PRACTICAL TECHNIQUES OF OBSERVING, INTERVIEWING AND ADVISING PARENTS IN PEDIATRIC PRACTICE AS DEMONSTRATED IN AN ATTITUDE STUDY PROJECT

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PRACTICAL

TECHNIQUES

OF

OBSERVINGI

INTERVIEWING

AND

ADVISING

PARENTS

IN PEDIATRIC

PRACTICE

AS

DEMON-STRATED

.

IN

.

AN

ATTITUDE

STUDY

PROJECT

By Barbara Maria Korsch, M.D.

Department of Pediatrics, Cornell University Medical College and New York Hospital

467 INTRODUCTION

T

HE ATITFUDE STtLTDY PEOJECr1 conducted by David M. Levy represents one prac-tical approach toward the application of psychiatric observation and techniques to pediatric practice.#{176} In the 7 years of its operation, the author and other participants in the project have made a number of obser-vations which may be useful to practicing pediatricians as well as to those interested in pediatric education. This paper will be devoted to a presentation of some of these experiences and observations.

BASIC PRINCIPLES

In medical education, physiological proc-esses and the illnesses of the body are pre-sented to the student in a scientific manner as objective phenomena about which he must learn in order to be abbe to deal with them in the most effective manner as a phy-sician. When it comes to psychological proc-esses and the illnesses of the mind, this scientific and objective approach is, un-fortunately, not as prevalent. In spite of verbal recognition of the need to consider mental ailments as dispassionately as physi-cal ailments without moral censure or emo-tional reaction, in practice, many students and physicians approach the psychological aspects of their work on a subjective emo-tional level. When this beads to a kindly, human and sympathetic interest in patient welfare, it may be a constructive force. However, when it comes to learning about

0 The Activities of the Attitude Study Project

are not limited to the scope of pediatric practice, but methods evolved there are such that they may apply to many other professional relationships. For the purposes of this paper, however, which is ad-dressed to pediatricians, the pediatric aspect will be

stressed.

ADDRESS: 525 East 68th Street. New York 21. New York.

human motivation and psychological proc-esses, the subjective response of the stu-dent often blocks the learning process and interferes with the choice of the most ap-propriate treatment measures. An example of the difference in approach would be the change in a medical student’s reaction to a skin eruption when this is observed at the outset of his studies and again after he finishes his medical course. A beginning student of medicine (or an untrained lay person) on inspecting a severe skin erup-tion might react by shuddering in distaste and describe the lesion as disgusting or hor-ribbe. A student who has finished his medi-cal training would more probably describe the condition in objective terms-as a sebor-rheic dermatitis with papules, blebs and pustules, for example. The exact descrip-tion would then serve as a basis for classi-fication, for understanding the etiology, and perhaps for formulating a sensible plan of treatment. The emotional response of finding it disgusting would in no way increase the physician’s understanding of the condition and would not constitute the basis of any plan more sensible than re-vulsion and flight from the afflicted patient.

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468 KORSCH - TECHNIQUES IN AN ATTITUDE STUDY PROJECT

one of condemnation rather than evalua-tion. If one then proceeded to ask him for the evidence on which he bases his judg-ment, it would often fall far short of what he himself would consider valid to form the basis of a conclusion in any other branch of science.

In spite of the fact that medical educa-tors and physicians everywhere have been forced to consider psychological problems an increasingly important part of their sphere of interest and activity, they have continued to find themselves singularly ill-equipped for this part of the job. Pediatrics is probably the specialty in which the de-mand for psychological understanding and guidance from the physician has been in-creasing most rapidly in the past few dec-ades.21#{176}Because of this increasing demand, pediatricians have looked to many other disciplines for contributions to the psycho-logical understanding of child development, parent-child relationships, and emotional problems in children. In recent decades significant contributions in this area have come primarily from the fields of psycho-anabysis,’117 child psychiatry,’82#{176} psychol-ogy,2 1-27 education, anthropology,’8’ and

psychosomatic medicine.3236

In this review, no attempt will be made to make mention of all the scientific disci-plines or all the individual persons who have made significant contributions to the development of the psychological approach in pediatrics or to outline the content of these contributions. The purpose of this article is to describe in some detail one experiment that has been carried out in the New York City Department of Health since 1948 under the direction of David M. Levy and which has not yet been pre-sented in the pediatric literature. The ex-periences of others will be alluded to only as they illustrate the present experience by contrast or elucidation. For other reviews of the literature and bibliography in this area of pediatrics, the reader is referred to Leo Kanner’s excellent comprehensive

review, “The Development and Present

Status of Psychiatry in Pediatrics” which appeared in 1937, to the monthly sections on “Psychological Aspects of Pediatrics” in the Journal of Pediatrics where Harry and Ruth Bakwin have regularly presented on-going work from the field of child psy-chiatry and psychology to pediatricians, and to Dane Prugh’s recent review37 in The New England Journal of Medicine.

In recent years within the field of pedi-atrics itself, Milton Senn, in our opinion, has made the greatest single contribution toward orienting pediatric education and practice to the importance of the psycho-logical and emotional processes as they op-erate in the developing child, his family, and his pediatrician. In Dr. Senn’s teach-ing7’ 8, 38, 39 the focus is on the basic attitudes

and relationships of the pediatrician to the families with whom he is dealing. His teaching is aimed at improving these rela-tionships by helping the pediatrician to gain increased insight into his own atti-tudes. This, in turn, would enable him as he relates to his patients

(

or in most cases, the patients’ mothers), to help them gain increased understanding and insight into themselves. As a consequence, improved parent-child relationships and better con-ditions for the child’s development and growth may then be possible.

Dr. Senn has also emphasized the basic dynamics of child behavior and the need for looking beyond the symptoms to the underlying relationships and unconscious forces in the personality. In doing so, he has placed decreased emphasis on the description of the child’s behavior and on specific techniques used in treatment#{176} al-though facts concerning child development, symptomatology of behavior disturbances in childhood, and therapeutic techniques are, of course, also an integral portion of his teaching and the teaching of the pedi-atric educators who follow his precepts.

a One may conclude that “emphasis on doctrine or mode of procedure alone is not only ineffective

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This aspect of the teaching of pediatri-cians was emphasized in an article’s re-cently published in this journal by Milton Senn and his associate, Albert

J.

Solnit and will not be presented here more specifically even though it is an approach to the teach-ing of pediatricians which is

complemen-tary to the approach of Dr. Levy’s Attitude Study Project.

The de-emphasis of the superficial and descriptive approach has constituted a sig-nificant advance in pediatric thinking about relationships and emotional problems. The pediatrician has. become educated to an understanding of the deeper emotional needs of the growing child as they are expressed in various kinds of behavior and by various symptoms. By now it is axiomatic that such symptoms as enuresis often do not constitute specific disturbances but may be an expression of an underlying, usually unconscious, need in the child and that the doctor must focus his attention on the “whole” child and his family instead of limiting his concern to a particular symp-tom and its treatment.

