On Making a Difference

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on

Making

a Difference

Morris Green, MD

From the Department of Pediatrics, the Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis, Indiana

A question being much discussed today, here and

elsewhere, is how to be helpful to all children and their families, especially those who are highly vu!-nerable and at special risk. It is a question that also intrigued Abraham Jacobi, a vigorous advocate for

children and a vocal opponent of practices and

conditions he viewed as inimical to their best inter-ests.

Now, as in Jacobi’s day, the privileged status that

society confers on the professions carries implicitly, and increasingly explicitly, the charge that they remain responsive to the needs of the times. In the

case of pediatricians, there is the expectation that

we will do whatever is in our individual or collective power to help children and their families master

the rapid changes and risks that confront them

today. Pediatricians are being challenged increas-ingly to become involved in social as well as biomed-ical issues and to promote healthy adaptation as well as growth and development.

PEDIATRICS AND ADAPTATION

These remarks on the potential role of pediatri-cians in promoting adaptation to developmental,

social, educational, and psychosocial issues call for

an extension of their traditional role in helping

children and parents cope with biomedical

prob-lems.”2 As exemplified in Table 1, such adaptation

may be biomedical or psychosocial and prospective, concurrent, or rehabilitative. For successful

adap-tation to occur, the child or adolescent must

ad-vance from the “Risk” box in Figure 1 to the one

Received for publication Jun 13, 1990; accepted Oct 3, 1990

Presented, in part, on the occasion of the Abraham Jacobi Award, American Academy of Pediatrics Spring session, Seattle,

Washington, May 1, 1990.

Reprint requests to (M. G.) 702 Barnhill Drive, Indianapolis, Indiana 46202-5225.

labeled “Mastery.” Those who end in the box

la-beled “Maladaptation” are life’s losers, penalized

by symptoms, poor functioning, and unhappy

fam-ilies.

Table 2 is a list of groups of children, adolescents, and families currently at risk in our society.3’4 Those who confront a cluster of risks are in double,

triple, or even quadruple jeopardy.5 For example, a

child with a learning disorder may be poor, have epilepsy, live with a depressed mother in a single-parent household, and receive inadequate remedial education.

The outcome of the process of adaptation is vec-tored by the quantity and quality of protective and mediating factors available to contain an

individ-ual’s vulnerabilities.6’7 Table 3 is a list of some of

the protective factors which contribute to resiliency or “invulnerability.” One may predict confidently that a child or adolescent blessed with most of these

traits will do very well indeed; those who have few

such traits in the face of multiple vulnerabilities are destined by and large to have suboptimal or even tragic outcomes.

I have begun to develop an office screening

in-strument to identify such protective factors or

strengths as well as vulnerabilities as part of the

assessment of a child or adolescent when seen for health supervision or for a psychosocial, educa-tional, developmental, or biomedical disorder. The presently available behavioral screening checklists, which focus predominantly on problems and

symp-toms, are not very useful in transforming early

intervention approaches from deficit-based models

to those that also build on present or potential

strengths. Sharing with parents and children an

accounting of their strengths as determined by such a screening assessment will help to validate their

sense of efficacy and to promote the

physician-patient alliance. Parents are more likely to listen

(2)

Fig 1. Flowsheet for adaptation.

TABLE 1. Adaptation of Children and Parents

I. To biologic stressors A. Prospective

Immunization

Exercise-induced bronchospasm B. Concurrent

Antibiotics for meningitis

Insulin, fluids, and electrolytes for diabetes

C. Rehabilitative Birth defects Head injury

II. To psychosocial stressors

A. Prospective

Adoption

Hospitalization/surgery

B. Concurrent

Birth of an infant with a handicap

Death Divorce

C. Rehabilitative School avoidance Conversion disorder

The pediatrician’s role in promoting adaptation

includes, first, assessing the balance between the

patient’s protective factors and vulnerabilities and,

second, helping him or her develop additional

strengths. This is shown diagrammatically in

Fig-ure 2 as a balance with the patient’s protective factors or strengths loading the scale pan on the

right and their vulnerabilities loading the one on

the left. When this adaptive balance is in

equilib-nium or tilted to the right, the physician’s interven-tions need to be only minimal, eg, anticipatory guidance or suggestions for concurrent adaptation to relatively minor problems.

