Pediatricians need to wonder when dealing with behavior problems

Last week, I again had the privilege of teaching pediatricians in training. These students were very bright, challenging and asked excellent questions. They all agreed about the limit of the pediatric model of “giving advice.” One resident, who had young children of her own, spoke of new mothers using blogs for emotional support. Many of these mothers speak less than kindly about their pediatricians, who they perceive as “not getting it” and telling them “what to do.”

We agreed that being given advice could be disempowering and that many parenting books, full of advice, actually make parents feel worse.

My seminar’s aim was to teach them about the application of contemporary ideas about child development into their practice of pediatrics. This research shows that when parents can think about the meaning of their child’s behavior, rather than respond just to the behavior itself, they facilitate their child’s healthy emotional development. I shared with them an example from my practice to show how they could support parents in this task.

3-year old Mary had prolonged tantrums at bedtime and was up several times a night. Her parents told me that they would hold the door shut while Mary screamed and threw herself at the door in increasing agitation. Finally after an hour or so of this, one parent would go in to lie down with Mary because she was so agitated, and then she would fall asleep.

My students found the story disturbing, as it was obvious to them that this experience would be frightening for Mary. But I asked them to resist the impulse to give advice about how to manage bedtime and instead asked them to wonder, why were her parents, bright loving people, doing this?

I showed them a slide from a recent lecture by leading researchers in developmental psychology, Peter Fonagy and Mary Target. The slide showed how when people are stressed, their ability to reflect on another person’s experience significantly decreased.

Rather than give these parents advice about how to manage this sleep problem, my task was to listen to their story, support them and even perhaps uncover the source of this stress. In doing so I might be able to help them think about what was happening from Mary’s perspective.

Because we had a full 50-minute visit, and they began to feel comfortable with me, they did eventually share what was going on. They spoke of a terrible upheaval in Dad’s family business and significant financial stress. They realized that Mary was likely responding to the huge amount of tension in the household. she was struggling to engage her increasingly emotionally distant parents. They understood that Mary was experiencing a kind of separation anxiety,and was looking for reassurance. Her anxiety came out most intensely at bedtime, which naturally precedes a long period of separation.

I gave these parents minimal advice about what to do. Instead, I helped them to understand a different way to be with Mary at bedtime. Within a few weeks her sleep problem resolved. My wondering about the meaning of their behavior led them to wonder about the meaning of Mary’s behavior.

One of the residents asked me “what do I say?” Residents are taught “what to do” and then tell their patients “what to do.” I hope that I conveyed to them that is not about what to say. Its about being present, open and emotionally available. Its about wondering. If they begin to wonder why parents behave the way they do with their children, they will be able to support parent’s efforts to wonder about the meaning of a child’s behavior.

I realize it’s a big leap. One resident in the group was doing a rotation in the neonatal intensive care unit . When treating a critically ill newborn, knowing “what to do” is appropriate. I am asking him to use his brain in a completely different way.

Practicing primary care can be a deeply rewarding experience if we use our relationship with families in the way I have described. But it is not easy. One must be able to switch from a “what to do” mode when dealing with a sick child, to a wondering mode when working with behavior problems, which can make up as much as 40% of primary care visits.

However, if we can do this, we are in an ideal position to promote the healthy emotional development of the next generation. When seen from this perspective, primary care clinicians should be the highest, not the lowest, both paid and valued providers in our health care system.

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.

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  • Kristie

    Children’s behavior problems are very often a reflection of challenges their family is facing. I applaud you as a physician taking the time to help address some of their systemic family challenges in a non judgemental way. One other thing to consider is expanding the system to include other means of support. More than likely these financial challenges will remain, and there is often upheaval in families. Do they have support systems in place? Parenting groups, family members, moms clubs, family therapists EAPs, and other resources can help strengthen family systems. They may not be able to use a physician visit to address a systemic family issue that could again present as behavior issues in their child.

  • Anonymous

    One of my high school friends is a pediatrician and the parent of two children. They are horrible, whiny, demanding brats with no concept of limits but an excellent understanding of the best methods to employ in order to manipulate their parents and pit them against one another. It’s becoming impossible to socialize with these friends, though our children are approximately the same ages. On more than one occasion, my friend the pediatrician has asked for advice from my husband and I re: naps, tantrums, time out, etc. (we aren’t pediatricians – we have graduate degrees in unrelated fields). My husband and I are not perfect parents, and our children certainly have their moments, but it’s miserable to spend time with our friends’ kids and I don’t think they’re all that content, either.