In the Attitude Study Project, the focus is on those principles and practices which may be transmitted to the pediatrician who is well trained along traditional lines and who has limited time and resources for further special training. Since it is well known that basic changes in attitude are not readily effected as such, the problem is approached from a less ambitious view-point. It is hoped that the pediatrician’s attitudes about emotional problems may be gradually affected if he is exposed to observational material, increased content, and better techniques in this field, and that before he will have achieved any basic changes in his relationships, acquisition of increased knowledge and understanding will enable him to function better. Dr. Levy suggests that just as syphilis ceases to be a moral issue and pus no longer is an esthetic problem to the medical student who learns to see them as objective bodily phenomena, hostility, aggression, and other emotional

reactions may come to be viewed objec-tively as defenses built up in the person-abity, not as more or less willful undesira-ble personality traits in a patient.

No one would wish to go back to the time in pediatric history when understand-ing of emotional development and disturb-ances in childhood did not go beyond de-scription of symptoms. It is not as a sub-stitute for the more dynamic viewpoints that the various areas of study and training in the Attitude Study Project are suggested; it is in the realization that a basic dynamic approach is not always easily achieved. Even where it exists, the appropriate atti-tude does not necessarily enable the doctor

to understand the situation with which he is faced and how to handle it in the most effective manner. One can observe that some pediatricians who start with what appears to be a very good attitude toward the psychological problems with which they are confronted show progressive dis-couragement and decreasing interest in this portion of their work because their lack of understanding and inadequate arma-mentarium of therapeutic techniques makes them feel more and more dissatisfied with their own performance. They are, of ne-cessity, not often successful in modifying the basic attitude of their patients but may feel that they should not settle for anything less. Therefore, in the Attitude Study Proj-ect, attempts are made to transmit a cer-tain amount of content and technique to the pediatricians, and it is hoped that this will, in itself, help them in achieving greater objectivity and improved relationships with their patients.

HISTORY OF THE AlTITUDE STUDY PROJECT

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with advanced training in the field con-ducted a demonstration of the intensive clinical work-ups that can be carried out only by specialized personnel. In subse-quent years with the support of various outside groups and individuals at the Kips Bay Health Center, in the Astoria Project, again in Red Hook and finally in the Lower West Side, different approaches were tried. They all had in common the fact that they involved a group of experts, such as a “mental hygiene team” or “child guidance team” including a psychiatrist, a psycholo-gist and a psychiatric social worker. These were used in demonstrations, for referral of cases, to evaluate clinical and administra-tive aspects of the child health service, and in a limited way to give clinical supervision to the regular personnel of the child health service. Important improvements were noted to result from these various projects in respect to administrative procedures re-bated to patient care, the addition of spe-cially trained personnel to the department staff and other bess tangible effects. In retro-spect one feature of these projects appears to have been mainly responsible for their shortcomings in respect to initiating basting benefits and improved staff training. They

all depended on the work of a team of ex-perts without sufficient active involvement of the regular personnel. Therefore, when the team of experts left, all rebated activity gradually ceased. In addition, the kind of case study and therapeutic work which is carried out by such a team requires not only skill but also large amounts of time. In the regular operation of a child health service, or in the office of a practicing pe-diatrician, there is no team of experts, and there is not enough time to attempt the kind of clinical work usually demonstrated by such a team.

It was in the light of these considera-lions that the current project was planned.

AIMS OF PROJECT

David M. Levy has been primarily re-sponsibbe for the planning and conduct of this project. In setting up his teaching

ac-tivities in the New York City Department of Health, he was concerned with the chab-lenging problem of adapting some of the knowledge and techniques gained from child psychiatry and psychoanalysis for use by workers in the field of public health. This reviewer has been most specifically interested in the application of these prin-ciples to the training of pediatricians. Therefore, this will be the area of focus for the present description of the program, although in effect in the Attitude Study Project more time has been given to work-ing with public health n!.irses, since they are the group that deals most intensively with the parents of children in the Health Department clinics.

Early in the history of the project a number of working premises were arrived at which are still believed to be valid:

1) If the methods developed are to be useful and applicable in the public health setting (and this applies equally to pedi-atric practice), they must not require the pediatrician to undergo extensive special-ized training in the field of psychiatry.

2) The learning experience in a short course could not be expected to change the basic attitudes of the physician. There-fore, techniques were to be evolved which could be used for observation and practice without presupposing a basic change in the attitudes of the physician who applies them, but which while they are being used might in themselves effect such a change in the course of time.

3) The methods developed could not be as time-consuming as traditional child guidance work, but must be applicable in the limited time allotted to the pediatrician in clinic or private office.

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CONDUCT OF THE TEACHING PROJECT

There have been a number of modifica-tions in the actual procedure and organiza-tion of the Attitude Study Project during the time of its operation in its present form at the Kips Bay Health Center, but these will not be detailed here. Basically the pattern has remained constant. A number of physicians and nurses from the New York City Department of Health have been given the opportunity to attend the Attitude Study Project once weekly for a period of 6 to 10 weeks. On the day when the “spe-cial session” is in operation at the Kips Bay Health Center the procedure for the con-duct of the child health conference is not essentially different from the usual one, but the patients are seen in a one-way vision room and are scheduled at slightly longer intervals than is customary. One doctor and one nurse from the group of “trainees” actually conduct the examination of the child and interview with the parents as they would in the course of their regular work. The remainder of the group watches the proceedings from the observation booth.

Dr. Levy is in the examining room with

the doctor who is being observed. When indicated, Dr. Levy interrupts and enters into the interview with the patient; asks a few questions to illustrate a point that has been made; discusses a developmental problem that has been mentioned in greater detail; provides reassurance or advice; or elicits certain information for the benefit of the observers and the whole group.

The patients are told in advance that there will be an extra doctor in the room and that there will be observers behind the screen (“the nurses and doctors are trying to find out how to be more helpful to mothers and children and how to improve the service given-that is why they are ob-serving the session”). Patients very rarely object to this and they are always given the opportunity at the end of their visit to

request a return visit to the “special ses-sion” or to come on another day. Almost all of them choose to return to the session with the observers.

The doctor who is working in the room

with Dr. Levy at times feel self-conscious

or defensive about being observed and in-terrupted-but in most cases he realizes the additional teaching potential of having the opportunity for studying the doctor-patient relationship, as he, himself, relates

to the patient, in addition to being able to observe others.

The clinic observation is followed by an hour for case review, and discussion of rele-vant topics. Dr. Levy and other staff mem-bers are prepared to answer questions and guide the doctors and nurses in their dis-cussions of the patients seen and the meth-ods of handling problems that have been demonstrated.

