Pediatric Annals

Caring for the Pediatrician

T Berry Brazelton, MD

Abstract

As this volume outlines so well, stresses on parents and their providers are increasing in this generation of children. Such parenting stresses include: 1) both parents of small children who must work outside the home; 2) dubious daycare; 3) loneliness of being away from their own parents and familiar supports; 4) our country's values - war, aggression, money, power, leading to organizations that are not likely to be family friendly; 5) competition for our children's hearts and minds from television, internet, and the media; and 6) treating minorities and other groups as negatives.

Pediatrie preventive care needs to address two parental questions: a) how am I doing as a parent? and b) how is my child's development? As pediatricians, we need to share ideas about the child's development at each visit for the understanding parents deserve to prevent mental health issues. Stress for children may be likened to piling up blocks - one too many or one large block will make the tower topple. Stresses on pediatricians parallel these increasing stresses on their patients. A caring pediatrician will be likely to feel overwhelmed by all of these increased stresses on parents.

Where to begin? We have not been fully trained to be ready for these cries for help - for our training has been focused on disease and illnesses, not often the child's development or mental health. It seems impossible to set up a preventive health care visit to fit into the payment scheme of 10 minutes per well child visit, so it is easier to keep the issues in the area of physical concerns - immunization, height and weight issues, and illness.

PERSONAL STRESSES

The stresses on pediatricians are increasing as the ifragmented health insurance industry shifts financial risks and administrative burdens to physicians. The kind of stresses that this places on pediatricians are the following:

* Less time per patient visit - not enough time to observe the child, to discuss the issues and concerns that parents need to share with a supportive physician. The most important loss for us, as providers, is in the time to make and enjoy relationships. Both families and physicians pay a price for this.

* No safety net or financial leeway for needy patients.

Additional Stressors for the pediatrician include not enough training in child and family development for recognition of problem behaviors, language barriers, and ethnic belief systems that interfere with patients' communication, keeping up with new knowledge and technology at a time when parents can consult the internet and often know more than we do, and the sense that we have lost control of our professional lives.

The strategies to meet these challenges include:

* Using multidisciplinary teamwork within your office staff. The front desk and the waiting room can be a sounding board for parents. The team in the office can assess and record developmental issues and historical data of importance.

* Employing computer records that contain observations, which can be shared with patient and to family to produce "seamlessness" and the feeling of having a continuous meaningful relationship with each other ("The last time you were worried about. . .").

* Making appointments for parents with children the same age to wait together. The parents can learn a great deal from each other while they wait. These interventions may help a physician be aware of and to help stressed parents share the layers of stress we are all faced with and that threaten the child's development.

Pediatricians are finding that without deliberate efforts to reduce the stress that affects them, their own health, their patient relations, and bedside…

As this volume outlines so well, stresses on parents and their providers are increasing in this generation of children. Such parenting stresses include: 1) both parents of small children who must work outside the home; 2) dubious daycare; 3) loneliness of being away from their own parents and familiar supports; 4) our country's values - war, aggression, money, power, leading to organizations that are not likely to be family friendly; 5) competition for our children's hearts and minds from television, internet, and the media; and 6) treating minorities and other groups as negatives.

Pediatrie preventive care needs to address two parental questions: a) how am I doing as a parent? and b) how is my child's development? As pediatricians, we need to share ideas about the child's development at each visit for the understanding parents deserve to prevent mental health issues. Stress for children may be likened to piling up blocks - one too many or one large block will make the tower topple. Stresses on pediatricians parallel these increasing stresses on their patients. A caring pediatrician will be likely to feel overwhelmed by all of these increased stresses on parents.

Where to begin? We have not been fully trained to be ready for these cries for help - for our training has been focused on disease and illnesses, not often the child's development or mental health. It seems impossible to set up a preventive health care visit to fit into the payment scheme of 10 minutes per well child visit, so it is easier to keep the issues in the area of physical concerns - immunization, height and weight issues, and illness.

PERSONAL STRESSES

The stresses on pediatricians are increasing as the ifragmented health insurance industry shifts financial risks and administrative burdens to physicians. The kind of stresses that this places on pediatricians are the following:

* Less time per patient visit - not enough time to observe the child, to discuss the issues and concerns that parents need to share with a supportive physician. The most important loss for us, as providers, is in the time to make and enjoy relationships. Both families and physicians pay a price for this.

* No safety net or financial leeway for needy patients.

Additional Stressors for the pediatrician include not enough training in child and family development for recognition of problem behaviors, language barriers, and ethnic belief systems that interfere with patients' communication, keeping up with new knowledge and technology at a time when parents can consult the internet and often know more than we do, and the sense that we have lost control of our professional lives.

The strategies to meet these challenges include:

* Using multidisciplinary teamwork within your office staff. The front desk and the waiting room can be a sounding board for parents. The team in the office can assess and record developmental issues and historical data of importance.

