The Doublespeak Dilemma: Effectively Communicating With Children and Adolescents and Their Caregivers
Don’t laugh at youth for his affectations; he is only trying on one face after another to find a face of his own.—Logan Pearsall Smith (1)
Communication is the most common and, one might argue, the most essential “procedure” in medical practice (2). It is the foundation of the therapeutic doctor-patient relationship. Effective communication within the health care setting is essential for accurate diagnosis, successful treatment, and enhanced patient satisfaction (3). In the pediatric setting, the task of communicating effectively—building a rapport, listening empathically, and providing clear, culturally sensitive and developmentally appropriate observations and explanations—includes both the parents and the child or adolescent. This requires having specialized expertise for engagement, a high level of sensitivity to the parent-child dynamic, and attention to the needs and preferences of the parents while appropriately advocating for and protecting the confidences of the youth. This can be a fine line to tread, especially for the older child and adolescent.
Three basic elements of physician-parent-child communication were identified by Richard Street (4): partnership building, interpersonal sensitivity, and informativeness. The first task, partnership building, involves forming a therapeutic rapport, such that the child patient and his or her parents feel comfortable stating their concerns, perspectives, and suggestions during the consultation. A physician that is attentive and displays, by language and behavior, that he or she is interested in the patient as a unique person with a complex inner life is demonstrating interpersonal sensitivity. Finally, informativeness includes the quality and quantity of the health information provided by the physician. Skill in these three domains with child and adolescent patients and their parents is needed for successful engagement and adherence to an agreed-upon treatment plan.
One of the dilemmas for psychiatrists working with children and adolescents is the degree to which there is confidentiality in the doctor-patient communication. Confidentiality, one of the tenants of psychiatric practice, is a mutable dimension when treating a pediatric patient. For example, with infant mental health, the parent is the primary focus of treatment and the doctor-patient confidentiality is with the parent. As the child matures socially, emotionally, and intellectually, more confidentiality is appropriate. The issue of what is and what is not confidential is very important to address early in the therapeutic relationship—with parents as well as the child or adolescent patient. In general, the younger and more developmentally immature a child, the more a parent needs, and is entitled, to know about the treatment. Regular meetings with the child and parents may assist in providing information for the parents, while engaging them in the work of effective parent-child communication. For adolescents, the issues of safety take precedence, but confidentiality is maintained for more personal communications, as requested. Clear communication with the adolescent and parents about the nature of the confidential relationship helps to maintain parental support of the treatment. In addition, specifying how parents will be informed about the progress of treatment is required. Parent-adolescent meetings in which the adolescent shares the information they feel the parents should know is an excellent opportunity for enhancing communication within the family. Transparency about the process of treatment, the goals, and how issues of confidentiality will be addressed enhances engagement and improves outcomes (5).
For child and adolescent psychiatrists, the dilemma of communicating with anxious parents of an adolescent who does not want confidential information discussed may lead to a temptation for doublespeak—to provide the parents with vague information that is designed to conceal the true nature of the adolescent’s issues that have been identified in therapy. However, clear, honest communication with parents is essential to maintaining a trusting, family-centered relationship. What can and cannot be shared should be jointly discussed and understood.
Clinical Vignette
Leticia was a 13-year-old adolescent who presented with her mother to the pediatrician for an annual checkup. Dr. Qureshi always looked forward to seeing her. She was a bright, easily engaged, healthy, and spunky girl who delighted in teaching Dr. Qureshi about “kid culture.” “She’s a teenager now,” Dr. Qureshi mused, remembering her from when she was a toddler. She had started her menses last year, and Dr. Qureshi noted how much taller and physically developed she appeared sitting in the waiting room. He glanced at her screening questionnaires, and his brow furrowed instinctively. The Patient Health Questionnaire (PHQ-9) completed by Leticia was highly suggestive of depression. She even endorsed the PHQ-9 question about having “thoughts that you would be better off dead or of hurting yourself in some way” with a 2 (more than half the days). Dr. Qureshi took a deep breath, planted a welcoming smile on his face, and greeted Leticia and her mother warmly.
For patients of this age, Dr. Qureshi typically spoke with the parent and youth together, and then talked to the youth alone. Leticia said that school was “boring,” but that she did not have any particular problems. Leticia’s mother reported that, on the contrary, Leticia has gotten moody, talks back, does not finish her chores, does not spend enough time on her homework, and spends much too much time in her room on her computer.
Leticia gazed with contempt at her mother and replied “You just don’t understand teenagers, Mom. Jessica’s mother doesn’t nag at her all the time like you nag at me.”
