Family style

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at [email protected].

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at [email protected].

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at [email protected].

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.