Psychosocial Scenarios for Pediatrics

285 Pages·1988·4.846 MB·English

by  Paul V. Trad M.D. (auth.)

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.
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with respect to the material contained herein.
Media conversion by David E. 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.