For example, among African Americans compared with whites, it is said that the combination of isosorbide dinitrate and hydralazine is more effective for treating heart failure, angiotensin-converting enzyme (ACE) inhibitors are less effective for essential hypertension, and a therapeutic response to selective serotonin reuptake inhibitor (SSRI) antidepressants takes place at lower doses.

If there are potential adverse interactions or side effects of “alternative” therapies, or if there is concern that potentially beneficial biomedical therapies might be thwarted by other types of healers, the clinician should express these concerns but should always respect the fact that patients are the ultimate arbiters regarding the healing modalities for which they are best suited (see Chapter 33). +

For almost all patients, illness is not simply an individual malady, but a social disruption that both affects and requires the involvement of significant others.

On the other hand, rituals can impair communication if patients and practitioners differ in their expectations about how they are supposed to work, or if rituals become inflexible, blind routines that leave little room for digression, variation, and opportunities for patients to express themselves freely and in fully emotional ways.

CASE ILLUSTRATION 7 A patient has been diagnosed with hypertension. After explaining the benefits and risks of treating hypertension with medication, the physician tries to help the patient see the clinical challenge from her perspective. She explains, “As doctors, we often have difficulty helping patients understand why they should take medicines even when they have no unpleasant symptoms. Understandably, patients often hate to take medicines, especially if they feel perfectly fine. Yet medicines are important for preventing very serious problems down the road.”

Instruments such as the Test of Functional Health Literacy in Adults (TOFHLA) can provide rapid estimates of the ability to read and comprehend common medical and lay terms.

It is estimated that up to 21% of American adults are functionally illiterate and many more are only marginally literate, limiting their ability to understand medical information and engage in meaningful discussions with their providers.

CASE ILLUSTRATION 6 An immigrant, working-class mother is taken aback by the pediatrician’s diagnosis of “attention deficit disorder” in her child and concomitant referral to a child psychiatrist and prescription for stimulant medication. She believes these recommendations imply that her child is “crazy” and, by extension, that she, first and foremost, as well as the family as a whole, have somehow failed. Her anguish is compounded by the extreme importance she attributes to her role as a mother and homemaker. Furthermore, she holds that psychiatric medicines are “too powerful” for her child who, like all children, is “sensitive and vulnerable.” She would have benefited from a discussion that elicited these beliefs in advance, followed by an approach that acknowledged her fears, reaffirmed her maternal skills and concern, and attempted gently to address her beliefs and values.

CASE ILLUSTRATION 5 A 32-year-old woman, the daughter of a prominent local philanthropist, complains of chest pain and demands that her physician obtain a stress test to make sure she is not at risk of having a heart attack. The patient, an avid runner, does not experience exertional chest pain and otherwise has no cardiac risk factors. On questioning, the physician learns that the patient recently broke up with her boyfriend and that her parents are contemplating a divorce. The physician obtains an EKG and informs the patient that it is normal. She explains to the patient that chest pain is not unusual among patients living through significant stress, that these symptoms almost always resolve with time, and that she has no risk factors for cardiac disease. She further explains that stress testing in her situation has a real likelihood of leading to false positive results, prolonged anxiety, more clinic visits, and perhaps even additional, invasive testing. Ultimately, the physician is able to help the patient understand that a stress test is unnecessary. The patient agrees to return in a week to reassess how she’s feeling and consider whether referral to a therapist might be helpful.

It can be a significant challenge convincing patients that more care, more expensive care, or even the latest technology do not necessarily mean better care, especially because unmet expectations for care can be associated with less patient satisfaction and reduced intentions to adhere to prescribed therapy

Educating the patient about disease terms and pathophysiology should complement but not supersede the importance of understanding and acknowledging these other aspects of the patient’s explanatory model.

CASE ILLUSTRATION 4 A 65-year-old immigrant and former physician is diagnosed with cancer. The clinician is able to elicit the patient’s belief that cancer often occurs in people with “repressed personalities.” Believing that he brought his disease upon himself because of such a character flaw, he feels a lack of hope and is less inclined to treat the disease. He benefits from an impersonal biomedical interpretation of cancer that focuses on damaged cellular DNA leading to unchecked cellular proliferation, and treatment aimed at destroying aberrant cells.

Naming a disease helps to transform a patient’s inchoate fears into something that can be perceived and addressed directly. Speaking about disease in neutral and mechanistic ways can also dispel feelings of shame and ideas about etiology that are rooted in personal weakness and social failure.

For example, although clinicians with some ability in conversational Spanish may assume they understand a Puerto Rican patient’s use of the term “ataque de nervios” (literally a “nervous attack”), the patient is actually referring to a culturally specific syndrome with identifiable precipitants and clear symptoms that has little to do with a “nervous breakdown.”