In addition to the regular personnel of the child health station a small number of staff members assist Dr. Levy in the teach-ing activities of the project: 1 public health nursing mental hygiene consultant; 1

ad-miistrative director, and 1 full-time secre-tary participate on a regular basis. A small number of pediatricians who had contact with the project early in its history have maintained their interest and have either

carried on analogous teaching activities elsewhere or maintained their direct asso-ciation with the project at the Kips Bay Health Center.

It is of interest that the principles used in the teaching at the Attitude Study Proj-ect have been used elsewhere by pediatri-cians who had rotated through the project without requiring reorganization of clinic

or office procedure and without requiring

the addition of special staff. The extra per-sonnel at the Kips Bay Project is more ac-tively concerned with over-all planning, keeping of extensive records, follow-up studies and compilation of research data than with the actual teaching or with

patient care.

There is no didactic teaching in the

project. The concepts that make up the

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obser-472 KORSCH - TEChNIQUES IN AN ATTITUDE STUDY PROJECT

vation of the behavior of the patients, in-terview material, observation of interaction of doctor and patient, study of immediate and bong-term responses to the advice that’s offered-these are the methods by which the doctors in the project may gain better un-derstanding of the phenomena with which they deal in their work every day.

CONTENT OF LEARNING EXPERIENCE

AT THE AlTITUDE STUDY PROJECT

The physicians and nurses at the Atti-tude Study Project are exposed to learning experiences in 3 main areas:

1) Direct observation 2) Interview techniques

3) Techniques of giving advice and reas-surance

Each of these will be described in more detail below.

In addition, emphasis is placed on methods combining observation and brief interviews which will help in assessing quickly what are a patient’s present needs and how can they best be met by the pe-diatrician or nurse at the time of the regu-bar medical visit.

PATIENT CATEGORIES

It is generally recognized that parents come to consult their pediatricians for dif-ferent purposes and with varying needs.

There is one group of parents who come to obtain only physical examinations, pro-phylactic immunizations and certain spe-cific medical information, such as dietary advice. This group presents no excessive challenge to the pediatrician. His job in relation to these parents is exactly the one for which he is trained. He can use his skills and knowledge in a straightforward manner; he need use no extra time in dis-cussing problems; he need give no gratui-tous advice on subtler areas of child rearing. He does a thorough examination and as-sures the mother that her child is well, tells her what to feed him, and gives her other information she has requested. Doctor and patient will part on the best of terms, ‘each satisfied with the other’s performance, and

the baby will profit from the sound advice that the mother requested and received as well as from her satisfaction and relief that all was found well. In a study done by Mary Foster4#{176} out of 175 mothers inter-viewed, 86 stated that they came to the child health station for reassurance (“it makes me feel better when he has been examined and I know he is all right”). Some-times this was the only reason given; in other cases it was accompanied by another reason, such as wanting information about child care and training (“it helps me to learn how to take care of the baby”). It is our impression that this group of mothers can be spotted fairly readily and that it is important to do so because in these cases more extensive interviewing concerning at-titudes and emotional problems would no? be productive and would take away the time from mothers who could profit from more extensive contact with the physician.

From a pragmatic viewpoint it is

neces-sary to separate out one other group of patients : the ones that represent the oppo-site end of the scale from the ones in the previous category, i.e., those patients in whom there is such severe pathology (medi-cal, psychiatric, or social) that it would be unproductive to spend time on questions of attitude, minor emotional problems and child-rearing practices. This group has needs which if they can be met at all, can be met only by social agencies, medical clinics, or psychiatric therapy, and the pediatrician’s function in relation to these should be limited to case finding and help-ing in referral to appropriate resources. In these cases also the pediatrician will, of course, continue to give routine health supervision.

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of anxiety and guilt and in helping them gain insight into their own attitudes. This is the group in relation to whom the time spent by the physician is well invested and where the nature of the relationship he establishes with the patient is most im-portant in determining the success of his efforts on behalf of the patient as well as his own satisfactions.

It is to be understood that attention is also directed toward those patients in the first 2 categories in whom there may be oh-jective evidence of existing problems, but who do not ask for help, even when en-couraged to do so. Indications that suggest that a particular mother needs help, though she is not ready to accept it, are carefully noted and follow-up observations are made to see whether the problem persists and whether she may be ready to discuss it on

a subsequent occasion.

The outcry of the pediatricians in the Attitude Study Project, as well as anywhere else where they encounter teaching related to the psychologic aspects of pediatrics, is that they do not have enough time in their clinical contacts to deal with more than just the physical aspects of pediatrics. One reason for emphasizing the above grouping of patients is to point out that any tech-niques that a pediatrician evolves for him-self can be used selectively, so that if extra time is to be given, this will not be added to each patient visit, but that the time will

be redistributed to be used where it will do the most good. In addition, and this see-ond point will become clarified with further description of the project, in many cases the techniques applied in the Attitude Study Project are such that they do not constitute additional procedures, interviews, etc., but rather the emphasis is on having the pediatricians develop a clearer, more objective view of the processes in which they are engaging anyway and so to im-prove their methods without necessarily making any additions. In some cases it is believed that the insights and increased ob-jectivity that the physician can gain ac-tually facilitates his patient contacts and

renders them less time-consuming instead of constituting an additional burden.

DIRECT OBSERVATION

In direct observation of mother and child the pediatricians are encouraged to take notice consciously of all the items of be-havior which serve as the basis for the usual clinical impressions. These items of behavior are noted and if they are thought to be significant, that is if they are thought to indicate an attitude, or if they are in-terpreted as being symptomatic of an emo-tional reaction or personality trait, an at-tempt is made to test the validity of this interpretation.

Most pediatricians having spent a while

in the presence of a mother and child will feel prepared to describe the mother’s atti-tude toward the child on the basis of their observations. If they are challenged to state the evidence from which they conclude that a particular mother is “insecure,” “overprotective,” or is “a good mother,” they

may be able to list some of their observa-tions. In most cases, however, they will primarily experience an over-all sub jec-tive response to the behavior of the mother which may or may not be appropriate, and it will be difficult for them to describe what the mother did that made them categorize her in a negative or positive way.

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474 KORSCH - TECHNIQUES

IN AN

ATTITUDE

STUDY

PROJECT

table, or does she seem unaware of the fact that he appears about to roll off the table while all the observers and examining ph)’-sicians are tensely getting ready to jump to catch the baby in case he starts to fall to the floor? With the baby in her lap while she is talking to the doctor, how often does she glance at the baby? (This particu-lar observation can be made almost quanti-tative.) Does she pat him mechanically or caress him gently while he’s lying in her lap?

If the doctor compliments the mother on the baby whom she is holding in her lap, what is her response? Does she smile at the doctor brightly and say “thank you” or does she first glance down at the baby and then acknowledge the compliment (as has been observed to occur in most of the mothers who in other observations and follow-up study proved to be more highly maternal and warm in their relationship to the baby)? When the doctor administers an immunization, is the mother able to hold the baby securely and comfort him as it is done, or does she turn her head away and try to escape from the situation, apparently too preoccupied with her own reactions to respond to those of the baby?

