1. There is not enough time to delve into
psychosocial problems, such as a mother who is depressed. It
does take time, but there are ways to briefly assess and address these
problems, playing a valuable gatekeeper role. It is also a matter
of setting priorities. If these are serious and prevalent problems
affecting children, they deserve attention; other issues may be given
less time (eg, listening to the lung bases in an asymptomatic child
in a health maintenance visit). Knowledge, practice, and skills
enhance efficiency in addressing these problems. Strategies such
as having parents complete a questionnaire while waiting helps save
2. I am not sure how to handle problems like intimate
partner violence. It is clear that most pediatricians have
had little training is some of these issues (eg, intimate partner
violence). There is a need to obtain such training and to identify
local resources for consultation and referral. As with a worrisome
peripheral smear, it may amount to knowing whom to call.
3. These problems are very sensitive. I do not feel comfortable
raising them. The issues are sensitive but important. If
framed carefully (eg, “Lots of families have these problems,
so I’m asking everyone. .”), most families will
not be offended, and some will be grateful. Discomfort is also related
to not knowing what to do; knowledge and skill help. As an analogy,
asking adults about sexual practices was awkward for many, but the
prevalence of HIV disease has warranted overcoming that discomfort.
4. What if the screen is incorrect? There is the problem
of false positives and false negatives. First, it is important
to recognize that a screen is just a screen. In many situations,
assessment by the pediatrician will clarify whether the problem
exists. This 2-step process will help minimize false positives (eg,
falsely identifying a family as high-risk) while individualizing
services to a family’s specific circumstances. Screening
questionnaires may miss some at-risk parents. These false-negative
screens may occur when a parent is in denial about a problem or
is not ready to acknowledge the problem to others or begin to address
it. Development of an ongoing, supportive relationship with families
and periodic repetition of screening may increase a parent’s comfort
in relating information to the pediatrician and move the parent
toward action. It is also important to remember that while screening
may miss some at-risk parents, many others will be identified who
would have otherwise gone undetected.
5. I have assessed the need, but the appropriate services
are not available to address the family’s needs. This
issue is one that affects the larger field of child maltreatment
prevention. When a family is assessed as high-risk for physical
child abuse or neglect, there may be a paucity of resources or supports.
Identification of appropriate, accessible resources may require
assertive advocacy as well as collaboration with other community
providers, such as home visiting programs.
6. I have referred families for mental health services
but never receive any feedback from providers. Unfortunately,
there is often little integration across health care and mental
health systems. In addition, mental health providers may decline
to share information because of privacy concerns. Pediatricians
can speak with families about the importance of professionals sharing
information that relates to the child’s physical and emotional
health. Pediatricians may also ask parents to sign a limited release
of information to allow the parent’s or child’s
therapist to discuss specific issues.
7. We do not really know that these approaches work. This
is a fair statement given the paucity of research in this area.
It is also true for many other areas in pediatrics where the effectiveness
of interventions has not been evaluated (eg, achieving dietary changes).
There is, however, considerable clinical experience suggesting that
pediatricians can successfully facilitate referrals for mental health
and social services. There is also reason to believe that the positive
relationships pediatricians usually have with families enable them
to be trusted confidants and to offer valuable support and guidance.
Ideally, innovative models should be evaluated so that pediatricians
can learn what works and what does not.