CASE ILLUSTRATION 3 An older patient, originally a schoolteacher from the Philippines, is hospitalized for community-acquired pneumonia. The hospitalization is uneventful and on the day of discharge, the medical team enters his room to review his discharge instructions. When asked for his input about preferred follow-up or his understanding of the ongoing treatment, he averts his eyes, speaks quietly, and seems unable to comprehend the discharge plan. He repeatedly asks for instructions about the various forms. The team leaves the room uncertain of his understanding. Later that morning, the pharmacist on the team returns to review his discharge medications with him. She sits down and speaks softly and respectfully. Eventually, he opens up and it becomes apparent that he understood the prior conversation completely and speaks articulately about his concerns, although he continues to avoid eye contact.

CASE ILLUSTRATION 2 A 56-year-old woman who completed a grade-school education declines colon cancer screening. On questioning, she believes that cancer is not preventable and cannot be cured. Cancer terrifies her and she therefore sees no point in learning she might have it. The clinician explains that from a medical perspective cancer takes many years to develop, and that in people aged over 50 years it can happen in a few individuals out of a hundred. She then tells the patient that the purpose of colon cancer screening—a relatively safe procedure performed thousands of times every year—is not to find a big cancer (which would be extremely unusual) but to save lives by finding a few areas (polyps) where cancer could develop and then snip them out. She provides the patient with an illustrated brochure to look over and consider. In addition to the patient’s beliefs about cancer, the clinician suspects that she distrusts the idea of doctors doing something to her that she, herself, has not requested or previously thought about. Over the course of several appointments, the clinician gently revisits the issue. A year later, the patient agrees. Trust—developed through a continuing relationship, manifest concern on the part of the clinician, and openness in explaining the purpose of medical tests—was a key factor in the patient’s decision. Had the patient continued to decline screening, however, the clinician appropriately would have respected her decision, without overt negative judgment.

Fatalism does not usually imply a lack of interest in preventing or treating disease. Rather, it can be viewed as an idiom for describing a person’s perceived powerlessness in the world, lack of hope, and even distrust.

CASE ILLUSTRATION 1 A 72-year-old World War II veteran was diagnosed with localized prostate cancer. The patient is adamant about his desire to undergo curative treatment with radical surgery after the urologist explains that the likelihood of cure is the same with radiation therapy, after he reviews the specific and significant numerical likelihood of serious side effects associated with surgery and radiation, and after he proposes that watchful waiting and active surveillance are also reasonable options. After carefully eliciting the patient’s understanding of the disease and its treatment, the urologist learns, from the patient’s perspective, that: “cancer is a death sentence,” “the only way to cure cancer is by cutting it out,” and “radiation is dangerous.” By taking the time to understand the patient’s explanatory model of illness, the urologist is in a position to more effectively address his misconceptions and fears, thus allowing the patient to make a more genuine, high-quality decision about his care.

Studies have shown that most patients wish to be “maximally” informed about their diseases as well as medical treatments and evaluations, but there is variability in their desire to assume or share responsibility for making actual treatment decisions.

Shared decision making is most important for preference-sensitive conditions in which there are at least two legitimate treatment options available, but each has different levels of risk or types of side effects.

Table 15-2.Questions to elicit a patient’s explanatory model of illness.

The clinician should not expect patients to answer questions about causation with simple and mechanistic explanations.

With this in mind, this section reviews three fundamental aspects of communication to which the clinician should direct particular attention: (1) attempting to understand the illness from the patient’s perspective; (2) ensuring that the patient understands, as much as possible and at an appropriate level, biomedical explanations of the illness and its treatment; and (3) guiding patients through the ritualized clinical encounter and the health care bureaucracy in ways that increase their familiarity and comfort with it. +++

Equally important, however, is that clinicians develop an awareness of their own cultures and the unquestioned assumptions that are informed by their personal histories, the nonprofessional aspects of their daily lives, and the socialization imparted by their significant, lengthy engagement in biomedical training and practice.

The culturally competent clinician will understand these common features and negative patient perceptions of biomedicine, recognizing when they contribute to misunderstandings and impair a patient’s ability to feel at ease, communicate, and benefit from a biomedical approach.

Table 15-1.Characteristics of biomedicine and its practitioners.

Anomie (a sense of purposelessness) and alienation (lack of feelings of belonging) can contribute to anxiety, depression, and a decreased ability to cope with the new stresses of daily life.

The attributes of social location are more complete, specific, and clinically relevant than race and ethnicity alone.

social location. Social location specifies one’s position in society relative to others and is based on an amalgam of characteristics that include not only race and ethnicity but also gender, age, immigration status, language(s) spoken, neighborhood of residence, length of time and number of generations in the United States, educational attainment, income, occupation, religion, sexual orientation, and prior experiences with racism.

Commonly cited examples include beliefs in “fallen fontanelle” and “evil eye” among Latinos and “high blood/low blood” among African Americans, as well as values such as “individualism” among North Americans, and “family centeredness” among Asians.

Within the family, one of the most influential cultural systems, there is generally a clear-cut division of labor, regular routines such as meal and work times, explanations (or myths) about family origins, and strategies for fulfilling common goals and passing down shared values.

The goals of effective cross-cultural communication (or “cultural competency,” as it is sometimes called) are threefold: (1) to understand illness from the perspective of the patient; (2) to assist patients in understanding diseases and treatments from the perspective of biomedicine; and (3) to help patients and their families navigate, express themselves, and feel comfortable within large, complex, and often impersonal health care organizations.

Behavioral medicine, with its inherent awareness of the relationship between mind, body, and spirit is a field particularly amenable to incorporating the practices of IM.

While it is tempting to address a constellation of symptoms with complex treatments, careful attention to root causes and streamlining interventions may yield better patient outcomes.

CASE ILLUSTRATION A 70-year-old European American woman presents with “treatment-resistant” insomnia for over 20 years.

The National Acupuncture Detoxification Association (NADA) protocol is a type of auricular acupuncture that may lessen the severity of withdrawal symptoms when used adjunctively with detoxification treatment. The NADA protocol is typically administered in group settings to improve adherence and involves bilateral needle insertion at five specific acupoints located on the ear.

Acupuncture is one component of TCM treatment that involves placing thin needles on particular sites on the body in a specific way. Using functional magnetic resonance imaging (fMRI) studies of healthy subjects, Hui and colleagues found that acupuncture stimulation affects the emotional brain through primary deactivation of the amygdala and hypothalamus.

Osteopathic manipulative therapy (OMT) is a set of hands-on techniques aimed to treat structural, muscle, and tissue abnormalities; relieve joint restriction and misalignment; and promote circulation.

Tai chi and qigong are ancient forms of body movement practices. Both tai chi and qigong apply slow, intentional meditative movements that rely on self-awareness of body positions to adapt energy flow in the mind and body.

Yoga was found to significantly reduce PTSD symptoms, with effect sizes comparable to well-researched approaches for PTSD, including psychopharmacology and psychotherapy.

By combining mindfulness with elements from a validated treatment for depression, cognitive behavioral therapy (CBT), MBCT was created in the 1990s to reduce depression relapse.

MBRP has similar features to MBCT but is intended for relapse prevention of substance use disorders

Examples of mind–body therapies are breathing exercises, meditation, guided imagery, biofeedback, hypnosis, progressive muscle relaxation, yoga, tai chi, and qigong.

However, an RCT called the “SMILES” trial studied the effects of directly applying a dietary intervention to treat depression in participants with poor diet quality.

Kava is an herbal anxiolytic postulated to target the same neurotransmitter as benzodiazepines, gamma-aminobutyric acid. Several case reports of liver toxicity surfaced in the 1990s leading to an initial ban of kava in Europe.

Kava (Piper methysticum) is a commonly cited example where botanical quality and preparation make a difference.

The Dietary Supplement Health and Education Act (DSHEA) was enacted in 1994 to standardize how natural products are regulated, sold, and marketed in the United States.

mindfulness-based cognitive therapy (MBCT)

In contrast, most IM therapies (similar to many behavioral interventions) have multiple components, need to be implemented by a skilled practitioner, and aim to influence multiple symptoms.

It may be helpful for the clinician to organize domains on a spectrum, noticing how close an approach fits into a scientific paradigm. Typically, approaches falling closer to a biological, scientific model are a more natural fit for double-blind, randomized controlled trials (RCT) and thus more widely accepted into conventional medical practice.

As the patient is also taking an antidepressant, concurrent use of SJW could also increase risk of serotonin syndrome, a medical emergency.

Conversely, seemingly benign foods, such as grapefruit, may inhibit metabolism of many drugs and increase drug levels, conferring risk for side effects and toxicity.

ou and Johnson analyzed 2012 NHIS data and identified 7493 respondents who both used CAM and had a primary care physician. Approximately 42.3% of respondents did not disclose CAM use to their primary care physician.

According to 2012 NHIS data, anxiety, stress, attention-deficit/hyperactivity disorder, and insomnia were among the top six conditions for which CAM was used in children.

One-fifth of patients used CAM because standard treatments were either ineffective or costly. One-fourth of patients used CAM due to recommendation by a conventional provider.

Data from NHIS consistently show that one-third of U.S. adults have reported complementary and alternative medicine (CAM) use in the previous year.

CAM use was more prevalent in adults with at least one neuropsychiatric symptom (43.8%) as opposed to adults without neuropsychiatric symptoms (29.7%).

Table 35-1.Five domain system for classifying complementary and alternative medicine modalities.

Psychological contexts include traumatic experiences, psychological defenses, and traits. Social contexts include community support, social skills, major life transitions, employment, cultural beliefs, values, spirituality, and access to health care.

The term, “integrative medicine” (IM) defines an approach to healing that explores the whole person, including individual values and lifestyle, while making use of all appropriate and evidence-informed therapeutic modalities, health care professionals, and disciplines to promote optimal well-being.