Her mother bristled and looked at Dr. Qureshi pleadingly, “See what I mean?”
Without her mother present, Leticia reported that she has been cyberbullied by the “mean girls” at school. She is not sleeping well and has lost interest in academics and quit the soccer team. Dr. Qureshi, becoming alarmed, asked if she would be willing to talk to Dr. Pellova, the psychiatrist. The nurse left the office to make a call. Leticia initially looked curious and said she was interested, but then shook her head. “I don’t want my mom to know about this. She will freak out on me and give me even less freedom than I already have!”
Dr. Pellova, a child and adolescent psychiatrist, worked within the pediatric medical home. She poked her head into the office, having been summoned by the nurse for a safety assessment. “Hello, I’m Dr. Pellova. May I come in?”
“You called the psychiatrist on me?,” Leticia asked Dr. Qureshi, glaring.
“I did call the psychiatrist—to help assess to be sure that you are safe. Your thoughts of suicide concern me.”
“Does my mom know?” Leticia inquired. “Or perhaps you do an overhead announcement, ‘Psychiatrist to Leticia’s room, Stat!’” Leticia blurted, with no attempt to hide her sarcasm.
“I haven’t talked with your mother yet,” Dr. Pellova reassured.
“You sound concerned,” Dr. Pellova noted, looking quizzical.
Dr. Qureshi commented that he needed to go see another patient. “Leticia, will you stay and chat with Dr. Pellova, please?”
“I think you made me an offer I can’t refuse,” Leticia retorted.
“I hope you won’t—refuse, that is,” Dr. Qureshi said, his eyes softening to an empathic plea.
“I think adults have a pact to intrude upon teenagers’ privacy,” Leticia complained.
“Can you tell me what else is upsetting you?” Dr. Pellova inquired.
Leticia told her of the “mean girls,” and how her boyfriend broke up with her because of the rumors they started about “my being a whore” because I drank at a party and kissed a guy. She showed Dr. Pellova the superficial scratches that she had made on her forearms when she was upset, “to calm me down.”
“Do your parents know any of this?” Dr. Pellova asked, with a look of gentle concern in her eyes.
Leticia replied, “My mom just wants me to be a good little girl and get all As. My dad is always working. He doesn’t notice anything.”
After conducting a thorough risk assessment and determining that Leticia was not actively suicidal, Dr. Pellova noted, “You seem very depressed. And no wonder—you’ve had a whole lot going on. Did you know that about 20% of teens suffer from depression? You are not alone. However, you are particularly brave to have talked about it. That way, we can treat it. Unfortunately, only about 30% of depressed teens actually get help.”
“And my mom?” Leticia asked, her eyes looking apprehensive this time. “What are you going to tell her?”
“Well,” mused Dr. Pellova. “I thought that you might want to be the one to talk to her about it. My guess is that she already suspects something, and if you tell her, I won’t be saying anything you don’t want me to. You do know that if there are safety concerns, though, I would have to let her know. And some kids need to go to the hospital to be sure they are safe.”
“Are you going to put me in the hospital?” Leticia asked, outraged.
“That is not the plan. I mentioned it to be as honest as possible about the seriousness of safety issues,” said Dr. Pellova.
“Okay,” Leticia said, notably relieved. “I guess I will tell my mom, but can you help? Especially if she gets all freaked out?”
“Of course. I can tell you care about your mother and don’t want to make her worry. Dr. Qureshi was right—you really are a very special young person,” said Dr. Pellova.
Triadic Communication in Pediatric Healthcare
Pediatric health care quality has been found to improve when the child is optimally informed about his or her disorder and is engaged in the treatment planning. The principle of self-determination applies to children as well as to adults (6, 7). In fact, U.S. (8), Canadian (9), and United Kingdom (10) laws, policies, and court decisions recently concluded that there is a moral and ethical obligation to discuss health and illness with the child patient, along with the expectation that children will be active participants in their care (6–8).
Cahill and Papageorgiou (11) completed a literature review of the amount and type of involvement that child patients (ages 6–12) have in their primary medical care. The authors concluded that “children may have some input into the history and examination phases of the encounter, but much less involvement in the explanation and planning parts.” Typically, prior to the age of 13 years, children are seen with an adult caregiver “and the consultations are triadic” (11). Although it is essential to elicit the child’s developmental and symptom history from the child’s caregivers, adults involved in the life of the child tend to be most accurate when relaying externalizing symptoms (oppositionality, conduct problems, or attention deficit hyperactivity disorder). The child tends to be more accurate when describing internalizing symptoms (depression and anxiety). Gleaning information primarily from the caregivers may be particularly problematic when the child has suffered abuse or neglect and is reluctant to disclose, when symptoms are primarily internalizing (anxiety and depression), and when the child’s adherence to recommendations is impeded by not being involved in the treatment planning process. Tates and Meeuwesen (5) suggested that it is incumbent on the physician to provide clarity to both the child and adult of the desirability of the child’s maximal age-appropriate participation in health care discussion and decisions.
