Psychosocial Scenarios for Pediatrics Paul V. Trad Psyehosoeial Seenarios for Pediatries Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Paul V. Trad, M.D. Department of Psyehiatry The New York Hospital Comell Medical Center Westehester Division White Plains, New York 10605, USA Library of Congress Cataloging-in-Publication Data Trad, Paul V. Psychosocial scenarios for pediatrics. Bibliography: p. Includes index. 1. Pediatrics-Psychological aspects. 2. Sick children-Psychology. 3. Physician and patient. I. Title. RJ47.5.T73 1988 618.92'001'9 87-28481 © 1988 by Springer-Verlag New York Inc. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag, 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. 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Seham Associates, Inc., Metuchen, New Jersey. 9 8 7 6 5 4 3 2 1 ISBN-13 :978-0-387-96586-4 e-ISBN-13 :978-1-4613-8746-6 DOI: 10.1007/978-1-4613-8746-6 Preface My interest in writing this book was sparked several years ago when I serv ed as a psychiatric liaison on a pediatric unit of a major urban hospital. I was asked to assess a 7-year-old Hispanic boy who had been admitted to the hospital several days earlier with complaints of chronic abdominal pain. Comprehensive physical evaluations of the child had revealed no organic abnormality or disease process, and the pedia tricians assigned to the case had begun to suspect that the little boy's symptoma tology sternmed from an emotional problem. After meeting with the child for several sessions, I learned that his abdominal pains had persisted for approximately 3 years, preventing him from attending school on a regular basis or from engaging in other activities. A detailed elinical history revealed that roughly 4 years earlier, the child's mother had remarried and this stepfather had moved into the home. The child's comments with respeet to this man were highly ambivalent. Nor was the nature of these conflicting feelings apparent to me at the time. Several days later, however, when the child had been told the date of his discharge from the hospital, I was informed that his anxiety had increased dramatically. Eventually, after a few more consultations, the child reluctandy diselosed that he had been sexually abused by his stepfather and that he felt this information had to be kept a secret for fear his mother would be hurt. Following this confession and subsequent family therapy, the child's physical symptoms virtually vanished. In retrospect, the connection between this child's physical symptomatology and psy chological conflict loomed large in my mind. As aresult of this case, I became convinced that both pediatric medicine and child psychiatry often ignore vital aspects of a child's development that are manifested in both physiological and psychological symptoms. This book is designed to assist the pediatrician in integrating all factors that impinge on the maturation of young children. In addition, by helping the pediatrician to' 'represent" phenomena from the child's unique perspective, it is hoped that the book will enhance physicians' appreciation of the childhood experience. During the course of writing this book, I was especially grateful for the concem and professional guidance offered by Paulina F. Kemberg, M.D., Directorofthe Division of Child Psychiatry, Comell Medical Center, Westchester Division, and VI Preface by Daniel Stern, M.D., Director of the Laboratory of Developmental Processes, Payne-Whitney Clinic, New York Hosptial. My heartfeIt appreciation is extended, as always, to Richard White of Seattle, whose thoughtful comrnentary and unflagging encouragement made the long hours of labor on the manuscript rewarding. Sincere thanks as weIl to John Ribar for re viewing portions of the text and suggesting inciteful and probing critique in the spirit of support. Deep appreciation is also due to Wendy Luftig who, for the past 2 years, has stimulated my imagination and inspired me to exercise my professional skills to their fuIlest capacities. To Sharon Yamamoto, Derisha K yi, Vernon Bruete, and Mark Hamrner cordial thanks for assisting in preparing the manuscript. Finally, this book is dedicated to my parents, Blanche and Jorge Trad, for their continued faith and affeetion. Paul Trad White Plains, New York Organization of the Book During retlection about the main concepts conveyed in the following pages, the notion of representation emerges most prorninently. Representation is here defined expansively, to encompass the abilities to perceive phenomena, to describe ex perience, to encode information, to know things, to interpret, to construe, and to engage in introspection. Thus, representation involves the most intimate level of human interaction and remains the fundamentaI vehic1e whereby human beings communicate their feelings, aspirations, and desires. This book strives, above all, to mold and refine the pediatrician's represen tational perceptions with respeet to children. It is felt that during every aspect of the pediatric assessment, the pediatrician should attempt to integrate psycho logical and physiological representations in his or her mind and to convey these to