To maximize the therapeutic outcome, it is essential that the referring practitioner communicate with the specialist—before the visit—about the nature of the medical problem, the desired clinical outcome, and the patient’s expectations about treatment.

Table 5-3.Developing resourceful states with self-hypnosis.

Table 5-2.Eyeroll technique for self-hypnosis.

Table 5-1.Hypnotic smoking-cessation interview.

Certain dermatological conditions, such as warts and alopecia, have been treated successfully with hypnosis.

There is evidence that hypnosis is effective in alleviating the chronic pain associated with cancer.

Hypnosis has been used adjunctively with other therapies to help patients with chronic and terminal illnesses.

In some surgical or dental procedures, hypnosis can be used as an adjunct to, or instead of, anesthesia. In addition, patients with chronic pain can be taught to relax the muscles they tense around areas of pain as part of their “guarding” or bracing efforts.

The clinician can devote 15–20 minutes to inducing a trance, during which the patient is led to form a full sensory recall of an experience in which he or she felt deeply relaxed.

Recent brain imaging studies, employing PET and functional MRI, have shown that the hypnotic state is related to a widespread set of cortical areas involving the occipital, parietal, precentral, premotor, and ventrolateral prefrontal and anterior cingulate cortices.

CASE ILLUSTRATION (CONTD.) In the case of the woman with post-thoracotomy pain, the physician tried using the technique of eliciting a target state to alter the patient’s trance.

The unpredictable action might be the “Columbo technique” (named for the television detective). In this technique, the physician suddenly and dramatically remembers some minor personal problem (e.g., forgetting a spouse’s birthday gift), asks the patient’s forgiveness for the distraction, and requests the patient’s aid (e.g., in suggesting a store to purchase the gift).

The unconscious mind tends to delete negative modifiers, in this case “less.” The embedded suggestion becomes: “Ankle … hurt … in a few weeks.” A positive suggestion would be:

A positive suggestion—“Whatever residual discomfort you feel, in time you will notice more freedom of motion and activity”—can create expectations that are more likely to enhance healing and the resumption of activity.

CASE ILLUSTRATION A 55-year-old single woman was being followed by her primary care physician for chronic chest pain after a thoracotomy. The pain led the patient to withdraw from social activities. Her complaints, which continued for several months, appeared inconsistent with the progress of healing around the surgical wound. Various pain-management strategies that the physician proposed, including physical therapy, acetaminophen, and an antidepressant, had little effect on the complaints. Both patient and doctor became frustrated, with the patient feeling that nothing new was being done for her pain and the physician feeling powerless to alleviate the patient’s suffering.

Whatever the clinician says or does not say in the course of the interview can, because of the power generated by the patient’s suggestibility, further develop the patient’s trance, shift its focus, augment or diminish the patient’s somatic awareness, and influence ongoing patient emotions, cognitions, and behaviors surrounding the symptom.

Utilization: The therapeutic use of trance to achieve desired outcomes and the phase of hypnosis following induction in which this occurs.

Induction: The process by which a trance is initiated. This can occur naturally or as the first phase of hypnosis.

Hypnosis: A communicative interaction that elicits a trance in which other-than-conscious processes effect therapeutic changes in the subject’s mind–body system. Hypnosis can be either other- or self-induced.

Suggestion: A communication that occurs in trance, with special power to elicit a particular attentional, emotional, cognitive, or behavioral sequence of events.

Trance: A state of focused attention, in which a person becomes uncritically absorbed in some phenomenon and defocused on other aspects of reality. Trance states can be positive or negative.

The American Psychological Association in 1960 endorsed hypnosis as a branch of psychology. In 1995, the U.S. National Institutes of Health issued a consensus statement with evidence supporting the use of hypnosis for the alleviation of chronic pain. ++

Table 13-7.Recommendations for addressing needs of gay or lesbian youth.

Table 13-6.Strategies for improving compliance.

There is a heterogeneous group of between 500,000 and 2 million homeless teenagers in the United States.

CASE ILLUSTRATION 2 Two days after sustaining minor injuries in a traffic accident, Jeff, a 17-year-old teenager, comes to the physician’s office complaining of left shoulder pain. He is accompanied by his mother, who is concerned because Jeff was also recently arrested for driving under the influence of alcohol. There is no history of medical or behavioral problems, although, on questioning, his mother describes a 12-month history of moodiness and falling school grades. Using the HEADSS format assessment, the physician assesses Jeff’s health risks:

Table 13-5.Risk factors for major depression and suicide.

CASE ILLUSTRATION 1 Lauren is a 15-year-old girl admitted to the hospital with an arm fracture requiring surgical repair. The fracture occurred during cheerleading practice while climbing a pyramid of other cheerleaders. She reported being distracted while climbing, lost concentration, and fell to the ground. During the admission history the patient was talkative and easily distracted. Although she did not report taking any medications to the admitting nurse, when asked “are you supposed to be taking” any medications, Lauren reported that she should be taking medication for ADHD (see Chapter 28). She had not taken medication for the last several days because she was staying with a friend and did not want her friend to know that she took medication.