These are just a few examples of the kinds of behavior that every experienced pediatrician observes in his office and uses as a rough guide in conjunction with in-terview material and other observations in evaluating the mothers who come to con-subt him. There are other observations to which pediatricians respond often more violently but which in general have been found less indicative of maternal attitudes in the Attitude Study Project. These include noting whether the baby is dirty or clean, well dressed or not, whether the mother sticks the pacifier in his mouth when he is upset, whether she calls him by endearing names or jocularly uses scolding appebla-tions, and in the older child whether she will hit when provoked. Before even going on to the next step, that is, of helping the doctors in analyzing and checking the va-lidity of the conclusions concerning the

parent-child relationship that are drawn

from these observations, it has been found in the Attitude Study Project that the very fact of being encouraged to collect and note these observations sharpens the pediatri-cian’s perceptions and alters his own reac-tions to some of the mothers. Instead of responding to their behavior immediately and more or less intuitively, he develops a more detached interest in the sequence of events that takes place in front of his eyes so many times each working day. For those who are observing, there is no personal in-volvement in this situation and they are completely free to watch the mother’s and baby’s behavior unfold before them-for the examining physician it is a little more difficult to remain objective as he goes through the routines of the visit. Still he has the possibility of creating situations to

test his observations, of channeling the

in-terview and of using the observations in his contacts with the mother as he is mak-ing them. It is interesting that for any new group of pediatricians who present them-selves for training, there never is any dearth of hypotheses to prove or disprove from the start. Almost everyone who has worked with mothers and children has formed generalizations about their behavior that he has never really examined. One ex-ample of this would be the impression held by many physicians and nurses that Negro women are generally more maternal, and that sibling rivalry does not constitute as much of a problem in the large Negro families. Both of these generalizations were used as starting points for initiating more systematic observations and the preconcep-tions were quickly disproved in both in-stances. In addition to informal

observa-tions 2 areas of infant behavior which have been investigated more systematically by Dr. Levy and his associates will be briefly described as examples of an approach.

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con-ditions of the experiment most babies less than 9 months of age gave no evidence of memory of previous injections. In babies 9 months of age and older there were in-creasing numbers of instances of apparent memory of their earlier injections.4’

2) A

second study was concerned with infants’ and children’s resistance to physical

42 Here, as in the “memory of

the needle” study, almost all the participat-ing physicians started out with very definite and often faulty preconceptions. As the study progressed, it was shown that the degree of resistance to physical examination could be correlated in most cases with the baby’s chronobogicb age and not with the mother’s attitude during the examination, the doctor’s technique, presence or absence of the white coat, or other factors that had been considered significant by most of the doctors and nurses. Strong resistance was most frequently seen regardless of other variables in babies between 12 and 36 months of age (with its peak incidence at 18 months), while strong resistance oc-curred with greatly reduced frequency in babies below 12 months and above 36 months.

In this review no attempt will be made to summarize the many published and un-published researches of Dr. Levy”4152 or to describe the results of the varying ongoing research projects of the Attitude Study Project, but the study on resistance to ex-amination is cited here because it, as well as the other research activities of the project, contributes to the pediatrician’s increased objectivity in his approach to the patients. It is customary for pediatricians, especially early in their careers, to be fatigued and upset by the struggling with a resistant baby. The doctor’s exhaustion is often out of proportion to the actual physical strain of the situation (which may also be con-siderable). A number of emotions are called forth by a difficult experience with a re-sistant patient. One of these, to which no pediatrician ever becomes completely im-mune is the feeling of having been rejected because the baby “does not like him.”

Self-blame on the part of the pediatrician who suspects he should have been able to handle the situation more skillfully is an-other frequent reaction, particularly if he allowed himself to get annoyed with his small patient. Anger at the mother for not having handled the child and the conffict better is another possible consequence. These reactions are not conducive to a good relationship between the doctor, parent and patient. Admonishing the pediatrician to avoid emotional involvement is not likely to be very effective. However, if he can be brought face to face with a series of facts as presented in the resistance study and learns that most babies between 18 and 24 months showed 4+ resistance to anything that was done to them, no matter how fine the doctor and how helpful the mother, the pediatri-cian may be helped toward a more de-tached attitude. He may be able to accept 4+ resistance when he meets it in a 20-month-old child as a maturational phe-nomenon unrelated to him or to the mother’s inadequacies. In this state of mind and depending on the needs of the situa-tion, he may be able to calmly decide to defer the examination to a subsequent visit or to do the best he can for now, without feeling tempted to scold the mother or to forcibly examine the baby or to belittle his own pediatric skills.

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the nurse is asked to take the little baby in her arms and walk out of the room with it, there may be an instantaneous dramatic change in the older sibling’s facies and demeanor as if the world looked suddenly brighter. Mothers demonstrate their van-ous reaction to these sibling problems. Some mothers push the older child away roughly in helpless exasperation. Others make room for the older child on the lap that is already crowded with baby, blanket, and pocket book and apologize to the doctor for the older child by offering a sympathetic explanation for his behavior (e.g., “he is little more than a baby him-self, doctor”).

Dependency problems relating particu-larly to preschool and older children have been found to be more quickly perceived by pediatricians from the direct observa-tions that can be made in a few minutes in the office than through historical material obtained by long interviews. There is a wide range of varying dependence shown by preschool children accompanying their mothers for a medical visit. Three- to four-year-olds may insist on physical contact with the mother throughout the visit or may feel free to roam through all the available space and enjoy all the play materials. There are all gradations of willingness to separate from the mother in the age groups from 2 to 6 and all grades of independent performance with the doctor. One observa-tion may be sufficient to give the clue. For instance, if the doctor asks the 5-year-old his name and he turns to his mother for support before risking an answer, this may be sufficient warning to look further for signs of excessive dependency in this boy.

From this simplified account of the kind of observations that are continually availa-ble in pediatric practice and that are syst-matically used in the Attitude Study Project, it may be felt that undue signifi-cance is attributed to minor observations of behavior items which could be based on

many different motivations or circum-stances. In the conduct of the Attitude Study Project this danger is recognized and

isolated observations are not interpreted as signifying attitudes. On the contrary, the emphasis is on following up on suggested findings and on testing them by seeing whether the same constellation of behavior is also observed in other situations with the mothers who prove themselves to have basically different attributes, or with the same mother on subsequent occasions and under different circumstances. Whenever possible follow-up stu(lies are (lone and careful follow-up records are kept on all the patients seen to make possible contin-ned rechecking of the observations.