When, however, the balance is weighted toward

the left, the pediatrician can explore with the

fam-ily, child, or adolescent how they might develop additional strengths, ie, build up weights on the

right. This alternative kind of psychosocial, devel-opmental, and educational “weight” training may include, for example, developing social skills in a 10-year-old girl who is shy, encouraging a father to

spend more time with his underachieving son, tu-toning for a child having trouble with mathematics,

or referring a depressed mother for psychiatric help.

Gradually shifting the balance to the right in this

fashion may be a powerful intervention. Only a few

“grams” may be added to the scale pan as a result

of a visit, but just the right word at the right time

from a trusted pediatrician, the reinforcement that comes with a physician’s transmitted confidence

that the patient can do it, thoughtful suggestions

that might be tried, and access to other appropriate

professionals may make a large difference even

when the problems manifested by the patient

mi-tially seem overwhelming and intractable. In this

fashion, on occasion and seemingly magically, one

may transform a tiger of a problem (Fig 3) to a

pussy cat (Fig 4)! This is a highly gratifying

expe-rience for a clinician and a life boost for the child. In the hands of a skilled and thoughtful

pediatri-cian and with adequate community resources, this

recombinant process of splicing new adaptational and coping skills into a patient’s or family’s reper-toire is highly effective. It represents, in its own

way, a kind of recombinant biology that can be

applied practically by the practitioner in everyday practice. In addition to the help provided by the individual pediatrician, high-risk groups weighted

with multiple vulnerabilities need medical care that

is linked to organized and responsive nursing, social

work, and home visiting services.

TABLE 2. Children and Adolescents Potentially at

Risk

. Children living in poverty (20%)

. Single parent families (22%)

. Children with chronic illness or handicap

. Pregnant adolescents

. Abused and neglected children

. Children of divorce (1 million/y)

. Children in foster care (250 000)

. Adolescents in detention (>250 000)

. Children of alcoholic, emotionally ill, or otherwise

dys-functional parents . Risk-taking adolescents

. Adolescents who abuse alcohol and drugs

. Drug-exposed infants (375 000/y)

. Children exposed to environmental hazards . Absence of prenatal care (1 of 4 pregnant women) . Low birth weight infants

. Infants and children with acquired immunodeficiency

syndrome

I Emotionally ill children and youth (estimated to range from 11% to 19%)

. School drop-outs; illiterate children

. Children who have unemployable parents;

unemploya-ble adolescents

. Those with no health insurance coverage (up to 12 million children and adolescents)

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+

TABLE 3. Selected Protective Factors Which Contribute to Resiliency

. Temperament or disposition characterized by a positive mood and flexibility

. A supportive social network and positive role models: parents, relatives, teachers, and other significant adults and peers

. The feeling that one is loved and valued by parents and other significant persons

. Social skills; one or more close friends; ability to mobilize social supports; ability to ask for help with comfort

. Parents who allow age-appropriate autonomy

. Availability of parents at times of failure; to buffer and protect the child against excessive stress

. Ability to define and persist in achieving goals

S Sense of belonging to and active participation in a valued group S Physical fitness, endurance, and vigor

. Normal intelligence and good health

. Strong personal sense of competence based on achievements, successes, special interests, or talents

. A view of the world as coherent and controllable . Opportunities for mastery of new challenges

. Expectation of personal success . Positive perception of events

. Belief in ability to modify one’s behavior constructively

. Recognition of one’s effort and achievement by parents and others

. Ability to form trusting relationships

S A sense of responsibility for one’s own health

. Ability to enjoy life and to have had some joyful experiences

. Family warmth, cohesion, support, communication, and mutuality

. Ability to express feelings

. High self-esteem and constructive assessment of personal capacities

. A sense of efficacy; the belief that one knows what to do and can do it

. Access to educational, vocational, and social opportunities

. Presence of a positive value system

Fig 2. Adaptive balance.

j

Fig 3. Negative adaptive balance.

