The Doublespeak Dilemma: Effectively Communicating With Children and Adolescents and Their Caregivers.

Abstract

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 parentchild 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 psychiatristsworkingwith 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.