A Family Systems Approach to Pediatric Care
Carol Hubbard
William Lord Coleman
I. Description of the issue. Pediatric clinicians know well the impact that family function has on children. Behavioral, emotional, or physical complaints in a child may be a manifestation of underlying distress in the family system. Just as children are affected by their families’ well-being, children’s own health and behavioral issues can, in turn, disrupt the family balance, may make parents feel frustrated or powerless, and strain marriages and other relationships. In 2002, the American Academy of Pediatrics (AAP) Task Force on the Family summarized a large body of research about families, concluding that children’s physical and emotional health and cognitive and social functioning are strongly influenced by how their families function, and that there is much pediatric clinicians can do to nurture and support families. In this and other policy statements, the AAP has suggested that pediatric clinicians assess family relationships, health and behaviors, screen and refer parents for physical and emotional problems when needed, and practice “family-centered care,” on the basis of collaboration with families and recognition of their strengths, an important component of an effective medical home. Professionals who treat children are uniquely positioned to positively impact family functioning, as they may be the only ones in regular contact with the family during the early years of a child’s life.
A. The pediatric clinician’s attitude toward families. Sometimes pediatric clinicians may label challenging families as “dysfunctional,” “resistant,” and “noncompliant.” Instead, viewing family members as “multistressed” and identifying their strengths can enable clinicians to be more supportive and empathetic. Thinking of family members as separate from the constraints or problems in their lives allows the clinician to view the “problem as the problem, rather than the family as the problem”—an approach known as “externalization.” The clinician can become more aware of the family’s strengths and resources by getting to know about the family outside the context of the problem. Remaining respectfully curious and interested in a family, and believing that it has the capacity to grow and change, builds a collaborative relationship and gives a sense of hope to both the family and the clinician.
B. The importance of language. By listening carefully to the words family members use and the “stories” or narratives they tell to explain their experiences, pediatric clinicians can learn much about their attitudes and values. Ambiguous or emotionally laden terms should be clarified (e.g., what a father means when he says “pops” his son when he misbehaves). Respectfully clarifying language is especially important when working with families from different cultures. By listening carefully and using the family’s own words and phrases, the clinician can more effectively communicate with them. In addition, making the extra effort to learn and use family members’ names (rather than the generic “Mom” or “Dad”), in addition to the child’s name, powerfully conveys the clinician’s interest in the whole family.
II. Assessing and addressing problems within a family context
A. How family issues present. Parental or family medical and/or social-emotional health issues and other stressors should be explored in the initial family history and/or while providing ongoing care for a child. Some parents/caregivers may be open in discussing broader family issues and seeking guidance, but others may not perceive such issues as falling in the province of the pediatric clinician. The clinician should be aware of clues or “red flags” that raise the suspicion of underlying family stress (Table 8-1).
B. Shifting the focus from the child to the family unit. Techniques that can help to explore a problem within a family context include the following:
1. Showing empathy for parents by acknowledging the impact of the child’s problem on the family: “This must be a challenge for you all to deal with as a family. How are you handling it?” An opportunity for such a comment can occur when parents use the term “we” to refer to the people affected by the child’s issues.
2. Asking directly “Who are all the people affected by your child’s medical (or developmental or behavioral) issue?”
Table 8-1. “Red Flags” for potential family factors in a child’s presentation
1. An ambiguous chief complaint or reason for the visit
2. Recurrent, multiple, or chronic complaints without an obvious medical explanation
3. Lack of improvement of symptoms with standard therapy
4. Sudden unexplained changes in a child’s behavior or health
5. Unusual parental concern or anxiety about a child
6. Concerning parental behavior and affect (anger, hopelessness) in the office
7. Obvious conflict or estrangement between family members
8. Conflicting or very different parenting styles
9. A major family transition or crisis
3. Soliciting family members’ opinions about the source of the difficulties, “What do you think is going on?” and inviting them to work together with you to address the problem.
C. Gathering family information. Information gathering can sometimes jump start the therapeutic process toward better family functioning by encouraging family members to think about the issues involved. History taking also provides an opportunity for the clinician to comment on a family’s strengths and past efforts to address problems. Key areas to consider are found in Table 8-2. It may take more than one visit to obtain a detailed family history, or family information may unfold over time as a pediatric clinician cares for a child and his or her relationship with the family grows. Further techniques for understanding a family include.
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