PEDIATRIC COMORBIDITY AND SHARED

ETIOLOGY

Comorbidity, a term more traditionally

consid-ered in relation to the multiple disorders of the elderly or to psychiatry, is equally applicable to pediatric patients, especially when psychosocial,

family, and community morbidity is included. The

high prevalence of comorbidity in those who live in poverty, for example, needs to be reflected in their diagnostic assessments. That they are not included

customarily is attributable to lack of an adequate

pediatric nosology for family, community, and

so-cia! disease and to the absence of a tradition of

complementing the internal with the external

as-pects of medicine.

There is also increased recognition that many maladaptive symptoms and disorders emerge from common root causes. Such intertwined etiologies are at least additive but more often multiplicative.

These interrelationships may be shown graphically

in the form of a “life cycle” as shown in Figure 5

and with side chains as shown in Figures 6, 7, and

8.

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0

- _

Fig 4. Positive adaptive balance.

Marital Difficulties

Family Stressors

Lack of Values

‘I Lack Social Supports

Negative Peer Influences

Poverty Dysfunctional

, Family

Family

Violence/Abuse Poor Schools

t

Fig 5. Life cycle.

Poor

Parent-child Relationship

simplified fashion, in vivo, they would look more like the spider web shown in Figure 9. Enmeshed, suspended in time and space, feeling helpless and hopeless, such patients and families are unable to

extricate themselves without intensive

interven-tion. Interrupting these dysfunctional and devel-opmentally regressive life cycles is a daunting task.

It is difficult to change familiar life patterns; new

support networks may not be adopted quickly; and

social transplants simply may not take.

THE

ADAPTATION

OF THE

COMMUNITY

PRACTITIONER

Adaptation at the community pediatric practice

level is an emerging frontier in pediatric education,

care, and research. What can pediatricians do to

make a difference at this relatively new cutting

edge? How can the pediatric office serve more ef-fectively as a community-based parent and child

resource center? How can we help break the

dys-functional chain reactions that threaten the future of many of the nation’s children?

Responses to these questions include the

follow-ing:

I

LIFE

t

CYCLE

Serious Parental Mental Illness

Divorce

Diminished Economic Resources

Frequent Moves

1

Moratorium For Parenting

I

Emotional Symptoms in Child

Fig 6. Life cycle: side chain associated with parental mental illness.

S The staging of primary ambulatory care into

three levels of service rather than only the one

implied by the term “primary care” is a concept

whose time has come.8 To convey its complexity adequately, general pediatric care should be staged into Levels I, II, and III. In addition, these stages should be reflected in levels of

reimburse-ment.

Analogous to the traditional division of

hospi-tal-based practice into primary, secondary, and

tertiary care, the three hierarchal levels of

am-bulatory care shown in Figure 10 are defined by

the time required for a specific service; the train-ing, experience, and competence needed to

pro-vide the care; the complexity of the problem; and whether the pediatrician works alone or as a

member of a team. The time allotted by

practi-tioners to these three levels of care will depend on their special competencies, the needs of the

population they serve, and organization of their practice.

These levels apply to health supervision

serv-ices as well as to the diagnosis and management

of problems. Whereas a well-organized, low-risk

family may need only Level I health supervision,

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I

LIFE ‘

CYCLE

Fig 9. Spider web.

The Hospital The Community

Fig 10. Staging of pediatric health care.

STD

Vehicle Accident

Fig 7. Life cycle: side chain associated with risk-taking behaviors.

p

LIFE

‘ CYCLE

ADD/Hyperactivity

Learning Disability

I

Poor Peer Relationship

Depression

I

Conduct Disorder

I

School Drop-out

I

Ethnic Prejudice

I

Unemployment

Fig 8. Life cycle: side chain associated with ADD (at-tention deficit disorder).

Risk-Taking Behaviors

1

Cigarette Use

Alcohol Use

I

Conduct Disorder

Substance Abuse

1

Sexual Activity

Level II or III services.9 Levels I, II, and III apply to personal, one-to-one care, the predominant

daily work of the pediatrician. Community or

level “C” care, an increasingly full-time, part-time, or voluntary role of the pediatrician, is

concerned with the health of populations of

chil-dren. This includes improvement of access, the

coordination of care, and the establishment of community resources responsive to identified

needs. Just as hospital-based supporting services are essential to care for children with serious

biomedical illnesses, community-based resources

are required for the care of patients with Level II and III developmental, educational, and/or psy-chobiologic problems.

