Behavioral Consult

Ghost busting in pediatric primary care


As clinicians trained in the care of children, we have struggled in recent years with how much care is appropriate to provide to the parents of our young charges.

A doctor talks to patients Ridofranz/Thinkstock

Gradual progression has occurred from recognizing postpartum depression as affecting infants, to recommending screening, to creation of a billing code for screening as “for the benefit of” the child, and increasingly even being paid for that code. We now see referral of depressed parents as within our scope of practice with the goal of protecting the child’s emotional development from the caregiver’s altered mental condition, as well as relieving the parent’s suffering. Some of us even provide treatment ourselves.

While the family history has been our standard way of assessing “transgenerational transmission” of risk for physical and mental health conditions, parenting practices are a more direct transmission threat, and one more amenable to our intervention.

Aversive parenting acts happen to many people growing up, but how the parent thinks about these seems to make the difference between consciously protecting the child from similar experiences or unconsciously playing them out in the child’s life. With 64% of U.S. adults reporting at least one adverse childhood experience (ACE), many of which were acts or omissions by their parents, we need to be vigilant to track their translation of past events, “the ghosts,” into present parenting.

Just ask

“I barely have time to talk about the child,” you may be saying, “how can I have time to dig into the parent’s issues, much less know what to do?” Exploring for connections to the parent’s past in primary care is most crucial when the parent-child relationship is strained, or the parent’s handling of typical or problematic child behaviors is abnormal, clinically symptomatic, or dangerous. Nonetheless, helping all parents make these connections enriches life and meaning for families, and dramatically strengthens the doctor-family relationship. Then all of our care is more effective.

In my experience, this valuable connection is not difficult to make – it lives just below the surface for most parents. We may want to ask permission first, noting that “our ideas about how to parent tend to be shaped by how we were parented.” By simply asking, “May I ask how your parents would have handled this [behavior or situation]?” we may hear a description of a reasonable approach (sent to my room), denial that this ever came up (I was never as hardheaded as this kid!), blanking out (Things were tough. I have tried to block it all out), or clues to a pattern better not repeated (Oh, my father would have beat me ...). This question also may be useful in elucidating cultural or generational differences between what was done to them and their own intentions that can be hard to bridge. All of these are opportunities for promoting positive parenting by creating empathy for that child of the past to carry forward to the own child in the present.

While we may be lucky to have even one parent at the visit, we should ask the one present the equivalent question of the partner’s past. Even if one parent had a model that he or she wanted to emulate or a ghost to bust, the other may not agree. Conflict between partners undermines management and can create harmful tension. If the parent does not know, this is an important homework assignment to being collaborative coparents.

Next Article: