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Supporting Parents PDF Print E-mail
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Friday, 04 February 2011 05:29

Supporting Parents: Communication Tips

Clinicians know that it is important to listen to parent/guardian concerns, but in a busy practice it may be difficult to know how to respond when concerns are expressed, and which concerns should raise red flags. Equally complex are discussions in which a provider has to bring up developmental concerns that the parents may or may not share. There is a significant literature about, and provider training in, breaking “bad news” to families. There is less guidance for providers who need to address a possible problem. We provide guidance below that is informed by expert consensus: clinicians and parents who have been through this experience.

Guidance from Bright Futures: “Parents’ perspectives about the needs of their children and whether they view the infant’s behaviors as normal or typical for the child’s age are equally important considerations in developmentally focused anticipatory guidance. Because families vary in their responses and behaviors, the health care professional must learn about these customs and seek to understand parents’ responses and behaviors, even if they differ from those expected in the community context.” Bright Futures, accessed November 2010.

General tips when there are concerns from the provider and/or parents about a child’s motor development:

  • Take time to understand the parents’ concerns. Appreciate that socio-cultural background may affect whether and how parents discuss concerns with providers.
  • Pay attention to the parents’ tone of voice and body language as important communication cues.
  • Explain your own concerns (or why you are not concerned) in plain language.
  • Outline the plan for further assessment. Clearly describe what will happen next and which clinical professionals will be involved.
  • Ask if the parents have any questions. Realize that they may be so overwhelmed or concerned that they will not be able to take in much information, and they may need another opportunity to ask questions in the near future.
  • Ask the parents how they feel about the plan.
  • Respond to their feelings; even a simple reflection of their feelings goes a long way to the parents feeling heard.
  • Reassure parents that you will revisit concerns about motor development until delays are resolved and/or until the cause of the delay is known.

Though these tips may seem obvious, it is easy to overlook basic communication skills and make assumptions about parents’ understanding and perspectives, especially when the providers’ focus is on the child.

1. Communication tips when the parents bring up a concern about motor development

  • Appreciate that most parents are accurate at identifying delays in child development; as noted by the AAP, 80% of parental concerns are correct and accurate.
  • Use active listening. Ask questions to clarify and gather more information, especially if parents present vague concerns about development.
  • Use questioning to take advantage of the fact that parents have opportunities to see children perform gross motor activities that you may not be able to observe in the clinic setting (sustained running, climbing, bike riding, stair climbing, etc).
  • Encourage parents to come to appointments with a list of questions and concerns to help ensure that their needs are met during the visit.

1a. Communication if you share the parents’ concerns

  • Clearly explain where you see delays and how your assessment corresponds with or adds to the parents’ stated concerns.
     
    “You’ve told me that you are worried because Derrick isn’t able to get into a sitting position yet, though he is 9 months old. I agree that he’s behind what we’d expect in this milestone. I also notice that although he can sit alone, he’s still wobbly and he needs to use his hands to stay steady.”
     
  • Talk to parents honestly, though sensitively, about whether your assessment is more consistent with a minor delay that is amenable to quick catch-up, or whether you suspect a more serious delay.
     
    “Derrick should have more strength by now. We need to check into the reason that he is behind. Though it is possible that he might catch up if we didn’t do anything, I think that it’s best that we provide him with some extra help.”
     
  • As relevant, emphasize that all children are different and that it is difficult to predict whether delays will continue, get better, or get worse; when reasonable, reassure parents that the child is unlikely to suddenly and dramatically get worse (a common concern once delays have been noted).
  • Explain the follow up plan. Describe the timeline and any specialists or therapists who will be involved, their role, and why it is important that they evaluate the child.
     
    “I’m going to do a CK test today, which is a simple blood test. Weakness can come from different causes and the CK test may tell whether the cause is his muscles. I’m also going to refer Derrick to a child neurologist, Dr. Smith. She is an expert on things that can cause weakness in children. Some parents hear the word “neurologist” and get really worried, which is understandable—neurologists sometimes care for kids who are really sick, but they also see a lot of kids who do great. We want to make sure that Derrick gets the care he needs as soon as possible, so we can continue to work together to figure out why he is weak and make a plan for next steps.”
     