Table 13-4.CRAFFT* questions

Table 13-3.Substance abuse risk factors for adolescents.

A comprehensive health-risk assessment should cover issues dealing with home, education, activities, drug use, sexual practices, and suicidal ideation (HEADSS). Using the HEADSS format helps with organization and standardization

Table 13-2.Recommendations for care quality.

Table 13-1.Interview suggestions.

Although most teenagers want to receive health information and discuss personal behavior, these discussions must generally be initiated by the physician. Many teenagers are not accustomed to interacting in such participatory, nonjudgmental conversations with adults.

A general health assessment should include a review of systems and an evaluation of health-related behavior. This should include risk factors for accidents, STIs, including human immunodeficiency virus (HIV), pregnancy, interpersonal violence (including past physical or sexual abuse), nutrition, substance use including prescription medication abuse, exercise, sleep, learning, and mental health problems.

Late Adolescence (Ages 18–24)

Middle Adolescence (Ages 15–17)

Early Adolescence (Ages 11–14)

In 1992, the American Medical Association published Guidelines for Adolescent Preventive Services (GAPS), the first set of developmentally and behaviorally appropriate comprehensive health care guidelines for adolescents.

In psychosocial and behavioral terms, it is the time during which adult body image and sexual identity emerge; independent moral standards, intimate interpersonal relationships, vocational goals, and health behaviors develop; and the separation from parents takes place.

When bullies have unaddressed psychological problems that lead to poor conduct, poor peer relationships, and emotional upheaval, they have a significantly higher chance of engaging in criminal activity later in life.

CASE ILLUSTRATION 6 (CONTD.) The primary care physician made an agreement with the girl and her parents that they would work together on the problem until the bullying was over. The girl would share her experiences with her parents, despite embarrassment, and her parents would take these events seriously and keep her from facing them alone. The parents would speak with the school administration and suggest a plan. Further history taking revealed that she was an excellent artist. The parents were encouraged to praise her for her artistic accomplishments as well as other achievements, and they encouraged school staff to do the same. They also sought new opportunities for their daughter to exhibit these strengths to herself and to others. The youngster’s parents kept a record of bullying episodes and communicated these with the school principal. Eventually, enrollment in an after-school art class helped this girl develop new friendships, which improved her self-esteem and made her less vulnerable to being bullied.

CASE ILLUSTRATION 6 During a routine health supervision visit of a 12-year-old girl, your customary questioning of social development reveals that this seventh grade student has been having problems with peers at school. She dislikes school and many of her classmates. Problems began about 3 months ago when another girl knocked an apple out of her hand and onto the cafeteria floor. Your patient tried to swat at the girl (but missed) and was reprimanded by the lunch monitor. Your patient broke into tears at that time and has since been the butt of jokes among a group of girls. False rumors about her have been spread at school and through social media.

CASE ILLUSTRATION 5 A 3-year-old girl has shown her genitals to a peer and has commented on her father’s genitals. One week prior to their visit to your office, the little girl began masturbating at home and occasionally in public. Not knowing how to react, her parents have been begging their daughter to stop. They are concerned that her sexualized behavior indicates something is wrong.

CASE ILLUSTRATION 4 (CONTD.) In the second case, the child was offered three wholesome meals and one snack at preset times of the day. After telling their daughter once about the meal, parents were not to engage in any discussion with their child about the volume eaten. No other foods in the house were made available to her during this behavioral management period. Between meals this girl was allowed an unlimited quantity of water, but nothing else. After a difficult period of 1½ days (thrown silverware, persistent crying, etc.), she began to nibble at new foods and to enjoy the positive attention for doing so. Although the child still enjoyed only a limited range of foods, parents were able to expand her repertoire to include broccoli, milk, and pasta.

Coupling positive reinforcement (praising and rewarding good behavior) with ignoring undesirable behavior can be a powerful tool to reduce oppositional behavior.

CASE ILLUSTRATION 4 A father solicits your opinion on vitamin supplements to counterbalance his 28-month-old daughter’s picky eating habits. She drinks apple juice and eats hot dogs and Honey-Nut Cheerios and little else. When these foods are not offered, she protests violently and eats nothing.

CASE ILLUSTRATION 3 A 32-month-old boy refuses to go to bed on time. He prolongs bedtime rituals by making numerous requests (e.g., for water, use of bathroom, and adjusting the door). He repeatedly leaves his bed. On many nights he finally falls asleep in the living room or his parents’ bedroom while spending time with his parents.