* Employing computer records that contain observations, which can be shared with patient and to family to produce "seamlessness" and the feeling of having a continuous meaningful relationship with each other ("The last time you were worried about. . .").

* Making appointments for parents with children the same age to wait together. The parents can learn a great deal from each other while they wait. These interventions may help a physician be aware of and to help stressed parents share the layers of stress we are all faced with and that threaten the child's development.

Pediatricians are finding that without deliberate efforts to reduce the stress that affects them, their own health, their patient relations, and bedside manners will suffer. Physicians may be able to manage their stress with a fundamental sense of optimism, with an effort to focus on the joys of the work and maintain a sense of humor. (See The American Academy of Pediatrics' Joys of Pediatrics.) We must struggle to cordon off time for family, friendships, exercise, hobbies, and other stress reducers. The competitive environment of most medical institutions is aggravated by the pressures on time of managed care, and it deprives many healthcare providers of the opportunities to turn to each other for even the briefest of smiles or laughs. We need to take care of ourselves.

I have found that two maneuvers helped me to organize my practice to foster important relationships with my patients - which is both important to me and to them:

* Call hour every morning when patients could call me to keep in touch, or I could call them if I were worried. This helped me anticipate and organize my day. In addition, it gave the patient's parents a feeling that I was always available to them.

* "Out-the-door" questions that needed addressing but couldn't be addressed in the time allotted. I would say, "I'm so glad you brought that up and are ready . to share it with me. I have a special time at the end of the afternoon when parents can come in to share your concerns with me. You don't need to bring her because I know her well enough. We'll have plenty of time to spend together when there's not a full waiting room." Then we could discuss their issue at length. Often it would save a psychiatric referral.

TOUCHPOINTS MODEL

Fifty years of practice with intensely gratifying relationships with my patients led me to conceive of a preventive model that I have called "Touchpoints." I found that rewarding relationships with patients was the surest antidote to stress and burnout.

'Touchpoints" is named for the opportunity to touch into the family system at important times of change in the child's development. Touchpoints are the times during the first years of life in which children's spurts in development result in disruption within the family system. When parents understand the disorganization of this period as a natural precursor to the rapid and exciting development in awareness that follows, they will not need to feel that it represents failure. Parents find it reassuring that bursts and regressions in development are to be expected. In the face of their child's behavioral regressions, they wonder what they are doing wrong. Sharing these Touchpoints helps parents feel more confident, and the child's negotiation of these Touchpoints can be used as a source of encouragement for the family system.

Parents need to be treated as the experts on their child's development. That means, we listen and share, but don't tell them how to parent. Too often, we are driven by our own agenda, and we create a top down, telling parents how to be parents. Adult learning systems have demonstrated that parents will learn very little from such an approach, but they will learn a great deal from a shared supportive opportunity with a caring professional. In order to meet this requirement, we have found that the first step toward a working alliance is to change from a problem-oriented, deficit model to initial observations of parental behavior, which we can observe and share ("Look how comforting you are as you hold her as you come into this strange place"). You are likely to see the parent relax, let down her defenses, and be more open to a relationship with a provider who observes her positive attempts to parent. This will be the first step of a paradigm shift from a deficit model to a positive model.

Then, an observation of the baby or child's behavior becomes a magical way to value the parent. Using temperament, age-oriented observations and remarking on how the baby is developing, one joins the parent in seeing the same child they are. Less alone, and more confident in their parenting, parents' stress has been notched down by this quick and simple preventive intervention by the pediatrician. When we have helped parents feel less alone and more effective, it creates more rewarding relationships with our patients. These relationships will help prevent stress for us.

Copyright 2007 by T. Berry Brazefton, MD. All rights reserved.

RECOMMENDED READING

American Academy of Pediatrics. The Joys of Pediatrics. Elk Grove Village: IL, American Academy of Pediatrics; 2005.

Bowman P, Grady M, Kendrick M, et al. From the Heart: Stories by Mothers of Children with Special Needs. Portland, ME: University of Southern Maine; 1994.

Brazelton TB, Sparrow J. Touchpoints: Emotional and Behavioral Development, 2nd ed. Cambridge, MA: Perseus Publishing Company; 2005.

Brazelton T B. Soapbox: How to Help Parents of Young Children: The Touchpoints Model. Clinical Child Psychology and Psychiatry, vol. 3. London: Sage Publications; 1998: 481-483. Brazelton TB, Sparrow JD. Touchpoints: 3-6. Cambridge, MA: Perseus Publishing Company; 2001.

Bricker D, Squires J. Ages and Stages Social Emotional Scales. Baltimore, MD: Paul H. Brookes Publishing; 1994.

Piaget J. The Origins of Intelligence in the Child. London: Routeledge & Kegan Paul; New York: International Universities Press; 1936; English Trans. 1953.

Thomas A, Chess S, Brick HG. Temperament and Behavior Disorders in Children. New York, NY: University Press; 1968.

10.3928/0090-4481-20070401-14

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