PEDIATRICS Vol. 117 No. 1 January 2006, pp. 218-219 (doi:10.1542/10.1542/peds.2005-0380)
COMMENTARY |
All Parents Need Family Pediatrics
Center for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Edith Nourse Rogers Memorial Hospital, Bedford, MA; Health Services Department, Boston University School of Public Health, Boston, MA
Abbreviations: AAP, American Academy of Pediatrics
Two parts of my life cross continuously. One part is that of a health services researcher and a health psychologist, aiming to improve chronic disease care and management. The other part is that of the mother of a 3-year-old son with a rare neuromuscular disorder called Schwartz-Jampel syndrome. No university could have prepared me for the steep learning curve that I first encountered in July 2001. This part of my life has been challenging, humbling, and anxiety-provoking, yet it also has provided me with a perspective on parenthood, mental health services, and health care that I could not have gained except by first-hand experience. It is because of this part of my life that I became a mental health services user. It is this part of my life that made me rethink the way that health care is delivered in the United States. And, it is this part of my life that, hopefully, will help me explain to providers who lack first-hand experience why we need family pediatrics.
In 2003 the American Academy of Pediatrics (AAP) Task Force on the Family produced a report in which they called for pediatricians to "modify their practice behaviors to promote good family functioning and effective parenting."1 Included were recommendations for pediatricians to screen for family circumstances that put children at risk and policies and programs that promote family functioning and family-oriented care. Underlying these recommendations was the principle that "to address effectively the health and well-being of children, pediatricians must approach the family—not just the child—as the patient."1 However, it seems that few providers are aware of these recommendations. Billing issues, time constraints, and not viewing parents as potential patients are just a few of the problems.2 On 2 occasions in the part of my life as a mother, a pediatric provider has asked me how I was coping with the care of my son. Both times I put on a brave face and said, "Well, you know, it’s tough but we are managing," just as I was becoming clinically depressed and not knowing where to turn or what to do. In the part of my life as health services researcher, I have argued for family pediatrics and maternal depression screening by pediatricians. I was told by a well-meaning pediatrician that he always asks the mothers of his patients how they are doing. This was exactly my point. Even the most depressed mother can create a facade of health and competence; simply inquiring about her health will not yield valid answers. Pediatricians need to presume that we are at risk and use standardized screening tools to detect depression and other health problems.
Even as a psychologist, I was not aware at first that I was clinically depressed. I knew that my behavior was erratic and unpredictable, that I could scream at my then 4-year-old daughter for the slightest misgiving, and that minutes later I would hug her while crying, apologizing, and saying that I would never do that again. It was abusive behavior, and it only escalated over time, with near physical assaults on her that required my husband’s intervention. Some days I would not even get out of bed; at least I wasn’t being abusive, but I certainly wasn’t caring for my children adequately. Finally, I self-administered a depression screening tool and was alarmed that I scored in the severe category. Over the next few weeks I tried unsuccessfully to see a clinical psychologist. I was sent on a path of serial referrals, with each mental health provider explaining that he or she was not taking new patients but that I should call another recommended provider. Out of desperation, I visited my internist, who listened carefully to my story and felt that pharmacotherapy was warranted. I was not against taking medication, but I had recently read that the most effective form of depression treatment combined both pharmacotherapy and psychotherapy. I mentioned this to her and asked for a referral to a clinical psychologist. She knew of none to recommend. I filled the prescription, thankful to have some treatment that might help me, and wondered how mental health care had become so distinct and isolated from primary care.
The perils of primary care providers are well known: the endless paperwork, the battles with managed care organizations, and relatively low status and pay compared with specialist colleagues. As the mother of a son with special health care needs, however, it is my son’s primary care provider and his pediatric specialists whom I see most often. My own health has low priority; I do not feel that I have the right to ask my son’s providers about my health problems, because they are treating my son and not me. Or do I? How would this benefit my son? Screening and referring parents for depression care requires setting up systems interventions and reimbursement practices, yet a family view of health care would encourage this as time well spent. A healthy, less anxious mother is a better caregiver to her child than an unhealthy, anxious one. Similarly, a depressed mother is less likely to ensure that her child receives his or her necessary health care, therapies, medicine, and treatments than a mother who is not depressed. As a result, children of depressed mothers have more emergency department visits.3 The cycle is obvious to me and to the AAP, who stated that "children’s outcomes—their physical and emotional health and their cognitive and social functioning—are strongly influenced by how well their families function."1
The medical home initiative of the AAP has been a step in the right direction for pediatric health care, especially for the care of children with special health care needs.4 The recommendations of the AAP Task Force on the Family should be included in the medical home policy statement so that, just as children have providers who know them and their needs, so too do their parents. Parents of both typically developing children and children with special health care needs want their children’s providers to inquire about their health and assist with making appointments with an adult provider if necessary.5 I have always been thankful for my son’s pediatric providers, who inquired about how I was coping, but what I really needed was to have them systematically inquire about my health, through standardized screening, and then provide recommendations for providers and help me follow-up with them.
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FOOTNOTES |
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Accepted Apr 18, 2005.
Address correspondence to A. Rani Elwy, PhD, Center for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Edith Nourse Rogers Memorial Hospital, 200 Springs Rd (152), Bedford, MA 01730. E-mail: relwy{at}bu.edu
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
The author has indicated she has no financial relationships relevant to this article to disclose.
The ideas expressed by the author do not necessarily reflect those of the Department of Veterans Affairs.
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REFERENCES |
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 TOP REFERENCES |
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- Schor EL; American Academy of Pediatrics, Task Force on the Family. Family pediatrics: report of the Task Force on the Family.
Pediatrics. 2003;111
:1541
–1571
[Abstract/Free Full Text] - Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression.
Pediatrics. 2002;110
:1169
–1176
[Abstract/Free Full Text] - Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer CJ. Infant health care use and maternal depression.
Arch Pediatr Adolesc Med. 1999;153
:808
–813
[Abstract/Free Full Text] - American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The Medical Home.
Pediatrics. 2002;110
:184
–186
[Abstract/Free Full Text] - Kahn RS, Wise PH, Finkelstein JA, Bernstein HH, Lowe JA, Homer CJ. The scope of unmet maternal health needs in pediatric settings.
Pediatrics. 1999;103
:576
–581
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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