    How can parents expect pediatricians to provide support, let alone advice, when pediatricians themselves are not always comfortable with basic concepts of child development when it applies to their own children? Not all pediatricians are like Dr. Gold.

  • anon

    This is exactly the kind of visit that can be delivered with a cash-only practice.

  • karen norris

    How exactly does a general pediatrician bill for a “full 50-minute visit” to discuss toddler sleep problems. No insurance company would pay for it anyway. Most private practice pediatricians would be out of business with this sort o advice. This doesn’t seem very realistic for the general pediatrician

  • Cheryl

    A pediatrician is not by definition an expert on child psychology and parenting, and more than they are investment or horseshoeing experts! If A Dr. picks up on behavioral issues, it would help to have some means of referring people to more appropriate resources, which vary from community to community. Past experience in Child Protective has been that many pediatricians are so attentive to the parents(and granted it is necessary to seek their observations), sometimes they miss seeing the child in front of them, or they so need to believe they are in control of everything that they give poor advice.

    Pheski’s last comment is also right on – the important q is what do I ask them? You would not treat a physical ailment w/o an assessment and at least preliminary diagnosis – the same is true of behavioral/ “pstchological” problems. So clarify the issue as best possible and get that family to someone who has the time and training to deal with it.

  • pheski

    1. Most practices in my area schedule ~ 20 minutes for a well child visit. This encourages ‘fly-by’ approaches to issues beyond the pure age-specific well child agenda.

    2. Scheduling a second visit for an issue that arises during a WCC is feasible but faces challenges. It may delay addressing something a parent has already waited weeks or more to raise at this visit. The parent may be reluctant or unable to take more time off work (pay). The provider may not be available for an extended time.

    3. One can bill the separate dedicated visit based on face-to-face time, which is better from a revenue perspective than doing it as part of a well visit and billing nothing for it.

    4. The line I wanted to see in Dr. Gold’s contribution – but did not – is the emphasis on replacing the question “What do I tell them?” with the question “What do I ask them?”

  • AnnR

    There is tons of parenting advice available, and many other professionals who’ve made their life careers out of helping parents with behavior problems.

    What’s wrong with recommending a few books, having a rack of informational pamphlets in the hallway for parents to consult or offering the name of a psychologist if they need professional help ?

  • Marie

    Dr. Gold’s approach is forward thinking and positive. I am disappointed by the critical comments. Even if a reader had reservations, couldn’t they be worded differently?

    First, as far as billing, a physician could use a CPT code for a prolonged face to face visit. Documentation would need to support it, but the information is there.

    Is this physician out of her league? Surely not for an initial problem. It is ideal for a pediatrician to be on a family’s wavelength. Hopefully this is going to be an 18 year relationship. Not every family needs therapy, sometimes a professional who listens is exactly what fits the bill. Sometimes problems are self limiting. If not, this doctor sounds savvy enough to refer this family for more help.

    Here is a doctor teaching other doctors to be watchful and listen. This is not in a vacuum. The students have a whole curriculum devoted to preparing them for treating patients. Medical students are not usually dummies. I would hope they can put all their educational experiences together for a unified picture. It is never a bad idea to encourage medical students to be compassionate observers.

    Finally, the negative tone of some of the comments makes me wonder. Why can’t you encourage a colleague in something innovative? Does every idea have to be perfect out of the box? What ever happened to collaboration? Or suggestions rather than hostility?

    I applaud Dr. Gold for attempting to educate students in a way that can only make them better doctors.

  • Martha Dupecher

    In addition to having trained as a pediatrician, Dr. Gold follows the latest research on child development, studying in particular the role of interpersonal relationships in that development. If you are intrigued by her way of thinking you might check out her website and blog,

  • Susan

    I appreciate Dr. Gold’s investment in working with parents regarding their children’s behavioral issues. However, I’m curious why she does not refer or consult with a child psychologist?

    When I feel a behavioral issue may be medical in nature, I refer to a pediatrician. And I would hope when a pediatrician feels a child’s difficulties are emotional in nature she would refer to a mental health professional.

    I the example above, it seems Mary may have been anxious about problems in the family, but by having her scream for an hour and then lie down with her the parents were, unintentionally, teaching and reinforcing tantruming behavior. These behavioral patterns can take time to reverse and should be monitored on a regular basis.
    I’m not sure if Dr Gold has the type of practice that can follow up with such issues, but I hope people understand the boundaries of their expertise and consult with those who can help patients best rather than assume they work alone and are a child’s only hope.

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