CASE ILLUSTRATION 2 (CONTD.) In this case, the child’s tantrums began as a result of typical frustrations experienced by children his age. Over a period of months, as his parent became busier with other family needs, however, he discovered that expressing anger was an excellent way to get adult attention, and the frequency of these behaviors increased. As part of the management plan, his parent was instructed to ignore his anger and put him in his room for three minutes when he became physically violent toward others. She was also advised to increase time spent doing positive things with him, like playing games, going on walks, and having him help around the house. At day care he was given increased attention during times he was behaving well. Child care providers were asked to ignore him when he was aggressive toward other children and to shower a noticeable amount of attention on the other child. Within a couple of weeks he stopped biting and seemed happier. Although he still had tantrums, these strategies gave his mother the feeling that she had some control over the situation.

CASE ILLUSTRATION 2 The parent of a 3-year-old boy reports that her son throws himself on the floor, throws objects, and screams … usually when he does not get his own way. This seems to happen daily. At his child care center, he has begun to bite other children when he is angry, and other parents have begun to complain about him.

CASE ILLUSTRATION 1 (CONTD.) On further questioning in this case, the parents reported that their baby falls asleep immediately after daytime feeds and sleeps for 3–5 consecutive hours thereafter. Since this baby did not adapt to an acceptable day/night schedule, the doctor recommended waking the baby up after no more than 2–3 hours of daytime sleep. Parents were to occupy their infant’s daytime hours by walking around, talking, playing music, and other activities. It was recommended that nighttime feeds be made minimally stimulating: soften the lights, produce minimal noise, and avoid “fun” interactions at night. Although sleeping and feeding “on demand” does not need to be discouraged if parents find it acceptable, in this case the infant’s pattern was distressing to the parents. After 5–6 days of compliance with this schedule, it became easier for the parents to keep their daughter awake during the day, and they settled for a nighttime feed before they went to bed at 11 p.m. and another feed at 4 a.m.

CASE ILLUSTRATION 1 Parents of a 12-week-old girl complain that their daughter rarely sleeps more than a total of 4–5 hours between 8 p.m. and 6 a.m. She may fall asleep at 8 p.m., only to awaken an hour later. She seems to fall asleep during or after short feeds and then remains awake for hours later on. Each night is a struggle of long periods awake between short spells of sleep. Her parents note that she cries when left alone. She seems content at night when parents walk around with her.

There is growing evidence that one can promote childhood resilience through intervention during critical stages of development.

Emotional intelligence is defined as the ability to identify one’s own feelings, to identify the feelings of others, and to solve problems that involve emotional issues.

Motivational interviewing was designed as a technique to improve treatment outcomes for people with substance abuse disorders

Cognitive behavioral therapy (CBT) comprises a series of techniques based on the notion that there is a close relationship between a person’s thoughts, feelings, and behavior.

Family therapy is based on the premise that every family is a system (see Chapter 11).

Insecure attachment patterns (anxious-avoidant, anxious-resistant, and disorganized) are associated with caregiving that is not responsive to infant needs, including maltreatment and abuse.

In anxious-avoidant attachment, the infant shows reduced affect and interest toward the caregiver and treats the stranger and caregiver in a similar manner.

Attachment theory explains how infants respond to this vulnerability by developing a strong emotional relationship with a primary caregiver in the first year of life.

Jean Piaget described stages of cognitive development. Though his theories have since been proven to underestimate children’s abilities, they are still useful guides. For example, until around age 7 years children are what Piaget termed “preoperational.” They engage in make believe, which parents should not misconstrue as lying. Complex concepts such as cause and effect are not yet well developed, and parents should be wary of trying to rationalize with them.

A child’s temperament is the stable response to the environment across these various dimensions.

Erik Erickson’s stages are an expanded version of psychoanalytic theory. According to his theory, infants develop trust or mistrust through their experiences up to about age 18 months. In the next stage (ending around age 3 years), children develop autonomy or self-doubt, and in preschool (up to age 6 years) children learn to either take initiative or feel inhibited to do so.

Most children older than 5 years of age spend a large portion of their waking hours in school. Yet despite this, clinicians traditionally rely almost exclusively on parents (and the children themselves) to gather a behavioral history.

Asking parents about their children’s screen time on electronic devices can be a window into family habits and childhood behavior.

While primary care clinicians commonly use developmental questionnaires such as the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) and Ages and Stages Questionnaires (ASQ) to screen for autism and developmental delays, behavior-focused questionnaires are not as prevalent.

The American Academy of Pediatrics recommends universal screening for depression in children 12 years of age and older using a formal self-report screening tool such as the PHQ-9.

These associations are likely due to the impact of toxic stress on the neuroendocrine–immune network

Accumulating evidence demonstrates that these adverse childhood experiences increase the risk for diseases in adulthood such as cardiovascular disease, cancers, asthma, depression, and obesity.

Children living under any condition that seriously threatens healthy and successful transition through a developmental stage are at risk for behavioral problems.

Disorders are diagnosed in children when problems are not related to normal development, symptoms meet the threshold set out by the Diagnostic and Statistical Manual of Mental Disorders or related criteria, and the behaviors cause distress or impairment for the child.

Pediatric behavioral medicine is closely linked to child development because many problematic childhood behaviors are developmentally normal.