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average or low maternal.49 At first these sound like value judgments to many of the observers at the Attitude Study Project, but then it is demonstrated that if the pedia-tnician is willing to accept that some mothers are less maternal than others, he will actually become less judgmental and punitive in dealing with his patients. He will be able to advise the less maternal mothers more appropriately than will a doctor who has an implicit standard for the

“normal” mother as a highly maternal, warm, giving, seifiess person, and who meets any failure on the part of his patients to live up to this ideal with disappointment or indignation. Having classified a mother as “average” or low maternal, the doctor may, for instance, encourage her in a plan that would involve having her out of the house and away from the baby for a few hours each day instead of impressing her with the necessity of giving 24 hours each day to direct care of the child, an assign-merit which she might be unable to carry out without resentment and impatience with the baby.

INTERVIEW TECHNIQUES

Both in relationship to physical illness and psychological problems, history-taking and techniques of interviewing are of para-mount importance. Most traditional teach-ing of history-taking to medical students and doctors emphasizes what historical

facts are to obtained without going into the best niethods for obtaining them and little attention is paid to the actual technique of interviewing. Medical educators could profitably incorporate more of the emphasis on interview techniques that has long been prevalent in the training of social workers, since greater skill used in interviewing im-proves the relationship of doctor and pa-tient and also results in more accurate and useful information about the patient.

At the Attitude Study Project an attempt is made to help the doctors and nurses to make their interviews more productive of relevant information without making them excessively time-consuming and without

making them threatening or upsetting to the patients. Here again it is attempted to give the doctors a certain amount of specific content, that is, suggested questions and approaches, so as to give them the means of improving their patient contacts before any basic change in them and their attitude toward the patient could be expected to occur. It cannot be emphasized enough, however, that the fundamental relationship between doctor and patient is of course more important than any particular “gim-mick” that can be suggested for the inter-view. On the other hand, successful use of “gimmicks” in the presence of an awareness of the importance of a relationship may help the doctor in learning more about his patients and consequently in changing his feelings about them. He may be willing. to accept this kind of teaching, where a direct attack on his relationship problems would be doomed to failure.

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be needed in the difficult task of being a housewife and, more particularly, a mother. It leaves the mother free to answer accord-ing to her real feelings. A large variety of responses are obtained. In relation to screening there is one group of mothers who make it clear immediately that they feel they are managing competently; “No, I have no help, but I manage,” or, “No, I don’t have any help, but the baby is so good I get my work done while he sleeps and if my husband and I want to go out, my mother comes over to baby-sit.”

On the other hand a real need for help

and a sense of loneliness may quickly be communicated. “No, I have no help at all, and I’m all alone with the baby. When I first came home from the hosptial, I was so scared of being alone with him, I didn’t know what to do.” Besides a general sense of insecurity, answers to this simple ques-tion may serve to reveal an impressive range of specific relationship problems. “No, I’m all alone with children all day, and when my husband comes home at night, he wants to sit down with the newspaper and doesn’t want to be bothered,” may be a response that is more indicative of the nature and the shortcomings of the marital relationship in the home than the answers that are

usually yielded by more direct, threatening questions concerning the relationship, such as “Do you and your husband get along well?”

Problems in relation to grandmothers or other domineering relatives are often brought up: “Help? Do I get any help? I get so much help that I hardly know that I’m able to take care of my own baby. Between my mother and his (husband’s) mother and a few of the other relatives, they are always telling me what to do.” In addition to relationship problems and feel-ings of insecurity, the answers to this ques-tion may of course consist of straightfor-ward, practical information concerning ma-terial needs, housing problems, etc., which although as deserving of attention as the others, will not be detailed here. This par-ticular question has all three of the

attni-hutes that Dr. Levy postulates as essential if a question is to prove useful, namely:

1) It is easily understood; 2) It is accepted by mothers;

3) It produces useful information in a short period of time.

Other simple questions used by all physi-cians, such as “How are things going?” also fulfill these requirements. All of these are “open-ended” questions in the sense that they do not presuppose a specific short answer, i.e., cannot be answered by “yes” or “no” but give the mother the opportunity to formulate her concerns. Even, “How do you and your husband get along?” is more likely to help the mother express her-self than, “Do you and your husband get along all right?”

Another consideration that is stressed in the teaching at the project has to do with the fact that whenever possible, the physi-cian must eliminate his own preconceptions, standards, and expectations from the manner of questioning. Otherwise, the pa-tient will attempt to live up to the required expectation rather than responding freely and accurately. Many examples could be cited to illustrate this. For instance, it has been the accepted teaching on the part of those who are interested in the “mental hygiene” orientation to pediatrics that it is better for baby and mother to have the mother hold the baby while she is giving him a feeding than to let him have the bottle “propped” in the crib. Nurses and doctors used to ask mothers, “Do you hold

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him, and how often do you have to let him take the bottle in the crib?” was the first version of this question that was tried and when asked in this form, it disclosed that practically all the mothers were propping some of the feeding bottles each day. It also became apparent that many of them be-lieved that when a baby reaches a certain age, it is safe to prop his bottle-whereas, in his first few weeks he needs to be held. After this was observed, another question was used, “How old did you feel the baby had to be before he could take some of his feedings in the crib?” and here again the mothers responded readily and did not hesitate to admit to bottle propping. Naturally, if they feel strongly about hold-ing the baby, mothers are quick to so state even if the question is asked in a way that admits of both possibilities.

Another area that can be inquired into more successfully when these considera-tions are kept in mind is sibling rivalry. Every pediatrician has had the experience of asking a mother, “Is Johnny jealous of the baby?” and of hearing her answer, “No, he loves the baby.” almost as if she were fending off an attack on the good character of her older child. When mothers in the Health Department were queried as to whether their older child “shows jealousy toward the baby,” most of them denied this but when later they were asked, “Does he show the usual jealousy?” a much greater proportion of them were able to answer in the affirmative. More recently, the question, “Can you leave the children in a room to-gether?” has been experimented with, and it has been found that very helpful in-formation concerning sibling rivalry can be quickly elicited. A mother may be most definite in the early months that she would not leave the 3-year-old brother near the baby without watching them very care-fully, and at a later date volunteer that now she knows it is safe to leave the two

to-gether for a period of time without fearing mayhem. This question has the additional advantage that it relates specffically to the mother’s every day, practical experience in

the situation instead of being aimed di-rectby at the underlying relationship prob-lem. This makes it easy for her to answer and also makes the answer more reliable.

In relation to spanking a young child for

his misdemeanors, most mothers feel quite guilty and they are often reluctant to ad-mit that they spank at all. It may be help-fub for the mother to be able to discuss her feelings about this and here again one might ask, “How often do you find you have to spank him?” indicating an acceptance of the fact that the mother might have had to resort to this practice when she found her-self unable to cope with a difficult situation. If she admits to spanking and indicates that she feels guilty afterward and that the spanking doesn’t help, the doctor can sympathize by some statement, such as, “Many mothers get trapped that way,” and continue to give her the opportunity of discussing the situations in which she feels overwhelmed. Since most mothers do not hit their child in a calm considered moment as a disciplinary method but do so in mo-ments of stress, a discussion of the problem in an understanding way will probably leave the mother feeling less guilty, less tense, and less likely to be forced into a corner where she has to strike out at the child again, than she would be left if the physician approaches her in an authoni-tarian manner and adds to her sense of inadequacy and guilt over her imperfect handling of problem situations.

