Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Tuesday, June 21, 2011

Storytelling As Treatment for Common Childhood "Behavior Problems": A Clinical Example

I am most grateful to my patients, who are often my best teachers. I am moved to write about them, to spread the knowledge they have given me to a larger audience. Of course confidentiality is my top priority, so I aim to protect my patients' privacy while staying true to their story. This past week in the KevinMD newsletter, there was a piece about the new discipline of narrative medicine, which looks to literature and the power of stories to enhance the practice of medicine. The following encounter, from my behavioral pediatrics practice, is a perfect example of the power of storytelling.

Eighteen-month-old Joe was drinking up to 5 six ounce bottles a day. "He won't eat anything else, but when I say no to the bottle, he screams. It's just easier to give in." Joe's mother, Sandra, had been advised at multiple visits to the pediatrician that she needed to stop. He was at risk for nutritional problems including iron deficiency anemia, and his teeth were being damaged when he fell asleep with the bottle in his mouth. Yet despite having this information, Sandra was unable to set limits with Joe. Her pediatrician referred her to me.

I met with Joe and his mother for one 50 minute visit. We sat on the floor and talked while Joe played. He was a delightful boy who was very curious and quickly got absorbed with the selection of toys. He looked healthy and robust. His mother started the visit telling me that she knew she just needed to get rid of the bottles, but that she couldn't bring herself to do it. Rather than focus on what to do, I asked her to tell me about her pregnancy and Joe's infancy. Sandra was from Ecuador, and she had met her American husband when she came to the US as a student. They had gotten pregnant much sooner than they planned. Sandra's mother was unable to get a visa and had never met Joe. I asked Sandra what it was like to have a new baby without her mother nearby. "It's terrible," she said. Her husband worked long hours and she had only recently begun to make friends. She spoke with her mother on skype, but, she said, "for Joe she's not a real person." This made her very sad because her mother so much wanted to be involved as a grandmother. In contrast, her mother-in-law, who lived nearby, did not show much interest in helping her with the baby.

Sandra spoke of great difficulty nursing in the first days, when Joe did not latch on well. "He never would have survived in the wild," Sandra told me. She conveyed sense that both she and Joe had failed in some way. I pointed out that "in the wild" she would never have been alone without extended family.

Sandra began to talk about how things were so different in Ecuador. Parents were in charge of what their kids ate, and there was none of this "offering choices" that so many had advised her to do. In addition, a fat baby was a sign of a healthy baby. Sandra felt that to fail to feed you child was to be a failure as a mother.

Then Sandra remembered that she herself had been a very skinny child. In fact, she recalled her mother telling her stories about when Sandra was an infant and the other mothers would say to her mother, "What's wrong with you that you starve your baby?" Yet Sandra recalled that she was a very busy active child, very much like Joe, who often didn't want to be bothered with eating.

"It sounds like you are having s similar experience with Joe to what your mother experienced with you," I said. Sandra was quiet as she seemed to be thinking this over. "You're right," she said. "Maybe this is more about me than about Joe."

We spoke some more about Joe's behavior around eating and the differences between American and Ecuadorian ideas about raising children. I said that she would have to decide what she wanted to do, but that I thought that if she continued to battle with Joe around eating, this would likely continue to be a problem. My only "advice" was that she consider giving Joe more independence to feed himself. We made a follow up appointment in a few days, when her husband would be able to come.

"I got rid of the bottles," Sandra told me as soon as we were settled on the floor. Joe once again was contentedly playing. "How did he do?" I asked, surprised by this rapid development. "Well he cried at night, but he seems OK during the day." Then she told me that he had eaten some new foods, and was interested in what another child was eating at a play date. "I knew everything we talked about last time. I just didn't want to do it." "What made the difference?" I asked. She claimed that she had realized she needed to protect his teeth.

We talked some more about bedtime and some other parenting issues that they had been struggling with. I asked if she wanted to schedule another appointment. "Well, we solved the problem," she said. She told me that she would call if things did not continue to go well.

In this age of "evidence-based medicine" I wonder how I would design a study to show if telling her story to a supportive non-judgmental person was the reason Sandra was finally able to follow through with what she knew she needed to do. Would one group get standard "advice" while the other had the opportunity to sit on the floor and tell their story? I'm not a researcher, but from what I know about research, designing such study to have statistical significance would be very difficult. All I can say is, "I was there." I am pretty sure that having her story heard was what enabled her to act. I'll leave it to the researchers to prove it.

2 comments:

  1. This is a great illustration of why randomized control studies can not be the gold standard of psychotherapy outcome research, and why such studies of CBT are of limited usefullness in the real world.

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  2. This made me think of an interaction I had with my 4 year old this morning... As she was talking with me about something she asked me to not speak so loudly that her daddy could hear what I was saying. After feeling curious about this with her, she was able to remind me that SHE wanted to talk to her daddy herself. I let her know that I understood that it was important that I not deprive her of the opportunity to use her own words and experience to share her thoughts and feelings with her father rather than having to listen to my words and interpretation. It was an important reminder for me as a parent and clinician.

    Angelina Ramos-Marchand, PsyD.

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