Summer 2002 Issue:

Contents:

• Chair's Column;
• Enhancing Parent-Adolescent Communication and Cooperation;
• Feeding in Preterm Children.

Chair's Column:

As we head into the new academic year our new residents have been oriented and are settling into their routine. Our residents spend the majority of their time on the KU Campus but also rotate through the greater Kansas City Community, including continuity clinics in some private pediatricians' offices.

Our weekly Pediatric Grand Rounds resumed on September 13th. Some of the first topics include "Update on Arthritis in Children", "Recent Advances in the Pathophysiology and Management of Neonatal Jaundice", and "Neurogastroenterology and the KU Motility Center". We invite any practitioner in the community to attend.

We have a new Dean for the School of Medicine, Dr. Barbara Atkinson, previously Chair of Pathology.

Dr. Randy Goldstein, a recent graduate of the KU Pediatrics residency, has joined our General Pediatrics Division and an additional pediatric neurologist will be joining the faculty January 1, 2003.

Sincerely,

Carol B. Lindsley, MD,

Professor and Chair.

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Enhancing Parent-Adolescent Communication and Cooperation:

Michael A. Rapoff, Ph.D.

Professor and Division Chief, Pediatric Behavioral Sciences

Parents and teens are often referred to our division because of breakdowns in communication that lead to frequent and, sometimes, serious conflicts. Developmentally, adolescents are trying to establish their own identity and independence while parents are holding on for dear life to control as much as they can muster to protect their teen. This can be a explosive combination of diametrically opposed but worthwhile agendas. The following guidelines will help teenagers and their parents communicate more effectively and solve problems and conflicts.

• We encourage families to set a convenient time for family meetings (such as after dinner once a week for about 30 to 60 minutes). Family meetings should not occur after a big "blow-up". At each meeting, someone is chosen to lead the family meeting. During family meetings, the following rules for effective communication and negotiation should be followed:
  • " Focus on one or two issues per meeting.
  • " Make sure everyone has a chance to speak uninterrupted by others.
  • " The leader should make sure everyone stays on task and does not shift to other topics not under discussion for a particular meeting.
• Family members should specify problems or complaints in a constructive and non-attacking way, using "I", rather than "YOU" messages. For example, a parent may be upset because one of the children has not been completing homework assignments. Instead of saying, "You have been very irresponsible and lazy about doing your homework!" (a "YOU" message), the parent could say "I am concerned that because your homework assignments have not been getting done, your grades will suffer" (an "I" message).
• When first beginning family meetings, members of the family may have to be reminded to state problems and complaints in a constructive manner. Sometimes a person may be asked to leave the meeting for a short time to defuse anger and negative comments.
• Once a specific problem has been identified in a constructive way, the person who identified the problem should first suggest a possible solution. Others are then encouraged to offer their opinions.
• A plan for solving the problem should then be voted on. The plan should include a specific way to monitor how it is working and a time limit for determining if the plan has been effective.
• To formalize solutions to problems, families may find it helpful to draw up a written contract which specifies the conditions of agreement reached during family meetings. Contracts should be positive, mutually negotiated, and fair to all parties. They should focus on specific behaviors (responsibilities) to be performed and should specify rewards/privileges which will be given after behaviors are performed. Specific ways to monitor the terms of the contract should be spelled out clearly. The time period that the contract is in effect should be specified and at the end of the time period, the contract should be reviewed and modified as necessary. Contracts can also include a bonus for performance that exceeds some specified level and a penalty for failure to perform to some minimum level.

Families with less serious conflicts may be able to follow these guidelines and conduct effective family meetings without professional help. However, families with more serious problems will require professional assistance to learn how to more effectively communicate and solve problems. Our experience is that adolescents will generally want to participate in this process as it gives them an opportunity to have input about household rules and regulations. If needed, psychologists in our division are available to assist families in this process (to refer a family, call our office at 913-588-6323).

An expanded version of these guidelines and a sample contract can be obtained from our division by emailing Dr. Rapoff or calling our office (913-588-6323).

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Feeding in Preterm Children — A Multidisciplinary Approach:

Ann M. McGrath, PhD

Assistant Professor, Pediatric Behavioral Sciences

As advances take place in prenatal and neonatal care, increasing numbers of premature or very low birth weight infants are surviving to childhood. Although most of these children progress well medically and developmentally, there exists a sub-sample for whom this is not the case. These children can have a variety of complications, including poor feeding and growth. Within the first year of life, approximately 31% of children cared for on a Neonatal Intensive Care Unit (NICU) will experience difficulties with feeding and growth. Thus, it seems clear that for those of us working in pediatrics, feeding issues will be a part of our practice.

Assessment:

Nutrition and Growth. A pediatric nutritionist or dietitian should be included in the care of children with feeding problems. These specialists typically begin by obtaining accurate height and weight measurements and using growth charts to compare children to national norms. They will often use a food record or food recall measure. This information will allow assessment of the amount and type of foods consumed to look for problems such as low caloric intake and inadequacies of important vitamins and minerals.

Physiologic. When an infant is ready to be fed orally, an assessment of their physiologic structures may be in order. A pediatric gastroenterologist might assess for Gastroesophageal Reflux (GER), laryngomalacia, aspiration pneumonia, and necrotizing enterocolitis. They may also obtain gastrointestinal motility studies and gastric emptying scans to identify abnormalities affecting digestion.

Visual inspection of the child's oral structures and ability to handle oral secretions is typically done by an occupational or speech therapist who specializes in feeding. These specialists will assess oral motor and communication development. If airway protection problems are suspected, these specialists may determine that a videofluoroscopic swallow study (VSS) or a fiberoptic endoscopic evaluation of swallowing (FEES) is necessary.

If a child has difficulties with sitting, holding utensils, or head placement, a physical therapist who specializes in feeding should be involved in the team. They can help with positioning the child and recommending the correct eating utensils to ensure the highest chance of comfort and success.

Psychosocial. A pediatric psychologist with experience in feeding should also be included in the assessment process. The psychologist will observe a feeding session between the primary feeder (typically a parent) and the child and conduct a parent interview. These assessments will inform the specialist about difficulties with feeder-child interactions, developmental functioning, current feeding practices, and family psychosocial functioning.

Treatment - The Multidisciplinary Approach:

Because the assessment and treatment of these children is so complicated, a multidisciplinary approach is ideal. This team should assess the child and family together at a single appointment. Determination can then be made regarding treatment goals and progression of treatment for each child and family. For example, for children who are fed parenterally or enterally and are moving to oral feeding, it is often necessary for a pediatric gastroenterologist to treat the child before they can begin feeding. Then, the occupational or speech therapist may complete their evaluation to determine if the child can protect his/her airway during feeding and has the skills necessary to begin an oral feeding program. If necessary, the physical therapist may recommend a special chair or spoon depending upon the needs of the child. Then the dietician and pediatric psychologist can be involved to teach the family about healthy eating habits and positive behavioral feeding practices.

For more information or to arrange for a referral, please contact Ann M. Davis, Ph.D. (913-588-6323) or the Interdisciplinary Feeding Team (913-588-5926).

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