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their OWfl shortcomings and fear the judg-ment of doctors and other authorities. They attempt to gain approval where possible and often hide information because of fear of censure, even concerning minor matters. A mother will ask, “Is it O.K. to start giving cereal to the baby now, doctor?” If he says “yes,” she is apt to answer with all signs that she is pleased and relieved : “Oh, I’m glad you think so, because I started to give it to him last week and he seems to like it so much.” Obviously such a mother is not looking for information but wants approval. If the doctor says it’s not all right, she will

not mention that she has tried it but will probably continue to give the cereal which she started to give for reasons of lien own. She may, however, feel a bit more anxious lest she is not doing the best for her child which will make her more hesitant both to use her common sense independently in the care of her child and also more hesitant to discuss other questions freely with the doctor. It should not be inferred that by listening in an accepting fashion to the mother’s account of her situation and her reactions, the doctor necessarily implies

approval but it is expected he indicate

inter-est and understanding before he gives forth

with any specific judgment or specific ad-vice that indicates criticism of the mother’s current practices.

In the realm of the more emotionally charged material put forth by mothers, how does the interview continue after the mother has been given the opportunity to express her feelings in the manner that has been indicated? In a general way the same principles are used, that is, the physician indicates acceptance of the feelings that are expressed and responds by indicating this rather than by expressing his reactions, opinions, or hastening to give dogmatic counsel and so preventing the mother from further expression. It has been observed by those who have worked in this field in van-ous settings (psychiatrists, social workers, counsellors, etc.), that the very process of expressing feelings and discussing situa-tions that have given rise to anxiety helps an individual to gain a clearer

understand-ing of himself, increased insight into his I)rollems an(l iii some cases a sense of

mastery and relief of Dr. Senn in the same article that was alluded to formulates this process very clearly : “As the interview proceeds, the patient through talking out often consciously becomes

aware of the real difficulty and now with his new insight is in a position to assume responsibility for himself and for the work-ing out of his problems.”

For instance, if a mother expresses con-cern over a child’s eating, claiming, “He doesnt eat a thing,” with all signs of in-tense anxiety, while it is obvious on inspec-tion of the child that his state of nutrition in no way justifies lien anxiety, the doctor is helped to see that lie must not let himself be trapped into focusing all his attention on discussion of the child’s nutrition but that the real problem is the mother’s feelings about his eating and that lie must respond to these feelings rather than to the objective findings concerning the child. If lie im-mediately assures the mother she has “nothing to worry about,” this will be cold comfort to her who obviouslij is worried

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nothing more specific than an indication that he is responding to her feelings as she expresses them, will give the mother a sense of relief, help her from a state of diffuse anxiety and frustration to a better realiza-tion of the roots of her problems and an increased confidence that she can cope with them.

It may be asked, doesn’t this kind of interview take a tremendous amount of time? It does not have to. On not a few occasions students at the Attitude Study Project were impressed with the amount of progress that could be observed in 5 or 10 minutes. On the other hand, every pediatrician knows how endless can be the kind of tug-of-war that results if the other approach is used, that is, if the pediatrician persists in his attempts to convince the mother that she has no serious problem and that the child is o.k. and has eaten enough, which only spurs on the mother toward more desperate insistence that he is eating nothing and toward more determined efforts to prove to the doctor that she does have a serious problem.

This kind of reasoning applies to all prob-lems that concern mothers no matter what they have reference to. Sleep problems on closer inspection often reveal themselves as problems neither to the baby non to the mother but to the household routine, to a hard-working father or to the neighbors in the building. Often when the mother has the chance to work this out, she is much less worried. In other cases where the problem has been unravelled the physician is in a better position then to offer advice and reassurance.

There are 2 indications that can be used to determine which problems will not re-spond to a simple educational approach or to straightforward reassurance but need further investigation of the mother’s atti-tudes and feelings as suggested:

1) If the usual education and reassurance is obviously in no way getting across to the mother and effecting no change in her

atti-tude.

2) If the mother’s affect in presenting her problem appears disproportionate to the

magnitude and severity of the problem as it is manifested objectively.

There are, of course, situations where the physician must do more than simply to take verbal cognizance of the mother’s attitudes and feelings as she expresses them in order to help her reveal the nature of the prob-lem. One may have to use statements such as, “Many mothers find that they are not able to feel the same closeness to each of their children because some babies take cuddling better than others,” to

a

mother who has indicated that her problems in disciplining one of her sons may have to do with guilt feelings over her lack of posi-tive response to the child in question. Again the emphasis is on accepting and general-izing the feeling expressed so as to permit

the mother to face it ind see it in perspec-tive rather than letting her be motivated by her deeper feelings to what she herself knows rationally to be inappropriate be-havior.

Not all physicians in the Attitude Study Project have the opportunity to participate in or observe the various fine facets of interviewing, but most of them do become more perceptive and gradually acquire a sense for using their observations of the mother and her attitudes as a guide in con-ducting their therapeutic interviews with her.

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sphere. The combination of presenting them with techniques of obtaining informa-tion, and confronting them even for a short exposure with some of the actual case ma-tenial, stimulates a more objective interest that leads to a better relationship with the patient, a better understanding and conse-quently a sounder approach to therapy. Having a small anmamentarium of stand-ardized questions to try has the advantage of providing a structured situation in which

responses can be compared where in the absence of any systematic approach, the physician is overwhelmed by what appears to be an aggregate of qualitatively differ-ent individual problems that cannot be classified or generalized about.

It may be asked whether the techniques suggested do not lead the pediatrician be-yond his depth and get him involved in psychological problems with which he is not trained to cope. It has been the experi-ence at the Attitude Study Project that this approach is less likely to lead the pediatri-cian afield than the more direct probing questions that are so commonly asked con-cerning maternal attitudes and family re-lationships, (“Did you want this baby?” “Dd you want a boy or a girl?” etc.). With the nondinective kind of opening questions indicated, mothers will raise only subjects they wish to discuss and feel up to dis-cussing. The doctor does not introduce anything threatening into the situation by his questions or by the advice that he offers,

as will be described below. If a mother is so disturbed that she introduces serious psychopathology into hen contact with the doctor, this approach will help him to recognize the severity of her disturbance and earmark hen for referral more quickly than would have been possible in a more traditional interview.