. Seeing more of these problems in their current

practices, many practitioners wish to augment their psychotherapeutic skills. A number of ex-cellent books, tapes, articles, continuing medical

education courses, and minifellowships on the

psychologic and developmental aspects of

pedi-atrics help meet this need; however, in my view,

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such competencies is through continuing

partic-ipation in what I have termed Collaborative

Of-flee Rounds groups. A group that consists of seven

to eight pediatric practitioners, a pediatrician

interested in developmental psychobiology, a

child psychiatrist, and a child psychologist meet

regularly approximately every 2 weeks to discuss

the treatment of patients currently being seen in

the practice of one of the pediatricians. Several

Collaborative Office Rounds groups have been

funded recently by the Bureau of Maternal and

Child Health, and I would encourage this

ap-proach as an effective continuing pediatric

edu-cational strategy for the American Academy of

Pediatrics.

. For practitioners to provide an increased amount

of Level II and III care, reimbursement for

cog-nitive services must be available. The lack of

adequate payment is a major impediment to

in-elusion of such care. A positive change would lie

in the proposed adoption of a resource-based

relative value system for reimbursement of

med-ical care. For populations at special risk, funding

also should be provided for social work, nursing,

and home visitor services.

C The pediatric practitioner has experience with

some types of pediatric morbidity that for a

num-ben of reasons are not experienced or discussed

during residency training. In front-line settings,

the initial complaints, their duration, and patient

expectations often differ from those in teaching

hospitals with their nonrepresentative patient

populations. In addition, the practitioner gains

the long-term view of a child, family, or problem

made possible by continuity of care. Such rich

case experience and naturalistic observations

need to be added to the cumulative knowledge

base of pediatrics. Transmission of that

knowl-edge to others may be achieved either by the

individual practitioner publishing reports based

on his or her individual experiences or through

collaboration, as in the Pediatric Research in

Office Settings program of the American

Acad-emy of Pediatrics.

C In addition to one-to-one health supervision

vis-its, some practitioners schedule group sessions

for parents with children in the first 2 years of

life. There is also a growing emphasis on parent

education through newsletters, handouts,

audi-otapes, and videotapes.

. Self-administered and automated screening

as-sessments are being explored along with

corn-puter-generated reports, including focused health

education advice. Based on an individual

assess-ment of a parent on child’s questions, presenting complaints, and family protective

factors/vulner-abilities, a current and periodically revised

Per-sonal Health Plan, analogous to the Individual

Education Plan, may be computer-generated.

This process would include an individualized

printout of specific advice, anticipatory guidance,

and a listing of family strengths.’#{176} Where

mdi-cated, the printout would also highlight one or

more specific objectives to be accomplished by

the child, adolescent, or parent before the next

visit. Personal Health Plans would be especially

important for children and families with

long-term disorders. Such Personal Health Plans

would document for health services researchers

and third party payers the content of pediatric

care currently being delivered in various settings.

. Pediatric participation in planning, consultation,

or direct service in community settings such as

schools, child care centers, and public health

de-partments is an established tradition. ln the care

of individual patients many pediatricians now

work collabonatively with social workers and

psy-chologists in their offices or in other sites, but

continued effort is needed throughout the country

for the further development of community-based

diagnostic and treatment resources to

comple-ment and supplement those available to the

prac-titioner.

. Coordination of services, especially when various

elements of a Personal Health Cane package are

given in many sites by multiple professionals, is

an appropriate role for the pediatric office serving as the child’s medical home. For highly vulnerable

families and groups, the organization of care must

integrate medical with other health and human

services. Whereas some sophisticated and

resili-ent parents successfully traverse the maze of

community or regional services, those who are

less resourceful or assertive become lost or

de-Spain of the dead ends, barriers, and Service gaps

they confront. The practitioner may elect to be

the case coordinator or may delegate that role to

another person in the office or community.