CASE ILLUSTRATION 1 (CONCLUSION)

CASE ILLUSTRATION 2 (CONCLUSION) “I am sorry that your headache is still bothering you. Your wife and daughter are still fighting, aren’t they? It’s too bad that you haven’t gotten to the therapist yet. I truly wish that there was more that I could do for you, but why don’t you go ahead and schedule that appointment. Now, why don’t we check your blood pressure.” ++

One of the goals of the first three steps of the counseling process is to prepare the patient for a discussion of how and why counseling will be helpful in addressing the problems that have been uncovered and validated.

CASE ILLUSTRATION 1 (CONTD.)

Step 3: Empathic Witnessing: “I Am So Impressed With How Well You Are Doing Despite …”

Step 1: Assessing the Family: “Bringing the Pain Into the Room”

Step 2: Reframing Attention to the Underlying Family Problems

first, although patients often experience and describe their problems as a conflict or problem with one person, for example, “my wife,” “my kid,” “my mom,” these conflicts between two people inevitably draw others in and “triangulate.” Second, families that are having difficulty, are stuck in circular patterns of behavior (as reflected in the family therapists’ saying, “What do families in trouble do? The same, thing but harder”).

Getting the patient to talk about their feelings often requires gentle persistence. This is a good situation to use the request, “Tell me more about feeling sad … angry … disgusted.” Patients often use vague descriptors of negative emotion such as “upset” or “it got to me.”

CASE ILLUSTRATION 1 (CONTD.)

Patient-centered emotion-supporting interviewing techniques are instrumental in “bringing the pain into the room.” Simply asking about the patient’s feelings when they are recounting a distressing situation is a powerful technique, “That must have been very distressing. How did it make you feel?”

Table 11-8.Family intervention.

owever, it is often necessary to proceed to the next level of family intervention in order to make the referral a success.

CASE ILLUSTRATION 2 A 36-year-old man with hypertension presents to a walk-in clinic with tension headaches that have been going on for 2 weeks. The genogram interview (see Figure 11-2 and Table 11-6) reveals that he is distressed by ongoing conflict between his wife and teenage daughter about rules governing her behavior with peers outside the home. At home, the father remains silent until the fights between mother and daughter become intolerable. Their fights stop only when he complains about the headaches the fights have given him. He has never discussed his own ideas about rules for his daughter’s behavior—or of family arguments—or negotiated a common position with his wife.

CASE ILLUSTRATION 1 (CONTD.)

Table 11-6.Family life cycle screening questions for families with young children and adolescents.

Table 11-5.Family assessment screening questions.

Table 11-4.Presentations and problems associated with family dysfunction that should trigger screening for family dysfunction.

The cycle usually “begins” with the separation of the individual from the family of origin (stage 1), followed by the formation of a new family (stage 2), the raising and “launching” of children into the world (stages 3, 4, and 5), and the family later in life (stage 6).

Figure 11-2. Genogram of the family in Case Illustration 2.

However, skillful parsimony is acquired with experience, and efficiency is produced by following three principles: ++ Engage patients and encourage active participation—they will take you to the heart of the story. Focus the interview on family life cycle tasks and issues—they are almost always the focal point of stress and dysfunction. Draw and examine the genogram—a picture is worth thousand words (e.g., picture a single mother, six children, parents, and siblings in another country; three different fathers in various places; and a new boyfriend).

Begin with the core members of the family, that is, household members, parents, children, and past and present partners and spouses. Identify the family life cycle stage of the patient’s family from the ages, relationships, and household composition of the nucleus of the patient’s family. As described below, the family life cycle stage will almost always predict the locus of stress, challenge, or conflict in the patient’s family system.

CASE ILLUSTRATION 1 Ariana is a 40-year-old Italian-American woman with multiple somatic complaints. She has complained of chronic diarrhea, dyspepsia, and “asthma” but has had a thorough normal gastrointestinal and pulmonary evaluation. She has made multiple visits to her primary provider and to an urgent care clinic, has been hospitalized two times, and has been seen in several subspecialty clinics. She has made an average of 15 visits per year for the past several years.

clinicians need to learn to infer what is going on at home—to “see the family over the patient’s shoulder”—by imagining how members of the patient’s family might be reacting or behaving in ways that the patient does not understand or will not report.

Table 11-3.Goals of basic family assessment and intervention.

he authority to prescribe changes in role function for the patient further involves the physician in the life of the entire family. In effect, the physician and patient develop an alliance that compensates for the dysfunction and deficit at home. Hahn, Feiner, and Bellin have termed this a compensatory alliance.

The physician’s role in determining that the patient is entitled to the special prerogatives and dispensations of the “sick role” makes the physician a central and powerful member of these family systems.

Physicians play a critical role in establishing the legitimacy of the sick role by certifying the prerequisite illness or disability, and attesting to adequate adherence to treatment.

Table 11-2.The family life cycle.

