Anticipatory Guidance in Pediatric Mental Health Care
Anticipatory guidance is a cornerstone of pediatric healthcare that involves proactive counseling to parents or guardians about the expected growth and development of their children. Anticpatory guidance lets caregivers know what is coming up next in their child's development, how to facilitate and foster healthy development and how to prevent illness and injury.
Anticipatory guidance around mental health is no different than anticipatory guidance around safety, diet, or school readiness. It is based in knowledge of normal development and of the ages and stages when problems tend to arise.
Elements of anticipatory guidance
- Family history and family experience
- Anticipate and guide: encourage healthy practices for all children while acknowledging family risk factors (primary prevention)
- Monitor growth, development, and symptom emergence
- Anticipate and guide: targeted practices to decrease risk and alter emerging patterns (secondary prevention)
Family mental health history & experience
Our perinatal mental health colleagues have made great progress in identifying and treating prenatal and postpartum depression in the mothers of our infant patients. Most pediatricians are comfortable screening for postpartum depression in moms. But we need to ask about other mental illness beside depression, and we need to ask about dads, siblings, grandparents, aunts and uncles.
The impact of parental depression- in both mothers and fathers, can have lasting effects on children. Compared with the offspring for whom neither parent is depressed, the offspring of depressed parents have increased rates of MDD, particularly before puberty, and phobias, panic disorder, a 5-fold increased risk of alcohol dependence, and greater social impairment (Weissmann et al 1997).
Gentle, consistent, nonjudgmental questions about parental mental health, and parents' hopes for their children's mental health can promote a therapeutic alliance that will help you mitigate the impact of parental mental health disorders on families.
Questions like those listed here are meant to help parents explore their role as their children's mental health models. The questions are not meant to induce guilt in parents or make them feel deficient. They are meant to acknowledge that parenting when you have a mental health concern is not easy, but that you are available to help them with strategies to raise healthy children.
Questions for parents:
- How does your [depression, anxiety, anger] affect your life?
- What are you doing to control your [depression, anxiety, anger]?
- What kind of help are you getting?
- How do you want to help your child grow up without [depression, anxiety, anger]?
Questions for anxious parents:
- How can you let your child take risks and learn from mistakes?
- How can you tolerate letting your child tolerate distress?
- How can you model bravery, facing your own fears?
Questions for depressed parents:
- How can you keep your child physically and mentally active?
- How can you model positive and constructive thinking?
Questions for angry parents:
- How can you model frustration tolerance and self-control?
- How can you help your child out of a tantrum when you are feeling frustrated?
Anticipate & Guide
Encourage healthy practices for all children
Anticipatory guidance guidelines such as those found in Bright Futures cover many aspects of parent behavior that foster physical, mental, and social health in their children. At its most basic anticipatory mental guidance boils down to a few key concepts:
- Positive attention
- Promote self-regulation
Monitor psychological growth, development, and symptom emergence.
Targeted practices to alter emerging symptom patterns
Address separation anxiety early
Gemma’s mother has brought her in twice for stomachache since Gemma started kindergarten. Both times Gemma had gone to the school nurse complaining of abdominal and begging to go home. After checking in at your office with a normal exam, Gemma has enjoyed her afternoon at home with mom.
Brief intervention: Partner with mom and school nurse. If Gemma has a stomachache at school with no fever, vomiting or diarrhea, she can rest in the nurse’s office for 10 minutes and then return to class. Mom will not be called. If Gemma is worried and missing her mom, she can look at a laminated photo of her mom she keeps in her backpack. If Gemma stays in school all week, she and mom will do something special on the weekend.
Address disruptive behavior early
Braydon is seeing you for his 30-month checkup. As you take your history, Braydon wanders around the exam room, then begins tugging on his mom’s purse, and when she does not respond, he hits her. Mom looks embarrassed and takes out her phone, ready to give it to Braydon to distract him.
Brief intervention: Ask mom to hang on a second before giving Braydon the phone. Ask how she usually handles it if Braydon hits her. She says she usually says “No!” and gives him her phone. Ask mom if she would like a suggestion for a different way to handle Braydon’s hitting. If she consents, let her know the most effective response is to immediately get down on his level, look him in the eye, and say calmly and firmly, “It’s ok to be mad but you may not hit”. If he continues to hit you may calmly hold his hands and say, “I will not let you hit.” As soon as he relaxes his hands/arms, give him positive attention, but don’t give him the phone as a reward.
Promote mastery and family allegiance through chores
Jamie is 9 years old. His mother comments that she cannot get him to do his homework. She says that homework is the only thing she asks of him. She has never asked him to do any chores or help around the house; she does all the cooking and cleaning and laundry. She does not know why he does not appreciate all the things she does for him.
Brief intervention: Including children in chores from early on, even if they can’t do them perfectly and it takes time to supervise them, helps build a sense of efficacy and responsibility and being a participatory member of the family. Children who do chores are generally happier than children who do not, and are more likely to complete homework and other tasks independently.
Supervision means paying attention to the details
- Knowing where the child is
- Knowing what the child is doing
- Knowing who the child is with
- Supervision involves contact and awareness.
- It is the parent actively caring and doing the work of parenting.
- It creates the setting in which the child can safely become aware of himself as his own person.
- Effective monitoring leads to knowledge of child and parental self-awareness.
- Supervision is central to the development of attachment, identity and conscience.
Poor supervision is associated with poor health and behavioral outcomes. Accidents and injuries are more common in poorly supervised children. Adolescents with poor supervision engage in risky sexual behaviors, substance abuse, and antisocial behaviors more often than their better supervised peers. They often find that they lack direction, motivation, and a sense of identity.
Teenagers like to complain about supervision. They often feel that independence in certain areas should come a year or 2 earlier than parents think it should come. This can create tension between parents and children, but in most cases this is a healthy tension that decreases incrementally as the adolescent proves herself responsible and worthy of increased independence from supervision.
Resources & References
Weissman, M. M. (2020). Intergenerational study of depression: A convergence of findings and opportunities. Psychological Medicine, 50(1), 170–172. https://doi.org/10.1017/S0033291719002939