SPECIAL ARTICLE How I Got to Be What I Wanted to Be

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SPECIAL ARTICLE

How I Got to Be What I Wanted to Be

Morris A. Wessel, MD

I

t is a unique honor to receive the Aldrich Award. I first became aware of Andy Aldrich in 1942, my third year in medical school, when I discovered Babies Are Human Beings1 in the Yale Pediatric Li-brary. This book set a goal as to the kind of a pedi-atrician I hoped to become.

I was fortunate in 1947 to receive a Pediatric Fel-lowship at the Mayo Clinic. I sought this position because of my interest in the Rochester Child Health Project that Dr Aldrich created to serve children and to study “what a child is doing in the process of growing up.”2I recall with appreciation Dr Aldrich’s extraordinary clinical skill and his ability to discuss young children’s behavior in language easily under-stood by students and house officers.

This award is particularly meaningful as I recall many discussions with Dr Aldrich 50 years ago dur-ing my Fellowship at the Mayo Clinic.

I wish to discuss briefly the contributions of six previous recipients of the Aldrich Award, namely Benjamin Spock, Edith Jackson, Milton Senn, Albert Solnit, Sally Provence, and Anna Freud. These teach-ers were important mentors during my training. They had a passion for ideas, a clarity about what they believed, and a love of communicating with students and house officers. Their approach has par-ticular relevance today as the role of the primary pediatrician assumes increasing importance in the reorganization of the health care system in this coun-try.

I first met Ben Spock in 1947 when he joined the staff of the Rochester Child Health Project. His per-sistent commitment to a pediatrician’s role as a citi-zen inspired me to assume a comparable position in my community. Also, like so many other pediatri-cians, I readBaby and Child Care3from cover to cover! In 1948, I received a Fellowship in the Rooming-in Project in the Department of Pediatrics at Yale New Haven Hospital. Rooming-in, an elective lying-in ar-rangement for mothers and infants began at Yale in l946 under the direction of Dr Edith B. Jackson.4

Fellows interviewed couples who chose the room-ing-in plan. It was surprising to me that women, and men too, eagerly shared their concerns with a pedi-atrician. I also discovered that many expectant fa-thers experienced morning sickness, food fads, and abdominal discomfort during a wife’s pregnancy. Rooming-in Fellows assumed pediatric care of in-fants during the lying-in period, visited homes a few days after discharge from the hospital, maintained frequent phone contacts, and provided well-baby care for the first year of life.5

Dr Edith Jackson, a distinguished senior member of the Pediatrics Department met with Fellows daily. Her unwavering concern with the welfare of parents and infants encouraged Fellows to place high prior-ity on the role of a pediatrician during the initial phase of family life.6

I reviewed my notes of the prenatal conference before examining a newborn infant at the mother’s bedside. I found it helpful to be familiar with the specific interests, family medical history, details of pregnancy, and specific areas of concern for each set of parents. I soon learned that many normal features of the neonatal examination, such as contour of an infant’s head, dilated capillaries of the eyelids, and blue tinge of the extremities concerned many par-ents. They were reassured when I noted the normal-ity of these findings. Mothers often remarked, “How did you know I was worried about the shape of my baby’s head, the eyelids, and the blue color of his hands and feet?” The neonatal examination usually revealed a rapid heart rate when the infant was crying. However, a few infants presented a slowed heart rate during these stressful moments. I won-dered, and still do, whether this cardiac response represents a life-long reaction to stress. I assumed that I had made an original observation regarding autonomic activity in newborn infants. I discovered recently that Julius Richmond and his colleagues7 reported this variation in cardiac rate 45 years ago. I am pleased to be in good company!

House calls during the first week at home famil-iarized Fellows with the “baby blues,” the tendency for mothers to experience tearful moments often without any discernible reason. We also learned that many women in the initial weeks of parenthood experience a transitional state during which they are almost totally preoccupied with caring for their in-fant. They often have little interest in the world about them. This phase, designated as “primary maternal preoccupation” by Donald Winnicott,8a British

psy-From Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut.

Presented at the Section on Developmental and Behavioral Pediatrics, American Academy of Pediatrics Annual Meeting, November 2, l997, New Orleans, LA on receiving the C. Anderson Aldrich Award in Child Devel-opment.

