Throughout my third year I had met many patients whose stories lingered with me – from an old man who stoically digested his unexpected cancer diagnosis, to a young woman struggling with her psychiatric illness. I always enjoyed getting the chance to talk to those individuals, to hear precisely what was important to them and how they wanted to be treated. Children, on the other hand, especially ones who are not even two years old, cannot always tell you what happened, what they feel, or what they want. Therefore pediatricians must rely the parents can tell us what the problems are, but what happens when the parent is the problem?
Ana’s enlarged head was from subdural hygromas caused by subdural bleeds thought to be due to non-accidental trauma. There was a woman in the exam room, who gently held Ana’s head as I peered at her tympanic membranes, but this woman was her foster parent, not her birth mother. Although this woman had been assigned to Ana by CPS, the affection between the two was palpable and even as she squirmed on her lap, it was clear Ana felt comfortable. This was a therapeutic alliance that I could understand –clearly both of us had Ana’s health and wellbeing as our primary goal.
What I struggled with was the appropriate way to interact with Ana’s biological father, who sat awkwardly on the other side of the room. This young man was alert, eagerly asking questions about her lab results, and clumsily held her tiny hands during the ophthalmoscopic examination. Without knowing the full details of the CPS report, how do you include a parent in a visit who has been judged unfit to take care of their own child? Even if you are privy to all the information, how do you respect parental rights when they have been stripped away? Clearly the child’s best interests are the priority, but what level of parental involvement with medical care when a child is in foster care is appropriate? With the possibility that Ana may one day be returned to her parents’ custody, physicians must keep a balance between not alienating the parents while also keeping them at an appropriate distance. We are trained to see the red flags of child abuse and how to sound the alarm, but I do not know much about the aftermath of child abuse as it relates to the family structure. While the technicalities of the process of rebuilding a safe parent-child relationship are not strictly within the physician’s domain but at the same time a pediatrician will take care of a child for nearly two decades and throughout that time can offer guidance as well as serve as a safe harbor.
*Not the patient’s real name.
- A, M4