. Because community ecology and resources play

such an important role in child health, it is

ap-propniate in 1990 for Departments of Pediatrics

to establish Sections of Community Pediatrics,

as some have already. Progressive departments

will, I believe, add to their residency programs

more of the content and skills needed for

pedia-tnicians to work in community as well as hospital

settings.” In those educational rotations,

pedi-atnic practitioners will be the teachers, and

pedi-atnic offices on community child health centers

will be the training venues. In the future,

accred-itation of pediatric residencies may require this

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. Not all the changes in our society have been

regressive or hazardous for the development of

children. Progressive advances include Public

Law 94-142, the Education for the Handicapped

Act, and Public Law 99-457, the Amendment to

the Act for intervention programs for 0- to

3-year-olds; the concern expressed by business and

government leaders about child and adolescent

health, development, and education; the presence

of several coordinated, comprehensive

commu-nity systems for children, adolescents, and

fami-lies; the growth in home care and

community-based services for children with special needs; the American Academy of Pediatrics initiative to gain

increased access to health services through health

insurance for all children and pregnant women;

the growth of school-based health clinics; and the

improved education of pediatric residents in the

psychosocial and developmental aspects of child

health.’2”

. Continued responsiveness and renewal in pedi-atnic education and practice and in public policy for children at state and national levels would be facilitated considerably by the establishment of

one or two National Academic Centers for

Corn-munity Pediatrics. I would also hope that

Corn-munity Pediatric Interdisciplinary Program

Grants would be made available to promote a

productive collaboration between departments of

pediatrics and departments and schools of

behav-ioral and social science, nursing, education,

man-agement, public health, business, and

govern-ment.

. Finally, we must augment actively our individual

and joint community, state, and national

advo-cacy for child and adolescent health.

Eric Erickson concluded his 1973 Jefferson

Lee-tures with the valediction, “Take Care.”4 He

fur-ther expressed the hope that those two words would

“come to mean more. . . than we should be careful,

or take care of ourselves.” These remarks outline

some of our present opportunities to meet

Enick-son’s challenge. ln so doing, we can make a

sub-stantial difference in the lives of children.

REFERENCES

1. Green M. Pediatric education and the care of the person.

Pediatrics. 1986;78:431-437

2. Cohen F, Lazarus RS. Coping and adaptation in health and illness. In: Handbook of Health, Health Care, and the Health Professions. New York: The Free Press; 1983

3. Alpert JJ, Weitzman M. An overview of childhood mortality and morbidity. In: Green M, Haggerty RJ, eds. Ambulatory

Pediatrics. Philadelphia: W. B. Saunders Co; 1990:4-9

4. Starfield B, Katz H, et a!. Morbidity in childhood: a longi-tudinal view. N Engl J Med. 1984;310:824

5. Garmezy H, Rutter M. Acute reactions to stress. In: Child

Psychiatry: Modern Approaches. 2nd ed. Oxford: Blackwell

Scientific Publications; 1985

6. Dugan TF, Coles R, eds. The Child in Our Time: Studies in the Development of Resiliency. New York: Brunner/Mazel; 1989

7. Masten AS, Garmezy AS. Risk, vulnerability, and protective factors in developmental psychopathology. Adv Clin Child Psychol. 1985;8:1

8. Green M. Coming of age in general pediatrics. Pediatrics. 1983;72:275-282

9. Green M. Behavioral and developmental components of child health promotion: How can they be accomplished?

Pediatr Rev. 1986;8:133-141

10. Elias MJ. Long-term social adaptation. In: Green M, Hag-gerty RJ, eds. Ambulatory Pediatrics. Philadelphia: W. B. Saunders Co; 1990:64-68

11. Green M. Building a model in educating pediatricians to

provide access to primary care. Proceedings of a conference

on Educating Pediatricians to Provide Ascess to Primary

Care, Easton, Maryland, June 6-8, 1989. Supported by the Bureau of Maternal and Child Health, US Department of

Health and Human Services. 1989:27-32

12. The First Sixty Months and Bringing Down the Barriers.

National Governor’s Association, 444 North Capitol Street, Washington, DC 20001

13. Schorr LB. Within Our Reach: Breaking the Cycle of Disad-vantage. New York: Doubleday/Anchor Books; 1988

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1991;87;712

Pediatrics

Morris Green