Received for publication Jan 23, 1998; accepted Jan 23, 1998.

Reprint requests to (M.A.W.) Department of Pediatrics, Yale School of Medicine, 61 Elmwood Rd, New Haven, CT 06515-2241.

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choanalyst who was originally a pediatrician, is fa-miliar to obstetricians and pediatricians. Many cou-ples wondered whether this state represented a serious psychologic disturbance. They were relieved by my comment, “Many women find the first weeks of motherhood exhausting. It is quite normal for a new mother to be totally preoccupied with the baby. I have noted that usually by 6 or 8 weeks mothers do begin to regain interest in the world about them.”

I believe that a pediatrician’s interest in parents during the pregnancy, lying-in period, and initial weeks at home with a new infant establishes early in the relationship one’s concern with their lives. It initiates a trusting bond with parents that in later years leads to a comparable relationship with chil-dren and adolescents.

There are as all pediatricians recognize, infants who are “highly perceptive,” that is, they perceive external and internal stimuli more intently than most infants. This terminology characterizes the unique-ness of these infants and decreases parents’ feelings of failure as they struggle to comfort their infants. I always commented during the visit, “Babies with this nature are difficult to care for. You are doing a great job!”

Dr Milton Senn,9 who had assumed the director-ship of the Yale Child Study Center in 1948, was well known for his leadership in training pediatricians to comprehend the behavioral aspects of growth and development. The Child Study Center under Milton Senn’s creative leadership achieved international rec-ognition as a center for the study of behavior in early infancy, toddler, and school years, and for the treat-ment of children experiencing difficulties dealing with developmental challenges or unusual stresses in their lives.

In 1951, Dr Senn added to his responsibilities the Chairmanship of the Department of Pediatrics at the Yale Medical School. I was pleased when he invited me to join with Dr Albert Solnit, who was well trained in pediatrics and child psychiatry, and Mary Stark, a seasoned social worker, in the teaching pro-gram for third year medical students during their assignment in the pediatric clinic. Two distinct mem-ories stand out as I recall this experience. Dr Solnit and Miss Stark broadened tremendously my under-standing of the meaning to parents and children of the illness, injury, or behavior that motivated their visit to the clinic.

Equally vivid in my memory is the eagerness with which students and house officers integrated this comprehensive approach as they dealt with parents and children.10On many occasions the clinic served families experiencing the birth of a child with a sig-nificant handicapping condition or the onset of a chronic illness. Mary Stark’s and Al Solnit’s11 discus-sions sensitized me to the enormous task these par-ents face. As they mourn the loss of the healthy infant they anticipated producing, the parents must assume care of the child who differs greatly from their expectation. I gained tremendous admiration for parents as they assumed nurturing roles in this difficult situation.

A former patient, now an adult, recalled recently

that as a healthy sibling she felt deprived when parents, and physicians too, were preoccupied with the needs of her handicapped sibling. I quote with her permission, “All those years my sister was so sick, I felt that I never had a mother, a father, or a doctor. When I came to your office your first words were always. ”How’s your sister?“ Her memory of my greeting was correct! I am grateful that her ments served as a reminder to initiate visits in com-parable situations with ”How haveyoubeen?“

In 1954, Dr Sally Provence of the Child Study Center invited me to participate in a study of the relationship between perinatal stress and infant de-velopment. Formerly a practicing pediatrician, Dr Provence joined the staff of the Child Study Center in l948. She was skilled in evaluating development in infancy and toddler years.12Under her supervision, I learned to assess development in the first 3 years of life. This training was invaluable in my practice. I continue to evaluate development of infants and tod-dlers as a pediatric consultant at Clifford Beers Guid-ance Clinic in New Haven.

Sally Provence alerted me to the fact that parents often misinterpret normal behavior in young chil-dren. For example, during the second half year of life, mothers frequently comment, “Last month I could leave my baby with my mother when I went shopping. Now he cries when I walk to the door. What did I do wrong? How did I spoil him?” I learned to respond, “Your baby’s behavior suggests that you have done something right! He is now suf-ficiently mature to appreciate your good care. He prefers you to anyone else, even his grandmother!” Usually a mother smiles, cuddles her infant against her body, and places a light kiss on the top of his head. Some mothers however, find this behavior less satisfying. I recall a discussion with a group of ado-lescent mothers who felt put upon by their infant’s attachment, even though I considered this action as evidence of excellent nurturing. Sally Provence em-phasized the importance of comprehending the meaning of an infant’s or child’s behavior to parents in terms of their needs and interests.