  • Finally, keep in mind that your confirmation of the parents’ concerns may raise conflicting feelings, including relief at being heard, worry because you share their concerns, and even anger at you for bringing unwelcome news. Take a few moments to ask about the parents’ feelings.
     
    “I know that this isn’t the news you wanted to hear. How are you feeling right now?.... What is your main worry right now?”
     

1b. Communication if you do not share the parents’ concerns

If parents raise concerns that you think are unwarranted or premature, consider the following.

  • Listen to their concerns and use reflective statements so they know you understand their perspective.
     
    “I hear you saying that based on your older son’s age at walking, you are worried that your daughter’s walking is behind.”
     
  • Explain clearly why you think the child’s motor development is in an acceptable range.
     
    “It’s true that your daughter is later to start walking than your son. But children develop at different speeds, and your daughter is only 12 months old. Only about half of children are walking at 12 months. I’m also reassured that she met all of her other milestones at the right times, and she looks great on her check up today.”
     
  • Reassure the parents that you will evaluate motor development at each well-child visit.
     
    “I’ll see you and your daughter again in 2 months for her next visit. If she is having any issues with her development, we can talk about next steps. I suspect that she’ll be walking by then, though.”
     

2. Communications tips when you have concerns and the parents don’t, or if you don’t know if parents have concerns

  • Explore whether the parents have any concerns about development. If this is a first child, ask if the parents know when motor milestones should be achieved. Ask if the parents have noticed any differences among their child’s development and those of siblings/peers.
  • Bring up your concerns as you educate about when milestones should be attained. Emphasize the range in attainment in healthy, “normal” children.
     
    “I have noticed that Derrick isn’t able to get into sitting yet, though he is 9 months old. I also notice that although he can sit alone, he’s still wobbly and he needs to use his hands to stay steady. Though babies develop at different speeds, by 9 months most children are able to sit very steadily and get into sitting by themselves.”
     
  • Ask if the parents have noticed your concern, or anything else that concerns them about their child’s development.
     
    “Do you see what I mean about Derrick’s sitting?... Tell me how you feel about his development overall.”
     
  • Ask them how they feel about you bringing up the developmental concern.
     
    “No parent wants to hear that their baby is behind in anything. In a minute we are going to plan what to do, but right now, tell me how you are feeling…. What’s your biggest worry?
     
  • See the tips under Communication if you share the parents’ concerns, above, for guidance on continuing the discussion.

2b. Additional communication tips for parents who deny a motor delay or are resistant to follow up

  • Confirm (don’t assume) that the parents do not share your perspective. Keep in mind that couples may not agree.
  • Appreciate that resistance or denial may be rooted in fear or anger, influenced by your own bedside manner, and impacted by their socio-cultural perspective. Understand that denial may be a valid coping mechanism to protect the parent from pain or avoid conflict.
  • If a brief “wait and see” time is acceptable, consider asking the parents to look for specific motor milestones for one month, then bring the child back before recommending any follow up. This may allow the parents time to appreciate your area of concern and adjust to the need for follow up. If possible, call to check in with the family after two weeks.
  • When reasonable based on your clinical judgment, reassure the parents that many children benefit from early therapy.
  • Explain the follow up plan. Describe the timeline and any specialists or therapists who will be involved, their role, and why it is important that they evaluate the child.
  • Engage the family as much as possible. Ask if they have questions. Ask if they can re-state in their own words why you have raised a concern.
  • Be transparent about the fact that you and the parents disagree, and that you are still willing to work with them. Try to come to a shared goal, e.g., you all want to do your part to be sure the child develops to his/her highest potential.
     
Last Updated on Monday, 21 May 2012 19:56
 

Did you know?

Children can make developmental progress, even with progressive weakness. Developmental progress does not exclude the possibility of an underlying neuromuscular condition.
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