Stressed Doctors, Parents, and Children

This past weekend I had the privilege to present the ideas I have been describing in my blog and book to an audience of general pediatricians at the North Pacific Pediatric Society.  It was a wonderful, highly receptive audience. The essence of the problem, in my opinion, is that this cascade of stress impairs effective listening.  We have a basic human need to be heard and understood. This holds true for clinicians, parents and children.

 The American Academy of Pediatrics, in a recent policy statement, has charged pediatricians, along with a very long list of things to do in a 15-minute visit, with preventing "toxic stress" or stress in the absence of a secure, safe caregiving relationship. Extensive research has shown that these kind of relationships can protect against many negative health outcomes. We are ideally suited for this task, as primary care clinicians as a profession have by far the largest interface with young children and families, and usually have a relationship of implicit trust.

Time to listen to parents and an opportunity to share their own experiences with other clinicians are two essential components needed to enable primary care clinicians to take on this critical task of promoting healthy relationships. Currently a pediatrician is paid more for a 10-minute visit for an ear infection (that may very well get better on its own) than a 50-minute visit for an emotional or behavioral concern. On the policy level, changing this would be a good place to start.

As is usually the case after giving such a talk, I think of points that I would have liked to address but did not. Fortunately I have this blog, so can add them here.

 1) I spoke about the need to reframe a child's "difficult" behavior as "stressed" behavior. Over the course of the weekend, a number of references were made to the "difficult" parent. Equally important is to reframe this notion of the "difficult" parent" as the "stressed" parent. We cannot help the child if we do not have an empathic stance toward the caregiver.

 2) I talked about the significance of D.W. Winnicott's contributions, but neglected to mention his very important notion of the "good-enough mother."  The essence of this idea is that mistakes we make as parents, moments when we miss our children's cues, lose our cool or any number of things that inevitable go wrong in the daily life of families, if these "mistakes," or disruptions, are recognized and addressed, are not only OK but essential to move development forward in a healthy direction.

 3) A general pediatrician questioned why I, as a specialist in infant mental health, would ever be referred a patient with colic, a problem that is so common and so much considered the job of the primary care clinician. The point I wanted to make is that meaningful evaluation of this issue may involve more than a 15-minute visit. Colic is traditionally viewed as residing in the baby. But when we see it as a relationship problem, it makes sense to give it more time. For a new mother who imagined blissful hours of with her newborn, having a baby who is either crying or sleeping with little time available for gazing lovingly into each other's eyes, colic can be devastating. At the very least there is severe sleep deprivation, and there may be feelings of low self-esteem and even depresssion. Bringing these issues out in the open at the beginning, validating the mother's experience and helping her to find support, may prevent more long-term problems.

 The last talk of the weekend was about mindfulness. The speaker was a specialist in adolescence, and she was advocating for mindfulness both for parents of teenagers and for the clinicians in the audience. She offered Jon Kabat-Zinn's definition:

Mindfulness means paying attention in a particular way; On purpose, in the present moment, and nonjudgmentally.

This is one tool that can help us to slow down just enough to be able to carefully listen to each other. In doing so, we will go a long way in stopping this cascade of stress that has potential to wreak havoc on our society in the long run.