the child in their most adaptive fashion. In this manner, not only will the contours of internai organs be envisioned or physiological measurements be re corded, but the pediatrician will also come to conceptualize the child as a unique individuai, whose distinctive anatomy, precise developmental status, and personal environmental milieu cause the child to manifest a particular c1uster of symptoms or behaviors. It is hoped, therefore, that the pediatrician can interact during each encounter with a vital and panoramic understanding of the patient. Moreover, it is not merely sufficient for the pediatrician to refine these rep resentational skills. For the pediatric assessment to be successful, it is necessary that the physician convey representations back to the ehiid, as a fellow traveler, in the exploration of the child's physical and psychological development. The crucial issue here is whether the child is accurately representing the myriad of phenomena that are occurring within his or her own body. Only if the pediatrician can gauge the level of the child's perceptions can he or she provide the com munications necessary for helping the child understand why an injection is required or how chemotherapy can be used to combat leukemic eelIs or even how the physiological alterations that accompany puberty are an integral aspect of de velopment. In the following chapters, numerous techniques are recommended for assisting the pediatrician in evoking and relating to the child's innate representational proc1ivities. Encouraging play behavior prior to the physical exam, suggesting viii Organization of the Book miniature fantasies to capture the child's imagination, or simply engaging in a few minutes of conversation can all help to allay the child's anxiety and coax the child to reveal internaI perceptions about the impending physical exam and developmental issues. For example, one specific strategy involves asking the child to close the eyes and verbalize what he or she is thinking. In patients under the age of 5 years, this exercise will help the child focus on internaI representations and will foster fantasy disclosures. The pediatrician will thus be able to judge whether the child's perceptions are realistic or distorted. In addition, the pedia trician can use this soothing exercise throughout the course of the physical exam, periodically asking the child what he or she thinks will happen when the pedia trician touches the body in a certain way or applies a particular instrument to a bodyorgan. The ultimate goal is to obtain insight into the child's perception. This interplay of reeiprocal and attuned representations is, in a fanciful way, reminiscent of the parable about the blind man and the crippled man. Each of these characters alone is incapable of progressing on his journey. But when the two join forces and the blind man carries the maimed companion on his back, the pair is able to complete the journey. The relationship between the child and the pediatrician is similar. By engaging in a mutual and harmonious exchange of representations, both actors in the pediatric drama gain indispensable insights into the nature of perceptions dealing with the child's physiological and devel opmental status. In addition to adopting a representational model, pediatricians are tutored to adapt this for understanding the developmental status of children. In children younger than age 2, for example, an autonomous sense of self has not yet con solidated, and the infant generally perceives himself or herself as being intricately intertwined with the caregiver. Thus, during the physical assessment of these infants, it is important for the pediatrician to engage in a form of parental ref erencing, which involves including the caregiver in virtually all interactions with the child. Children between the ages of 2 and 3 years usually view themselves as in dependent explorers and are beginning to distinguish between reality and ap pearance. Nevertheless, these children may need assistance in distinguishing be tween objective phenomena and perceptions triggered by anxiety. The pediatrician should focus on exploring the child's unconscious wishes and fears and should attempt to dispel negative perceptions. In addition, it is important to assist these children in integrating conflicting representations that might precipitate noncom pliance or in dispelling emotions that may exacerbate a physical condition. UI timately, the pediatrician' s task is to assist the child in entertaining a variety of perceptions pertaining to the bodyand to clarify misconceptions about the way in which the body functions. In children older than 3 years, the pediatrician's goal is to integrate a repre sentational format into the nuances of inquiry and clarification. Children at this developmental st age should be encouraged to use all skills at their disposal for the purpose of expanding their perceptions. To promote this heightened state of awareness in the child, the pediatrician should ask questions periodically Organization of the Book IX throughout the exam to ascertain how the child feels when touched; how the child visualizes