Feedback maintains the integrity of the family system as a unit, establishes and maintains hierarchies, and regulates the function of boundaries in accordance with the individual family’s norms and style. This tendency toward maintaining “homeostasis” is critical. All family systems must learn to balance the desire for stability with the inevitable need to evolve and change.

Families as systems are characterized by the following: ++ External and internal boundaries An internal hierarchy Self-regulation through feedback Change with time, specifically family life cycle changes

Table 11-1.The role of the family: a partial list.

So, rather than define the family in terms of its members, we describe it as a system having certain functional roles.

The first is to understand that the principal goal for the medical clinician is not to fix the problems that they encounter when they explore the patient’s psychosocial context.

The second remedy is to understand that a semistructured four-step family-systems-based assessment described in this chapter, can be an effective strategy that can be applied in the context of primary care clinical practice.

Practicing “family-centered care,” that is, making the patient’s social context an explicit part of medical care, will affect every step of the clinical process, from basic assumptions about who the patient is to the conceptual framework for the database, theories of causality of symptoms, and the implementation of treatment.

Screening for and treating IPV should be a routine part of the practice and training of medicine. We all have the obligation to confront the epidemic of IPV and strive to lessen its impact as one of the most important public health issues of our time.

Videoconferencing-based health interventions such as telemedicine have been shown to help trauma and abuse victims by providing psychological services via telemedicine.

Most interventions are ordered by the criminal justice system and, unless mandatory, have very high dropout rates.

Why they remain in these relationships is complex. Some of the reasons include the following: ++ Fear. Fear for their own safety or for their children. Patients often are not at home when the assault takes place, so it is clear that leaving is no guarantee of safety. Economic. Many IPV victims lack employment skills or experience and would find it very difficult to support themselves and/or their children outside of the relationship. Psychological. Some may find it difficult to leave because of the “psychological dependence” the years of repetitive abuse have created. Survivors are told overtly and covertly that they are “worthless”; some eventually internalize this and come to believe that they are incapable of surviving on their own. Social support—or the lack thereof. Survivors are often encouraged by well-meaning friends and family members to “try to work things out,” or they are advised to stay “for the children’s sake.” Lack of other options. Shelters are often full, friends and family unavailable, and legal counsel not accessible. Not all survivors want the relationship to end, just the violence.

The third barrier to detection of IPV arises from practitioner discomfort.

First, many practitioners lack the appropriate knowledge and training to effectively detect and treat victims of IPV.

Many studies have revealed that physicians and other health care practitioners do a poor job of detecting IPV, with detection rates rarely exceeding 10% for women.

Lack of institutional support is a second important barrier.

There are four pitfalls to avoid when caring for victims of IPV: ++ Do not insist that the patient terminate the relationship, even if you believe that this is the most appropriate action. Only the patient can make that decision. Trying to control the patient’s behavior, albeit subtly, recapitulates the same negative dynamic that is taking place in the abusive relationship. Recommend couple counseling only when the perpetrator acknowledges the problem, wants to change his or her behavior, and both partners want to preserve the relationship. Do not use the word alleged in the medical record. It implies that you do not believe the patient’s story, and you may inadvertently impede his or her ability to bring the case to court. Do not ask what the victim did to bring on the violence.

CASE ILLUSTRATION 3

Finally, understand the IPV reporting requirements in your state. Health practitioners often are required to report to the police all incidents of IPV that result in an injury.

Fourth, the patient must be provided with information and appropriate referrals.

Third, it is imperative that practitioners document clearly and completely when they uncover IPV.

Second, it is essential

First, validate the problem by making a clear statement to the patient that violent behavior is unacceptable and illegal, and that nobody has the right to abuse him or her.

Multiple studies show that screening alone, without intervention, does not improve a woman’s health outcomes. Instead, an empathetic response by the health care provider, coupled with a multicomponent interventional approach, has shown benefit in patients who experience IPV.

Table 40-4.After detection: five tasks to accomplish.

Table 40-3.Screening questions.

The HITS screening instrument is widely used and consists of four questions (“Have you been hit, insulted, threatened, or screamed at?) on a 5-point Likert scale from “never” to “frequently”; it is available in several languages and has been validated for use with men and women.

In fact, for many patients, even in EDs, the presenting complaint is often medical or psychological, rather than a physical injury. For this reason, detection of IPV will increase only if clinicians include it on the differential diagnosis and actively screen for it during the medical encounter.

Injuries at Different Stages of Healing

Behavior that appears to be inappropriate at the time of the physical examination may be a sign of IPV.

Central Pattern of Injury

Multiple Injuries

Inappropriate Behavior

Table 40-2.Physical examination clues to the presence of IPV.

CASE ILLUSTRATION 2

Socioeconomic or Ethnic Status

Although some studies have found that women who are uninsured or on medical assistance are at increased risk of IPV, this is most likely due to selection bias in the studies.

Overbearing Partner

Family History of IPV

HIV and STIs