One day I was preparing a mother of a 6-month-old infant for the appearance in the next few months of the preference for the primary caretaker. She sud-denly burst into tears! When I asked why she was upset, she responded, “I am the breadwinner in our family. My husband is unemployed. He has cared for the baby since he was a month old. Bobby prefers him to me!” I then understood her tears! Many par-ents consider it a failure in nurturing when a toddler treasures a blanket, bottle, or toy when leaving home or going to sleep. They were relieved when I shared Sally Provence’s explanation that this behavior indi-cates that a toddler has been well nurtured. He uses his treasured item as a little bit of his mother while venturing away from her presence or separating at bedtime.

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delighted to discuss these important psychologic concepts with a parent and an infant as a living example. I was troubled however, when a student commented, “I heard all that jazz in lectures. I never thought it had any relevance for what I would do as a practitioner.”

I was pleased on my retirement from practice in 1993 to receive letters from many pediatricians re-calling spending a day with me during medical school and recalling the value of these discussions of behavior in early childhood. I am convinced that practicing pediatricians have a unique opportunity to serve as mentors for students and house officers! When parents reported that an infant or toddler was more demanding than usual, or suddenly awak-ening at night, I wondered what might be happawak-ening in the family. Milton Senn emphasized that a par-ent’s verbalized complaint often represented a desire to discuss other concerns. The simple question “How have things been going with you?” encourage a mother to discuss crises in the family. “Well, just now when I’m so tired with my pregnancy,” or “ I’m so upset that my husband is considering a new job and we may have to move again,” or “I’m worried sick about my mother who has cancer” were com-mon responses. A parent’s preoccupation with a spe-cific family crises influences the manner in which she nurtures her child. Toddlers sense these changes and often react by demanding increased attention. I also discovered that a young child who suddenly is de-manding may be reacting to the absence of a favorite staff member at day care or nursery school.

No matter how I tentatively assumed the basis for a child’s behavior, I always proceeded with an ex-amination. On many occasions I discovered that a healthy appearing child suffered from an unsus-pected otitis media, a foreign object in the external ear canal, or an inguinal hernia. In rare instances, I observed widespread adenopathy, an abdominal mass, hypertension, or other significant findings. I once discovered a small open safety pin in the phar-ynx of a toddler. I also learned that an examination, even when normal, was reassuring to both a child and the parents.

I wish to mention the contributions of Anna Freud. Although I did not have the privilege of working with Miss Freud, her writings profoundly influenced my understanding of children’s behavior.13Her early reports in Vienna in the l930’s and later in London conceptualize her ideas of child development and the way in which children handle stressful situations. She frequently quoted a folk saying, “Children often take two steps forward and one step backward.” She maintained that children often resolve problems on their own particularly if they have the affectionate and attentive understanding of parents and teachers. I believe she included pediatricians as a resource! There are of course children whose symptoms persist as they experience overwhelming family stresses or significant developmental delay in one or more ar-eas. They merit thorough evaluation and therapeutic intervention.

Parents frequently seek advice in preparing a young child for the birth of a sibling. They often

consider it their failure if an older child demonstrates jealousy toward a new sibling. Nothing could be further from the truth! The challenge is to help the older child deal with the inevitable feelings of dis-placement when a infant joins the family. Suggesting that feeding time for the infant be a party time with milk, fruit juice, or crackers for an older child is one way of easing tensions.

Children often demonstrate unique ways of cop-ing with a new siblcop-ing. Two children I knew sug-gested that the baby be put out for adoption. It will be no surprise to pediatricians that the father was a member of the Adoption Committee of the American Academy of Pediatrics and a member of the Board of the Child Welfare League of America!

