The pediatric literature of this country has drawn increasingly on material from a variety of sources relating to the psychologic aspects of child care. The number of papers appearing in pediatric journals on the topics of child psychology, deviant behavior and mental illness, mental health, child development, psychiatric treatment, sociology, and even anthropology bears witness to this occurrence. For example, the pediatrician is urged to become acquainted with the facts of growth and development so that, as a “developmental pediatrician,” he may predict and interpret the behavior of children to their parents.
Psychiatry, pediatrics, psychology, and education have all made contributions to the field of psychotherapy. Although each may credit specific techniques and methods from their respective professions, one wonders if the constituent principle held in common by these disciplines may not depend on a common factor that lies beyond the techniques and methods expounded. In searching for the essential ingredient in the therapeutic process, one discovers that what is important involves a process in the interpersonal relationships between the patient and the therapist. Successful psychotherapy requires from the therapist a highly personal and individual orientation and regard for the individual.
In our culture, the physician is considered to be a person of wisdom, perhaps even of magical power. Considered trustworthy, he becomes the repository of secrets about problems that cannot be shared with anyone else. In addition, he is expected to supply guidance and advice capable of practical application. In describing the pediatrician's view of the essential elements of his role as a therapist, first on the list are those qualities of character and personality that further the establishment of confidence, faith, or rapport.
The question that may be asked is, “How does a physician instill confidence in a patient and maintain rapport?” The primary requisite in the development of a therapeutic physician-patient relationship lies in the ability of the physician, first, to be aware of the feelings that the patient brings and, second, to be able to accept them whatever their nature. Actually, in order to help the patient it is neither necessary nor desirable in every instance to offer anything more than the opportunity for the establishment of a relationship. In the beginning of treatment the physician is an observer, interested in his patient and particularly the feelings that he brings with him. The important thing is not whether these feelings are positive or negative but rather how the pediatrician is able to allow the patient toexperience them in the time spent with him. Once the patient has had the experience of being accepted, he begins to develop trust in the physician. It may be said that the therapeutic situation has been established when the patient has succeeded in identifying the physician as a reliable and trustworthy person.
The patient enters the relationship with an ambivalent attitude—on one hand trying to receive help, on the other guarding against its receipt. To many physicians it seems contradictory that anyone should have such strong mixed feelings when in need. It is not always easy for the pediatrician on the basis of time and in the framework of therapy to permit the patient to bring out his feelings. At times, the physician will feel at-ease, calm, and relaxed and, in those states, he finds it easy to accept the patient as he is; in contrast, on other occasions, even with the same patient, he may feel angry, hostile, frustrated, or tense and find the situation almost impossible to bear without bursting out with a word of censure or of criticism.
The pediatrician must be able to keep himself sensitive and responsive to the needs of his patients, accepting them in their human qualities without becoming engulfed in their distress. In order to achieve such objectivity, every physician should have an understanding of the behavior of people under stress and an awareness of his own personality so that he recognizes the reasons for his different responses to the diverse emotions of patients.
To be truly effective, pediatric training must provide ample opportunity for the establishment of intimate teacher and pupil relationships. With these at the core of training, not only will pediatricians learn the fundamentals of child care, but they will be able to incorporate quite naturally psychologic insight with medical understanding and make pediatrics the comprehensive discipline it should be.
This contribution by Milton Senn on the psychotherapeutic role of the pediatrician was the first article published in Pediatrics on the psychosocial aspects of child health. In subsequent years, this paper was followed by a steady stream of articles in this and other journals on child behavior, development, and parent-child relationships.1 The current development of behavioral and developmental pediatrics, the practice of viewing children in the context of their family and community, and the integration of the pediatrician's role with that of the psychologist, the child psychiatrist, the child psychologist, the nurse, the educator, and the social worker owe much to Senn's pioneering exploration of this frontier in pediatric practice, education, and research.
The perspectives, principles, and guidance in this article were gained in the course of a geographic and intellectual odyssey that began when Senn left the University of Wisconsin to study electrolyte balance and lactate metabolism with Dr Alexis Hartman at Washington University in St Louis. His appointment as director of laboratories in the Department of Pediatrics at Cornell-New York Hospital followed in 1933.
