists? Should physicians in fields such as nephrology and gastroenterology consider mental health issues as well? In fact, they do. In my own future subspecialty, pediatric critical care, mental health issues apply in numerous ways that I had never before imagined. I remember vividly a meeting with a young family originally from eastern Europe. In the hours before our meeting, their 18-month-old son developed sepsis and was in danger of losing his legs. As I attempted to explain die situation to this family, I could see the psychological crises that they faced in the questions they asked, "Could this have been caught sooner?," "How sure are you that he'll lose his legs?," "What are his chances?" The child survived having lost his legs, and I am sure that his family was changed irrevocably by this event.
As specialists, we should recognize the signs of deteriorating mental health, both in the children and in their families. Patterns develop among caregivers and patients who seek treatment from particular specialties. For example, the psychosocial stressors among children with spina bifida are different from those with renal failure or diabetes. Our expertise as specialists includes becoming familiar with these circumstances and identifying difficult situations that go beyond simple adjustment problems. We also need to be part of a network of physicians that includes mental health specialists. The relationships among pediatricians, patients, and caregivers are critically important for easing the stress of chronic physical illness.
Physicians rarely recognize the powerful influence they have over the life of a family with a chronically ill child. Parents believe that they need to maintain a positive relationship with the pediatrician in order to facilitate the best possible care. Pediatricians who ignore, rather tiian nurture, these relationships can add to the psychological distress of both the patient and family.
I have learned during my residency diat mental health professionals are not always readily available, particularly for routine issues like sleep problems, coping with divorce, enuresis, and oppositional behavior. In addition, we live in stressful times with frequent discussions of violence, terrorism, and war. The primary care physician is often the initial and perhaps only source of support and intervention. We should maintain a basic level of competence on these issues beginning during residency training and not be afraid to address them in our practice. We should also maintain active communication with mental health professionals to assist us in this process and to be available when we need their expertise. If we want our patients to be well, not just in body, but in mind, spirit, and family life, it is our responsibility as physicians and pediatricians to form relationships with those who can help us achieve that goal.