I recall in the days of house calls having mothers phone stating that a child was feverish, listless, and irritable. When I arrived at the home, the child would seem only mildly ill. Mothers often remarked, “When I told him you were coming, he improved immediately.” I assumed that the child, confident in my ability to cure his ailment and knowing that I was coming, was relieved and able to return to normal activity. Anna Freud clarified this behavior in a lec-ture at Yale Medical School in 1950.14 She empha-sized that a major stress for a child during an illness is that parents frightened because of the child’s symptoms lose the capacity to nurture their child in their usual manner. I understood then that it was the parents who were relieved. Reassured that I would arrive soon, they were able to resume care of their child in their customary manner. The child thus re-lieved was able to return to some of his normal activities.

As children reached early adolescence I would seek an opportunity to comment to the patient in the presence of a parent, “Sometime in the future you may wish to change to another doctor. I can under-stand your feelings. I will suggest a good doctor for you. I want you to know that while you remain under care here, you have the right to a confidential relationship. What we discuss will be between us. If I think you have a serious health problem, we will decide together how to share this information with your parents. Your mother and father also have a right to a confidential relationship when they have concerns about you.” Having offered young patients the opportunity to seek medical care elsewhere, the majority remained in our care through adolescence and frequently into early adulthood. They appreci-ated being considered as individuals in their own right rather than as an appendage to their parents. Parents having developed trust throughout the years were relieved to know the doctor they knew so well would be available for their adolescent son or daugh-ter and also confer with them as necessary.

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disturb-ing to parents. They may not realize that rapid growth, increase in concentration of hormones, and changes in appearance often cause an adolescent to feel like a stranger in his or her body!

I remember a boy in the midst of his rapid growth phase who plopped into a kitchen chair with such force that he and the chair tipped over. As he crashed to the floor he grabbed the table cloth dragging the dishes and silverware on top of him. His parents did not know whether to laugh or cry. The boy resolved the crises exclaiming with a laugh, “Me and my crazy growing body!”

Serving both generations was challenging and sat-isfying to me. I am reminded of Anna Freud’s com-ments concerning adolescence in Worcester in 1957,15 “It may be his parents who need help and guidance so as to be able to bear with him. There are few situations in life which are more difficult to cope with than an adolescent son or daughter during the attempt to liberate themselves.”

I treasure a letter from a woman now in her thirties who wrote upon my retirement from practice. I quote with her permission, “I liked coming to you as a teenager because you always made my mother feel better about me.”

Throughout my years of practice I spent one day a week in community activities. Thirty-five years ago I served as school physician in an inner-city school. One day—30 years ago this month—a beloved first-grade teacher suffered a fatal heart attack in the hall. The principal requested that I meet with the children. I shall never forget this experience. The principal introduced me by saying, “You all know Dr Wessel. He’s going to make you feel better.” He then walked out the door! I had no idea what to do next. I finally said, “When someone we love dies, we are very sad. Some people like to cry, others like to listen to music or talk about memories of the person who has died. Others like to draw pictures, or just sit quietly and think about the person. What do you feel like do-ing?” The children knew what they wanted to do! “We must go to see her. Could we go now? Please take us in your station wagon.”

I struggled to think of an appropriate response. Nothing in my training at Yale Medical School, Ba-bies Hospital, or Mayo Clinic prepared me for this task! Patty, a 7-year-old with long pigtails and shin-ing black eyes, suddenly commented, “I don’t think it would do any good if we did visit Mrs. Smith. My dog was hit by a car last week. I found him lying by the road. He was stiff and cold. When I petted him, he didn’t know I was there. Mrs. Smith wouldn’t know either!”

Patty’s experience with the death of her dog en-abled her to comprehend the reality of being dead and to share her understanding with her classmates. I listed on the blackboard a list of the children’s pleasant memories of Mrs. Smith’s activities. We later requested the school secretary to transcribe these comments for the teacher’s husband.

This experience led me to concentrate in my prac-tice far more than I had previously on reaching out to families when they experienced the death of a loved

one. I commented to parents at the initial visit to our office that I hoped they would call me when they experienced significant family crises. It soon became common for parents to seek our help in supporting a child at tragic moments.

