Parental illness deserves attention.

When a child is ill, pediatricians are in their element. They delve for details, order tests, and consider the emotional--as well as the physical-impact of the illness.

But when it's the parent who is ill, the problem may seem to be best left at the waiting room door.

A friend's daughter recently moved to a new town and took her toddler to a pediatrician who was on her health plan. She was aghast that the new physician never alluded to her obvious, 7-month pregnancy!

Although pregnancy is not an illness, the story underscores how we, as pediatricians, can become so child centered that we forget to consider the key influences in the child's environment, especially the parents and close family members.

Parental illness, whether it's a broken arm, diabetes, or cancer, probably has significant implications for a child's daily life and well-being.

It behooves us to spend a few minutes of every visit looking the parent in the eye and asking, "How are you doing?" with an attentiveness that indicates we really do want to know the answer.

Obvious, subtle, or remarked-upon clues that the parent is dealing with illness deserve more attention, such as spending a few minutes alone with the parent, making targeted inquiries to the child about the illness's impact, and in some cases even scheduling a follow-up visit to assess the family's functioning.

If a parent waits until the last 30 seconds of the visit to mention a chemotherapy schedule or a spouse's position on the transplant list, fight the urge to ignore the opening of what hints to be a Pandora's box. If you're standing at the door, sit back down and acknowledge the importance of what has just been said. Assure the parent that it was an important thing to mention, and, if you have other patients waiting, set a time to meet again. And don't forget to make a note in the chart so you remember.

This approach indicates that you see the big picture, the distracted, pressured tumult that goes along with managing an illness while managing a family. A parent's illness may be influencing his or her ability to care for the child in terms of paying the bills; preparing meals; transporting the child to school and other activities; and maintaining a reassuring daily schedule. The illness could have direct infectious or genetic implications for the child.

And--perhaps most importantly of all the illness may be encroaching on important family interactions, when Dad's pain casts a nervous hush over the household, or Mom's depression has driven the family apart.

Children of severely ill parents very often take on parentified roles in the family, either resentfully or willingly abdicating childhood in the face of reality. Someone has to prepare the meals and watch the younger siblings; someone has to earn the next paycheck. They often feel guilty for not doing enough, or for being angry about the burden as well as the illness.

Children of ill parents often feel worried, either because they know the severity of the situation or because they haven't been told the situation and thus assume the worst. They may become worried about their own health, having spent much time around medications and medical offices. They also may just be angry that their freedom and fun are curtailed. The whole family can benefit from understanding these reactions and talking about them openly, without resentment.

Parenting itself also can be influenced by illness. Does the parent with a chronic illness build an overprotective cocoon around the child, or convey the idea that illness is inevitable? Has the terminally ill parent determined that the child's memories should not be of discipline, but only indulgence? Is the parent's pain level dictating how strictly household rules will be enforced? These parents need to be advised that maintaining routines and the usual discipline are among the most important things they can do to reassure the child and reduce the long-term effects from the family's journey through illness.

As a pediatrician, you are uniquely positioned to reach out to the family. You understand illness and its emotional fallout. You can ask open-ended questions--for example, "What's the hardest part?"--and respond with genuine empathy.

Not infrequently, parents who are ill may ask my advice about their care, not just about how to cope. My own personal philosophy is to offer whatever I can in terms of referrals and recommendations within the limits of my medical expertise. I try to remember that I may be the only physician the parent is seeing because shelacks insurance, or because I'm the only physician he truly trusts.

I also think it's important to foster a discussion of possibilities and creative solutions to the nuts and bolts of the illness burden, from household duties to the inevitable fatigue and irritability. Parental illness is a family problem, with many elements to solve. You may bring a fresh perspective and wisdom from witnessing other families deal with illness.

Many parents, once encouraged, will seek advice on ways to talk to their children about their illness.

You also might offer age-appropriate suggestions about ways to help children feel that they continue to play a necessary and meaningful role in a family burdened by illness, just by doing their daily chores, creating notes and pictures to decorate a hospital room, or being the photographer of family events that a parent might miss.

Finally, I like to put parental illness in perspective.

I let parents know that there is evidence that children learn empathy from living with an ill parent or sibling, and often become better people as a result.

Parents who learn to cope with the realities of illness can model for their children a valuable life lesson in facing adversity. Their children can grow up better prepared for life's challenges.

Families facing serious illness also learn to savor the important moments in life and to express to their children those sentiments that are too often unspoken: "I'm proud of you." "I have great hopes for you." And the simplest of all, "I love you."

BY BARBARA J. HOWARD, M.D.

DR. HOWARD is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and codirector of the Center for Promotion of Child Development Through Primary Care (www.childhealthcare.org). Write to Dr. Howard at our editorial offices, pdnews@elsevier.com.