the impairment, disease or injury; and how bodily organs are conceptualized in general. For each response offered by the child, the pediatrician can provide a reciprocal explanation that helps the child to integrate cross-modally a plethora of data about anatomical and psychological perceptions. Pediatric examinations conducted in this fashion enable the child to experience a rewarding relationship with another individual while learning about the nature of development. Children should come to view the pediatrician as someone who helps them integrate perceptions about the world and understand the intricate workings of their bodies. With this enriched level of perception, the child can begin to anticipate developmental change with the optimism and enthusiasm that are conducive to health-promoting behaviors. In this fashion, the pediatrician will become an individual with whom the child feels affectively and cognitively connected because of a relationship infused with empathic, synchronous. and attuned communication. The chapters that follow are designed to suggest methodologies the pediatrician can use for attaining this type of relationship with patients. In addition, the last portion of the book addresses various problems that arise within the context of pediatric medicineo Thus, the impact of the family and of environmental stress are discussed in separate chapters. Chapters are also devoted to the effects of illness, hospitalization, handicapping conditions, and child abuse on the child's capacity to represent physical and psychological phenomena. Finally, the pe diatrician is advised with respect to instances when further psychiatric assessments may be advisable. It is hoped that by integrating the representational experience s with the child's developmental status, pediatricians will be provided with a tech nique for transforming the pediatric encounter into a mutually fulfilling experience for both physician and child. Contents Preface .................................................................. v Organization of the Book ............................................... vii Chapter 1 Biobehavioral Approach to the Study of the Child' s Mind Chapter 2 Child's View ofInternal Control 31 Chapter3 Pediatric Communication: Sharing the Experience 59 Chapter4 Peership and Play: Techniques for Facilitating an Optimal Pediatric Visit ................................................... 92 Chapter5 The Relationship of the Pediatrician to the Child's Family 120 Chapter6 The Role of Psychiatric Liaison in Pediatric Medicine 141 Chapter7 The Psychosocial Model Applied to Pediatric Care ........................ 156 Chapter8 IIlness, Handicapping Conditions, and Hospitalization: Specific ChaHenges for the Pediatrician ................................... 186 Chapter9 Abuse and Negleet: Specific ChaHenges for the Pediatrician 219 Chapter 10 ConcIuding Remarks .................................................... . 237 References .............................................................. 239 Author Index 264 Subject Index ........................................................... 271 CHAPTER 1 Biobehavioral Approach to the Study of the Child's Mind CHnieal Vignette Jeremy fidgeted as he sat with his mother in the waiting room. He was a little bit scared, because the bone in his arm, the one near his shoulder, was poking through his shirt. Itjutted out strangely even under the sweat shirt his mother had hastily instructed him to put on before they had rushed to the doctor. He didn't understand what all the fuss was about. When he reached for the ball just as his friend David slid toward third base, his view had been blocked as Jonathan, the heavyset outfielder from the other team, lunge d on top of him, crushing Jeremy into the ground. Although Jeremy hadn't been hurt and didn't feel any pain-even now-that funny bone in his arm was sticking out. The coach had told him to go right home, and his mother, on seeing his shoulder, had insisted they go immediately to the doctor. But Jeremy wasn't really upset about the shoulder; he believed that Dr. Andretti would be able to fix it. Hadn't Dr. Andretti given him those shots and tol d him he would be all right when he had the measles last year? And when his sister Margaret had cut open her lip on the new re volving slide at the park, Dr. Andretti had sewn in 58 stitches-which Margaret told him didn't even hurt-and later you couldn't teil where the stitches had been. So Jeremy thought he would be all right if he could just explain what had happened to Dr. Andretti. What bothered him now was his mother. Glancing in her direction, he saw two sharp furrows between her eyes, the kind she got right before she yelled at him. At just that moment his mother stood up and went over to the nurse to say something. When she came back she looked annoyed and started smoking a cigarette. Jeremy felt embarrassed. Why did she always have to make such a big deal about everything? Then he fe It bad. He knew that his mother was just worried about him. If only he could teIl her that Dr. Andretti would fix everything up ... But then, suddenly, he wasn't so sure anymore.