Table Of ContentFAMILY-FOCUSED BEHAVIORAL PEDIATRICS
2001
Lippincott Williams & Wilkins
Philadelphia
530 Walnut Street, Philadelphia, PA 19106 USA, LWW.com
0-7817-2857-6
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any
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Printed in the USA
Library of Congress Cataloging-in-Publication Data
Coleman, William L.
Family focused behavioral pediatrics / William Lord Coleman.
p. cm.—(Core handbooks in pediatrics)
Includes bibliographical references and index.
ISBN 0-7817-2857-6
1. Pediatrics—Psychological aspects—Handbooks, manuals, etc. 2. Family counseling—Handbooks,
manuals, etc. I. Title. II. Series.
RJ47.5 .C65 2001
618.92′0001′9—dc21
00-067526
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accepted practices. However, the author and publisher are not responsible for errors or omissions or for
any consequences from application of the information in this book and make no warranty, expressed or
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Application of this information in a particular situation remains the professional responsibility of the
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this text are in accordance with current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of
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clearance for limited use in restricted research settings. It is the responsibility of the health care provider
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10 9 8 7 6 5 4 3 2 1
Author
William Lord Coleman M.D.
Associate Professor of Pediatrics
Center for Development and Learning, Department of Pediatrics, University of North Carolina School of
Medicine, Chapel Hill, North Carolina
Secondary Editors
Timothy Y. Hiscock
Acquisitions Editor
Sonya L. Seigafuse
Developmental Editor
Christiana Sahl
Production Editor
Benjamin Rivera
Manufacturing Manager
Jeane Norton
Cover Designer
Circle Graphics (Compositor)
R. R. Donelley
Printer
Crawfordsville
Printer
Foreword
This remarkable, far-reaching book breaks new ground in pediatrics. It is especially useful for behavioral
and interactional problems that persist or recur despite traditional child-centered interventions. Dr.
Coleman's watchword of “your family is your greatest resource” comes alive on every page.
The reader can learn some of the following skills from this book:
Identifying interactional problems;
Making the shift from child-focused to family-focused intervention;
Facilitating family meetings and family communication;
Helping families rediscover love, respect, communication, and fair play;
Helping families work together, find solutions, and become a team;
Charging appropriately for these services.
This book also gives numerous examples of therapeutic strategies and family interviewing techniques as
practical illustrations of the skill or skills that it has just taught.
Applying this book to clinical practice should bring the following results:
An increased comfort level with family disagreements and parent problems;
Rediscovery of the power of words;
Increased creativity in interventions;
Improved ability to help families find and utilize their strengths;
Doubled therapeutic impact;
Increased personal job satisfaction.
No matter what the reader's role in medicine or how much counseling he or she provides, this book helps
the reader accomplish it more effectively. The family counseling model crosses many disciplines, giving
this book immense value to all clinicians who work with children and adolescents, including general
pediatricians, family medicine physicians, developmental-behavioral pediatricians, adolescent medicine
specialists, physician assistants, nurse practitioners, physicians and nurses in training, clinical
psychologists, social workers, and academic clinical faculty. This practical and timely book gives them
methods for taking their skills to a higher level or for teaching those skills to others. This book is for the
reader who loves behavioral pediatrics and who wants to learn more about the art and science behind it.
Barton D. Schmitt M.D.
Professor of Pediatrics
University of Colorado School of Medicine and The Children's Hospital, Denver, Colorado
Preface
There is no perfect child. There is no perfect parent. There is no perfect family. Every family needs help
at some time. When they do, they often turn first to the clinician.
Helping children and adolescents with behavioral and interactional problems is one of the great joys and
challenges for all clinicians who care for children. Although many of these problems can be solved with an
approach that focuses on the child's symptoms, others prove more resistant. When those problems recur
or intensify, the clinician should consider an approach that incorporates the family context. This
approach, based on the biopsychosocial model, both assesses the child's problem and develops solutions
within the family-social context. However, the family counseling skills needed to use this approach are
either infrequently or inadequately taught in training programs or continuing education courses.
Give a man a fish and he can feed himself for a day. Teach a man to fish and
he can feed himself for a lifetime.
--Chinese Proverb
Family counseling is effective and efficient because it supports the family, which is the child's greatest
resource, and empowers the family to use its own strengths. In using this type of counseling, the clinician
not only helps the family resolve the problem but also uses strategies that are more time-efficient and
cost-effective. The clinician derives great satisfaction from knowing that the family has developed its own
problem-solving techniques (with guidance from the clinician) that will help it not only now but also in
the future. Finally, using a family context approach to child care provides the clinician with new
intellectual challenges, stimulating him or her personally and revitalizing his or her career.
Teach thy tongue to say, ‘I don't know,’ and thou shalt progress.
--Maimonides
This manual is for clinicians and trainees who want to enhance their skills in working with children and
adolescents within the context of their families. These clinicians include pediatricians, family
practitioners, pediatric nurse practitioners, child psychologists, child psychiatrists, social workers, and
school counselors. It is a beginner's guide intended for those just learning to use a family context
approach to resolve behavioral and interactional problems. It is not a textbook on family therapy. This
manual describes brief, practical, step-by-step methods for family counseling that the busy clinician can
readily incorporate into primary care and can easily tailor for his or her own use. The methods and
techniques are liberally illustrated with real-life case studies.
Clinicians work hard because of their deep commitment to improving children's health and well-being, but
they must be paid for their effort and time. Therefore, methods for coding and documenting to insure
adequate reimbursement are explained.
After reading this book, the clinician will know how to do the following:
Identify problems suitable for family counseling.
Plan family meetings in the office.
Interview families using a family systems approach.
Assess family interactions.
Help families cooperate and develop adaptive behaviors.
Support parents.