I learned that bereaved children and adoles-cents, just as adults, often experience somatic symptoms and fear they are about to die. I re-spected every call from a child, adolescent, or par-ent regarding symptoms. The examination usually revealed no serious illness. This was reassuring to both generations. However, I recall that 15 years ago I cared for an 11-year-old boy with no previous gastrointestinal history who experienced the onset of a bleeding gastric ulcer a few weeks after his father’s death.16I remember also that Michael Co-hen and his colleagues17at Einstein reported a series of children with gastric ulcers who had suffered a recent loss of an important person in their lives.

I will conclude by recalling another experience. My partner, Robert LaCamera, and I were sitting with the parents of an adolescent boy who had fallen off a cliff and sustained a critical head injury. He was being maintained on life support. One electroenceph-alogram had revealed no activity. We were awaiting the results of a second electroencephalogram. If this too revealed no activity, I commented that the end of his life was upon us. Suddenly the mother said, “I’m sitting here with my husband remembering the day we came to see you during our pregnancy. You were there at the beginning and now you are here at the end. Thanks for always being available.”

This mother sums up the potential role of a pri-mary pediatrician far better than I can express it. My goal was to use my relationship with families to maintain a child’s health at as high a level as possible and to enhance the capacities of parents and children to meet effectively the stresses in their lives.

I appreciate this opportunity of sharing memories of my 43 years of pediatric practice. I feel very much a part of a timeless continuity of values that binds pediatricians together as we care for children and families.

I realize that managed care is upsetting to physi-cians. We have a greater challenge than ever before because the primary pediatrician’s role is enhanced. I believe that the motivation that led us to become pediatricians will enable us to master current chal-lenges and provide the best possible care when par-ents entrust their children to us in sickness and in health. We also have an important role as mentors for students and house officers.

REFERENCES

1. Aldrich CA, Aldrich MM.Babies Are Human Beings: An Interpretation of Growth. New York, NY: Macmillan; 1938

2. Helmholz H. C. Anderson Aldrich. In: Borden Veeder, ed.Pediatric Profiles. St Louis, MO: Mosby; 1957:229 –244

3. Spock B.The Pocket Book of Baby and Child Care. New York, NY: Pocket Books; 1945

4. Jackson E, Olmstead R, Foord A, Thoms H, Hyder K. A hospital rooming-in unit for four newborn infants and their mothers.Pediatrics. 1948;1:28 – 43

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6. Wessel M, Blodgett F. Edith B. Jackson, M.D. and Yale Pediatrics.Conn Med. 1962;26:438 – 441

7. Richmond J, Lipton E, Lustman S. Autonomic function in the neonate III. Cardiac rate and skin temperature responses in newborn infants.

Psychosom Med.1955;17:425– 476

8. Winnicott D. Primary maternal preoccupation. Collected Papers— Through Paediatrics to Psycho-Analysis. New York, NY: Basic Books; 1958:302–305

9. Senn M. Relationship of pediatrics and psychiatry. Am J Dis Child. 1946;71:537–549

10. Senn M, Solnit A. Teaching comprehensive pediatrics in an out-patient clinic.Pediatrics. 1954;14:547–556

11. Solnit A, Stark M. Mourning and the birth of a defective child. In:The Psychoanalytic Study of The Child. New York, NY: International Univer-sities Press, Inc; 1961;16:523–537

12. Provence S.Guide For The Care of Infants In Groups. New York, NY: Child Welfare League of America; 1967

13. Freud A.Normality and Pathology In Childhood. Assessments of Develop-ment. New York, NY: International Universities Press, Inc; 1965 14. Freud A. The role of bodily illness in the mental life of children. In:The

Psychoanalytic Study of The Child. New York, NY: International Univer-sities Press, Inc; 1952;7:69 – 81

15. Freud A. Adolescence. In:The Psychoanalytic Study of The Child. New York, NY: International Universities Press, Inc; 1958;13:255–278 16. Wessel M, McCullough W. Bereavement-an etiologic factor in peptic

ulcer in childhood and adolescence?J Adolesc Health Care. 1982;2: 287–288

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DOI: 10.1542/peds.102.2.384

1998;102;384

Pediatrics

Morris A. Wessel

How I Got to Be What I Wanted to Be

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DOI: 10.1542/peds.102.2.384

1998;102;384

Pediatrics

Morris A. Wessel

How I Got to Be What I Wanted to Be

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