Paediatrics: Systemic thinking

Systemic thinking

No child is an island. No family should be one. Children and families pre-sent within the context of systems; nuclear and extended families as well as the local and school communities. They are also affected by regional and national phenomena such as employment and poverty gradients and access to services.

Systemic thinking involves viewing the child within the context of the family and these broader systems. Such understanding is especially impor-tant when treatment systems intersect around complex psychosocial presentations. The difficulties some physicians caring for adolescents with anorexia nervosa experience in balancing the various inputs from mental health therapists, dieticians, school teachers and heads, the child, and par-ents is a good example.

Understanding the family system is essential: whether the parents work together or undermine the other one’s parenting; the function of sibling subsystems; whether there are typical alliances (i.e. father and son going to the football) or unhealthy alliances (i.e. cross-generation grouping to remove someone from family activities). Other types of questions that could be asked include;

·  Has a child been elevated into a decision-making role?

·  Has one parent been demoted?

·  Is a child an ‘identified’ rather than actual patient, e.g. the child is presented with withdrawn behaviour when the real problem is an imminent parental separation?

·  Have healthcare staff been unwittingly triangulated by some family members to exclude others from carer roles?

There are a number of schools of systemic thinking, but all tend to focus on understanding a number of key issues about the family and their rela-tionship with the environment;

·  Family functioning, roles, and relationships.

·  Attitudes and beliefs within the family.

·  Patterns of communication and interaction.

·  Problem solving abilities.

·  Strengths within the family.

• Social and cultural backgrounds.