Although immersed at that time in metabolic disorders and biochemistry, Senn increasingly came to the belief that pediatrics should be concerned with the emotional and developmental as well as the biomedical aspects of child health. Acting on that personal conviction, Senn decided to expand his knowledge of the former. At that time, there were neither structured fellowships in behavioral and developmental pediatrics nor any assurance that an academic appointment in this field would be available. Despite what many might view as deterrents, Senn persevered in his quest—a trait that he continued to demonstrate throughout his groundbreaking career.
Senn started this phase of his career in 1936 when he left New York Hospital for a year at its Westchester Division to learn more about psychologic influences on parental and adolescent behavior. This experience was followed in 1937 by his move to Philadelphia to study with Fred Allen at the Philadelphia Child Guidance Clinic. In those early years, 6 decades ago, most pediatricians who took additional training in psychiatry were identified by themselves and by others as child psychiatrists. Senn, however, always retained his identity as a pediatrician. Although he collaborated frequently with psychiatrists and psychologists, he saw their role as complementary to, but distinct from, that of the pediatrician.
In 1938, Senn returned to New York Hospital to develop a teaching program for pediatric residents, medical students, and nurses that included a seminar in human development with an emphasis on developmental psychology and the social sciences. The seminar faculty included a physiologist, a psychologist, an economist, a sociologist, a psychoanalyst, and an anthropologist. In collaboration with the Bank Street School (now College), Senn also established a nursery school in New York Hospital to provide the pediatric residents experience with healthy young children.
In 1948, Senn moved from New York to establish a child development training and research program at the Yale Child Study Center in New Haven. Consisting of a diagnostic developmental clinic, a child psychiatric clinic, and a nursery school, the Center was staffed by a faculty of pediatricians, child psychiatrists, psychologists, social workers, and early childhood educators. Three years later, Senn was named chairman of the Department of Pediatrics in addition to his directorship of the Child Study Center, giving him the opportunity to integrate further the teaching of child development with that of the biomedical aspects of pediatrics already highly developed at Yale.
Senn's views have had a considerable impact on pediatric education and practice. It is not possible to summarize them adequately in this brief commentary, but the following short list is intended to suggest some of the generalizations that may be drawn from his work:
A thorough familiarity with child behavior and patterns of development is an essential component of pediatric practice.
More than any other professional, pediatricians are in a key position to prevent many psychological and developmental disorders through contributing to parents' understanding of children and of parent-child interrelationships.
Skill in interviewing parents and children is the single most useful skill that pediatricians can master in relation to the psychosocial aspects of pediatrics.
Besides providing an opportunity to obtain the data needed for diagnosis, the interview also offers the opportunity to help the child and parent psychologically through establishment of a productive physician-patient relationship.
The “chief” complaint as initially given by a parent may not be the primary reason for the consultation. The real reason may not be disclosed until the patient believes the physician is accepting and trustworthy.
Important as detailed historical information is in relation to psychologic and developmental problems, recognition of the parent's and child's feelings and attitudes is of comparable significance.
The psychotherapeutic pediatrician has a highly developed ability to see, hear, feel, empathize with, and read the patient.
The psychotherapeutic pediatrician has well-honed observational skills.
The facilitative practitioner is perceived as an accepting, nonjudgmental, genuine, and mature professional to whom a patient feels able to talk freely.
The support of the pediatric department chairman and senior faculty is essential for the training of residents in the psychosocial aspects of pediatrics. Faculty with special competence in child development and human behavior are a necessary resource if such education is to be effective.
This article, published 50 years ago, exemplifies the foresight of Milton Senn. A pioneer, he was there at the beginning of what has become a major area of pediatrics. Today, research projects, publications, fellowships, continuing medical education courses, and professional associations of those who specialize in behavioral and developmental pediatrics are part of the mainstream of pediatrics and child health. Although Senn was occasionally misunderstood by some as “diluting” pediatrics by his advocacy for the inclusion of psychosocial considerations in pediatric education and practice, he was a true visionary. His innate modesty tended, at times, to belie the extraordinary talents of this pediatric giant.