ADVICE AND REASSURANCE

It must be reiterated that this paper is to deal with those aspects of pediatrics that do not easily lend themselves to fitting into the time-hcnored pattern of medical practice. In the traditional conduct of medical

prac-tice, the patient presents a specific medi-cal problem for which the doctor prescribes medicaments and other treatment measures

to be carried out, or in pediatrics, the mother brings her child to be examined. If the doctor finds something wrong, he pre-scribes for it. If not, he tells the mother that the child is fine and gives her specific advice concerning her care of the child. This kind of practice does not present any problem to the well-trained pediatrician. If he encounters a mother who refuses to follow his advice where he feels it is im-portant to do so, he will not hesitate to use forceful methods to persuade her. If a mother refuses to subject hen baby to pentussis vaccination, he points out the dangers of pertussis in the very young child and uses his authority to enforce his recom-mendation for the vaccination. If she re-fuses to co-operate with any important treatment, he does not hesitate to point out that she owes it to her child to co-operate with the doctor and that she is in effect a “bad mother” if she refuses to do so. The extreme situation of this kind is probably the one in which the doctor advises hos-pitalization or operation and the mother refuses. In this event, the doctor may make the mother sign a “release” which spells out the fact that she is not following the doctor’s recommendation and that she is personally responsible for any unfavorable consequence. For legal reasons such a docu-ment is sometimes necessary. It may also

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use of authority and fear. However, at least in these situations the doctor is sure of the medical needs in the situations and of the appropriate therapy so that he might be justified in being authoritarian and even rigid about the advice.

There are many more occasions, however, when the doctor is consulted about prob-lems which are not so serious and problems which are not so well understood that he cannot be sure that one method of dealing with the problem is definitely the best or the only one. Most of the situations that arise in the day-to-day care of a child and almost all problems relating to child rearing or emotional difficulties fall into this

cate-gory. It is interesting to observe that the advice that is given in these areas is often delivered with just as much authority and is also enforced by means of awakening and accentuating parental anxiety and guilt. One of the working hypotheses at the Atti-tude Study Project is that in these areas different viewpoints and other techniques are more appropriate and more helpful to the mothers and children involved. This category of “advice and reassurance” repre-sents another focus of study and training for the pediatrician at the Attitude Study Project.

One of the most interesting files at the Attitude Study Project is one that is labelled “mothers’ own resources.” It con-tains a collection of the methods for sobv-ing assorted problems that have been devised and used by the mothers who bring their children to the Well Baby Clinic. The various methods that are described are of intrinsic interest-some are bizarre, some eminently sensible, and many of them ap-parently were effective in solving the prob-bern for which they were devised. Looking through this collection increases one’s re-spect for the perceptivity and ingenuity that mothers show in bringing up their children. It also demonstrates impressively that any particular problem may be handled successfully by a number of mothers in many different ways. It also be-comes clear that a perceptive mother may

devise a method appropriate to the needs of a particular child and then have enough sense to use a different approach with another one of her children who presents the same specific difficulty but has a differ-ent personality makeup and different needs. In addition to the fact that this material is interesting, there is an important benefit to be gained by establishing such a file and by the collection of the data for it. The natural prompt response of a physician when presented with a problem is to offer a solution or prescription or specific advice to the patient. Depending on his interest

and his sensitivity to the personality and circumstances of the patient, he may at-tempt more or less individualization of his advice. Certain basic considerations are usually kept in mind. For instance, it has become a standing joke that the doctor must not prescribe a vacation in Florida to a patient who cannot afford a day’s out-ing in a local suburb. When it comes to the subtler factors that limit a patient’s ability to accept and carry out advice, there are many instances where such caution is not observed. To some mothers, it is as impossi-ble to “ignore” the child’s food intake or to “bet the baby cry it out” or to “give more attention to the older child after the new

baby is born,” as it is for a poor person to vacation in Florida. In this case the limits are not financial, but psychobogic, social or cultural. But although they may assess the patient’s monetary resources, many physi-cians make little attempt to assess other re-sources and deficits before prescribing for a patient.

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are then encouraged to consider any prob-lems presented in the light of their evalua-tion of mother and child.

In addition, they are encouraged to pen-petuate a tradition that is well established among physicians, especially among derma-tobogists. For instance : Whenever a good dermatologist looks at a skin lesion, before he prescribes his therapy, he asks, “What have you been using on it so fan?” The reasons for this are obvious. He wants to know whether the previous therapy has helped, has made things worse, on has effected no noticeable change. This aids in his understanding of the lesion and also prevents him from making the error of prescribing a remedy that has been found to be ineffective or harmful (this error, when it occurs, is doubly damaging because it will also undermine the patient’s confi-dence in the physician). For various reasons, pediatricians, especially when they offer ad-vice concerning psychological problems and child-rearing, very frequently neglect this essential step in prescribing treatment. It may have to do with the fact that they often have a strong emotionally rooted opinion as to what is the proper method for mothers to use with their children and do not even consider alternative methods. In this unstructured and ill-understood seg-ment of pediatrics, there is so little content that can be learned and analyzed rationally that the pediatrician probably has to fall back on his own prejpdices and emotional biases rather than objectively considering alternative approaches and deliberately choosing the most appropriate. In the Atti-tude Study Project an effort is made to present the pediatricians again and again with the varying solutions that mothers have used successfully to show that in this field more than any other, there is no single good or best method and that the advice that is given must be acceptable to the mother and must be such that she is able to carry it out. One simple question doctors are encouraged to ask before offering ad-vice concerning problems of feeding, sleep-ing, habit training, discipline, dependency

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may enable her to stand her ground. 5) She will not have the feeling that the doctor glibly offered a solution without under-standing the content and severity of the problem. (It has been observed that methods advocated by the doctor may, at times, be almost sabotaged by the mother as part of her campaign to convince the physician of the severity of her problem and the difficulty of its solution if she has felt the doctor to be insufficiently im-pressed.)

This approach also leads to a changed relationship between doctor and mother. Instead of feeling as if he has been burdened by the mother with a terrible problem which he must now proceed to solve, the doctor finds himself able to listen to the problem and then to book with inter-est and increased respect to the mother when he turns to her to find out what she

has thought of doing and how she is going to solve her problem. The reaction, “Oh dear, now what am I going to do about this mess!” which is usually productive of some anger at the mother for infficting the mess on the doctor, is gradually changed to “This is certainly quite a mess. Now I wonder how she is going to work it out?” Not infrequently, doctors who have partici-pated in the Attitude Study Project will re-mark that they feel their job becomes so much easier with the realization that they neither should nor can solve the patient’s problems. Also, the resentment toward the mothers who are “unco-operative” is de-creased and replaced by an investigative attitude in which the doctor becomes inter-ested in the factors that stood in the way of successful treatment. Going through some of the steps that have been outlined will prevent some of the unnecessary feelings of anxiety and guilt on the part of mothers that may arise from being told donatically that “you must never punish a child for wetting his bed,” or, “You must not pick up the baby whenever he cries,” or, “You must not attempt to bowel train the baby until he is at least 18 months old,” at a time when she may already have engaged in

some of the practices that are being cate-gorically condemned. Her guilt feelings will be even stronger when as is not un-common these admonitions are accom-panied by hidden or overt threats of horn-ble consequences that will occur if the ad-vice is not followed: “It has been found that babies who are toilet trained too early are more likely to be bed wetters or de-vebop behavior problems,” for instance, or, “If you pick up the baby every time he cries, he will become a spoiled brat.” On hearing this, the poor mother feels she has done irreparable harm to her child and feels that everything else she has done and will do on her own may also have dire consequences. This can largely be avoided by having the doctor inquire carefully into the mother’s ongoing practices before launching into specific advice.