Recommendations to Enhance Communication With the Pediatric Patient and Caregivers
1.
Set the stage: Provide information at the outset to the caregivers and child or adolescent about plans for evaluation and treatment.
a.
Emphasize the essential role of the child patient in providing input about symptoms, relaying their strengths and interests (resilience factors), and participating in treatment decisions consistent with age and developmental capacities.
b.
Discuss the issues of confidentiality and agree on methods of communicating general treatment progress while ensuring that the child has appropriate control over what is being shared with caregivers.
c.
Review that safety is of primary importance, and confidentiality cannot be assured if there are legitimate safety concerns.
2.
Children frequently want to please adults by providing the answers that they believe the adults wants to hear.
a.
Spend time getting to know the child’s interests, strengths, and values prior to asking more difficult or emotionally laden questions.
b.
Ask questions in an open-ended, curious manner that does not convey a “right or wrong” connotation.
3.
Use developmentally appropriate tools to enhance communication (12).
a.
Use developmentally appropriate language when explaining a disorder and recommended treatment.
b.
With younger children, playing together with toys, puppets, or dolls may allow the child to communicate via a play narrative.
c.
Ask the child to draw a picture (e.g., house, tree, person), which can be helpful in allowing the child to communicate nonverbally and in allowing the psychiatrist to understand multiple dimensions of development (fine motor, executive functioning and organization, social relationships, and fears).
4.
Use brief, evidence-informed procedures or protocols for screening sensitive topic areas, including substance use disorders, depression, and anxiety. Parent and child questionnaires may help elucidate the concerns of the parent separately from those of the child.
a.
Reviewing answers to these questions may facilitate discussion.
b.
Ask follow-up questions in a nonjudgmental manner.
5.
Emphasize strengths.
a.
Identify and name the strengths of the child patient and of the parents or caregivers to improve self-esteem and motivation, and to help guide treatment planning that is strength and resilience based.
b.
Ask child or adolescent patients and their caregivers about satisfaction with and the effectiveness of your communication style. Address any issues identified.
6.
Provide an open atmosphere for discussing problems and problem behaviors.
a.
Consider the technique of “gentle assumption,” in which the physicians assumes a behavior is already occurring and helps the patient feel more at ease discussing behaviors.
7.
Listen carefully and acknowledge the child’s or adolescent’s aspirations and values, as well as those of the parents or caregivers (13).
References
1.
Smith LP: Afterthoughts. New York, Constable, 1931
2.
Levetown M: Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics 2008; 121:e1441–e1460
3.
Stewart MA: Effective physician-patient communication and health outcomes: a review. CMAJ 1995; 152:1423–1433
4.
Street RL Jr: Physicians’ communication and parents’ evaluations of pediatric consultations. Med Care 1991; 29:1146–1152
5.
Tates K, Meeuwesen L: Doctor-parent-child communication: a (re)view of the literature. Soc Sci Med 2001; 52:839–851
6.
McCabe MA: Involving children and adolescents in medical decision making: developmental and clinical considerations. J Pediatr Psychol 1996; 21:505–516
7.
Dixon-Woods M, Young B, Heney D: Partnerships with children. BMJ 1999; 319:778–780
8.
American Academy of Pediatrics Committee on Bioethics: Informed consent, parental permission, and assent in pediatric practices. Pediatrics 1995; 95:314–317
9.
Canadian Paediatric Society, Bioethics Committee: Treatment decisions regarding infants, children and adolescents. Paediatr Child Health 2004; 9:99–114
10.
British Medical Association: Consent, Rights and Choices in Health Care for Children and Young People. London, BMJ Books, 2001
11.
Cahill P, Papageorgiou A: Triadic communication in the primary care paediatric consultation: a review of the literature. Br J Gen Pract 2007; 57:904–911
12.
Bannister A, Huntington A: Communicating With Children and Adolescents: Action for Change. Philadelphia, Jessica Kingsley, 2002
13.
Nova C, Vegni E, Moja EA: The physician-patient-parent communication: a qualitative perspective on the child’s contribution. Patient Educ Couns 2005; 58:327–333
Information & Authors
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Published in print: Winter 2016
Published online: 14 January 2016
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Competing Interests
Dr. Stubbe reports no financial relationships with commercial interests.
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