Improve family communication.
Deal with disappointments, failures, and difficult families.
Code and document for reimbursement.
Suggest strategies for specific problems.
Make a mental health referral.
The family is the most central and enduring influence on every child. Thus, sometimes the best way to
help a child is to help the parents. The family context is the domain of clinicians, who have been
sanctioned by society to advocate for the child and the family. Family counseling both satisfies this
obligation and also fulfills the clinician.
Acknowledgments
No one writes a book alone. It is a “family” effort because many people help make it happen. I thank
those who have helped me:
The thousands of families with whom I have worked for over 20 years and who taught me much of what I
know.
Colleagues and friends who have encouraged me over the years and/or provided specific advice about this
book: Drs. James Blackman, Tom Boat, Douglass Carmichael, Wendy Chabot, Bill Cohen, Robert Coles,
Paul Dworkin, Morris Green, Robert Greenberg, Robert Haggerty, Barbara Howard, Sam Katz, Desmond
Kelly, Karen Miller, Julius Richmond, Edward Schor, Henry Shapiro, Marty Stein, Jack Sternbach, Lane
Tanner, Stuart Teplin, Dominique Verut, Marc Wager, Lynn Wegner, Steve Wegner, Roberta Williams, Ms.
Margot Jones, Ms. Nancy Aronie, and countless others.
Laura Martin, my assistant in Chapel Hill, for her invaluable secretarial support. Renee Hardin for her
technical assistance. Cheryl Tucker, my editor in Chapel Hill. Sonya Seigafuse, Christiana Sahl, and Kathy
Drasky, my editors at Lippincott Williams&Wilkins.
Tim Hiscock, acquisitions editor at Lippincott Williams&Wilkins, whose belief in families and in this book
helped it become a reality.
Dr. Karen Wells (Duke University), Dr. Susan McDaniel (University of Rochester), and Ms. Insoo Kim Berg
(Brief Family Therapy Center, Milwaukee, Wisconsin), for the training in family therapy that they gave
me.
Dr. Edward Taylor (University of Illinois), for his friendship and family therapy mentoring.
Dr. Bart Schmitt, for his friendship and ongoing support of my professional work and this book.
Dr. Mel Levine, my “brother” and colleague in Chapel Hill, for 20 years of friendship, mentorship, and
partnership.
My family especially, for its unending love, patience, support, and good humor—my wife Julie, my
children Chandra and Justin, and my nephews Phil and Jeff.
I would also like to acknowledge the Administration on Developmental Disabilities (ADD) and the Maternal
and Child Health Bureau in Washington, D.C. for their generous support of the Clinical Center for the
Study of Development and Learning in Chapel Hill, North Carolina.
Contents
Authors
Foreword
Preface
Acknowledgments
Contents
I. Shifting to a Family Focus
1. The Family-Oriented Approach: Why and How It Works
2. Determining Which Problems Are Suitable for Family Counseling
3. Getting Ready for a Family Meeting
4. Coding and Documenting for Reimbursement*
II. Interviewing the Family: Practical Strategies
5. Facilitating a Successful Family Interview
6. The Four Steps of a Family Interview
7. Assessing Family Functioning: Additional Methods
8. Three Models of Brief Family Interviews
9. After the Initial Interview: The Post-Interview Phase, Follow-Up, and Choosing a Termination
Point for the Meetings
III. Clinical Issues and Strategies
10. Family Communication Problems
11. Supporting Parents
12. Strategies to Enhance Family Functioning
13. Dealing with Disappointment and Failure: Avoiding Pitfalls and Working with Difficult Families
14. Making a Mental Health Referral
15. Getting More Training and Knowledge in Family-Focused Pediatrics
Glossary
Appendix
Subject Index
P.1
I. Shifting to a Family Focus
P.2
P.3
1.
The Family-Oriented Approach: Why and How It Works
I. Purpose
The family-oriented approach is based on the biopsychosocial model and utilizes family systems
principles. These principles guide the clinician as he or she shifts the focus from a view exclusively of the
child's symptoms to one of the child within the family context.
The five levels of clinician involvement with families range from a minimal focus on the family to family
therapy. Clinicians work at one of these ―developmental‖ levels with every family encounter. Those
beginning to utilize the family-oriented approach are at or near level 3.
This chapter describes (a) the clinician's qualifications to use a family-oriented approach; (b) family
systems principles; (c) the family as a system; and (d) the five levels of clinician involvement with the
family. This information helps the clinician understand the need for shifting from the biomedical
approach to a family orientation.
II. The Clinician's Qualifications for Using a Family-Oriented
Approach
The clinician is qualified to use a family approach because of his or her special long-standing relationship
with the family. This relationship is based on knowledge, understanding, and trust. The clinician knows
and understands the family and also trusts them to work together and to follow the clinician's
recommendations. The family knows that the clinician understands them and cares about them, believes
that he or she is knowledgeable, and therefore trusts the clinician to help them. This special relationship
allows the clinician to treat a child's problem (e.g., depression) within a family context (e.g., divorce)
and to ―join‖ together with them as part of the treatment plan (i.e., the clinician facilitates the family's
efforts to change their behaviors). Some qualifications of pediatric clinicians (specifically, the
pediatrician, family physician, or pediatric nurse practitioner) are listed below.
A.
In the first few years of a child's life, the pediatric clinician is usually the first and only clinician to
see a child.
B.
Clinicians are therefore positioned to detect a “predictable” family problem (e.g., the stress of
adapting to the new parental roles) as soon as it arises.
C.
Pediatric clinicians are usually the first clinicians to see the child when the family presents with the
child, who is the “identified patient” or the “symptomatic patient” of a disturbed family (e.g., the
child with recurrent somatic complaints whose parents are experiencing marital conflict).