There will, of course, be many instances where the physician will need to advise the mother to change her handling of the child, but this can be done in much less upsetting fashion if he is aware of the mother’s current and past practices. (“Do you find that you have to put him on the toilet many times a day to catch his bowel movement? Well, perhaps it would be well to wait awhile, until he has a more regular pattern and could give you a signal when he needs to go. After all, he is not yet 1.” or, “Do you think you could hold out 10 or 15 minutes when you hear the baby cry because by then hemight be ready to go back to sleep on his own? Time yourself and try it a few times.”)

When more specific and more dogmatic advice is given at the Attitude Study Project an effort is also made to do this in such ways that the advice can be understood and can easily be carried out by the mother. Instead of admonishing the harried mother of a jealous sibling, “You must show more love and affection to the older child,” an order that she will have difficulty in

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hour’s exclusive time each day to the older boy?” She usually is able to work this out fairly easily and will feel satisfied with her-self for living up to the counsel which she was given instead of continually assuming that all her difficulty with the older child arises because she is “not showing enough love and affection.” It is interesting that this exclusive half-hour has not infrequently contributed considerably toward the im-mediate relief of some of the behavior symptomatic of acute sibling rivalry. Ap-parently the older child’s feeling of frustra-tion and resentment at having his previous close relationship with his mother disturbed is sometimes greatly diminished when there is one period each day when he can count on having his mother all to himself and when his needs are the primary considena-tion. Not rarely, as the mother notes the good response of the child to this half-hour, she finds ways and means for additional special times. There are other specific bits of advice that are offered frequently at the Attitude Study Project such as the sugges-tion that a mother hold out without giving in to the child in situations where disci-pline is a problem. Instead of advising the mother to be “gentle but firm,” on “firm but kind,” an admonition which is at best quite unclear and difficult to live up to, she is first asked, “What is the longest you ever held out without giving in to him?” She is apt to say that it has been a long time, but when she times herself, it usually reveals itself as a maximum of 5 minutes which seems long to her when the child is crying. After this she is asked if she thinks she could hold off for 10 on maybe 15 minutes before giving in. She is advised to time hen-self with a clock and to enlist the co-opera-tion of her husband in the experiment. Her visit for follow-up is scheduled fairly soon. This leaves her with a circumscribed as-signment, one in which she can check her-self and has a fighting chance of succeeding, and the opportunity to return to the doctor before her enthusiasm wanes on her con-viction weakens. Again, if she notes bene-ficial effects, for instance, if the baby goes

off to sleep promptly for a few nights instead of there being the usual long, nerve-racking battle, she is likely to go beyond the limited scope in which the advice was offered. She may have gained enough confidence to at-tempt to assert herself in some other situa-tion and each success spurs her on to other efforts. It has been observed that offering such simple specific prescriptions for mothers to follow in attempting to solve their daily problems with their children has been effective as an initial step in many different problem situations of varying severity. Of course, in approaching mdi-vidual problems in this specific, circum-scnibed way, nothing basic is being done to alter the mother’s attitudes toward her child. However, it has been found that often symptomatic treatment, where it is successfully carried out by the mother, is an important step in helping hen to develop confidence in herself and her own ability, and that this in itself will have a beneficial

effect on the basic relationship.

Making the recommendations cincum-scnibed and fairly easy to follow results in having the mother go beyond what was demanded of hen and letting her use her own ingenuity in implementing the pninci-ple that was the basis for the recommenda-tion. On the other hand, when general, not specific, advice is given such as “ignore it,” or, “be firm,” the only way in which the mother could feel she was really able to carry out the recommendation would be if she were able to improve her handling of the child in every situation that arises in the course of 24 hours, 7 days a week. Since such a total change cannot be expected to

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as much on the child’s needs to the excbu-sion of the mother’s needs and reactions. There is a well-known tendency for pedia-tnicians to identify with the child for whom they are caring and to be so intent on in-terpreting the child’s needs to the mother and on instructing the mother in her duties to the child that the mother’s own reactions are ignored. In the various activities at the Attitude Study Project, the pediatrician’s attention is forcibly drawn to the mother’s behavior, her responses to the child, and her capabilities as well as deficiencies so that the doctor is placed in the position of a mere objective counsellor to mother and

child instead of being partisan on the side of the child in the mother-child relationship. This emphasis on having the pediatrician an impartial observer of family relation-ships as he confronts them instead of be-coming more emotionally involved and more identified with one or the other mem-bens of the family, is carried farther than just into the relationship between mother and child. It is this relationship that the pediatrician most frequently has to work with but where other family members enter in-husband, grandmother, etc.-an effort is again made to evaluate them objectively in their relationships and not to take sides in any conflict.

There have been many occasions when grandmother, mother and child were in the examining room together and when the competition between the two women for the child was demonstrated dramatically to the group. The tendency of the younger pediatrician if he has achieved a real inter-est in the mother and in the child will often be to censure the grandmother in a feree-ful manner and to admonish her to leave the care of the child to its rightful mother. By upsetting the grandmother, he is doing no good to anyone in the situation. If she has been a domineering family member, her momentary loss of face will not basi-cally change her position in respect to the family group. However, she will become

angry and may do either of 2 things: 1) She may resent the mother for, as she

feels it, having misrepresented the situation to the doctor so that it made her, the grand-mother, look in the wrong. If so, she will find ways and means of taking it out on her daughter and none will be the better for the display of opinion from the doctor. 2) She may resent the doctor for his attitude. In this case, she will use her not inconsiderable influence to undermine what this doctor has been encouraging the mother to do or may even persuade the daughter to leave this doctor, who, as she sees it, showed such poor judgment.

If, on the other hand, as Dr. Levy has demonstrated frequently at the Attitude Study Project, the doctor can include the grandmother in his planning and concen-trate on her resources rather than on the havoc she may have wrought, she will often be quite receptive also to a plan that has evolved. Dr. Levy will often ask such a grandmother, “When you and your daughter enter a room together, to whom does the baby hold out his arms?” Some grandmothers respond immediately, others stop to think; but whatever the answer, this kind of question appears to help them con-siden for a moment where they fit into the family picture. “You’ve been a great help to your daughter with the baby. You must have taught her a lot. Do you think she might be ready to take over a larger share of the baby’s care now?” is another possi-ble approach to the grandmother. Again, the situation is so set up that no one is being condemned and a direction for per-ceptive constructive development is

mdi-cated without censuring the status quo cate-gorically.