Communicating with parents about psychotropic medication treatment
F. Alethea Marti and Bonnie T. Zima
The core of child psychiatry is the therapeutic relationship between the provider and the family. Mental health practitioners seek to develop treatment plans that will improve the child’s quality of life and lead to better long-term outcomes, and it is highly rewarding to see one’s patients achieve long-term success in school, in friendships, and in family relationships, months or even years later.
Parents and primary caregivers play a key role in treatment success: because they see the child every day, they are able to monitor symptoms and track behavioural problems, as well as make in-the-moment decisions about managing these problems. For this reason, treatment success requires a strong relationship of mutual trust and shared goals between parent1 and provider (Brinkman and Epstein, 2011). If parents do not trust providers, treatment adherence will be low and the likelihood of drop-out will increase. Similarly, if providers feel they cannot rely upon parents for accurate observations about the child, they will not have the necessary information to diagnose or monitor treatment effectiveness. For this reason, it is crucial that providers work to build mutual trust and a relationship that is non-judgmental and allows parents to express their fears and concerns, so that both parties can work together to develop best treatment options tailored for the family.
In this chapter, we focus specifically on the relationship between parent and psychiatrist during psychotropic medication titration, the process by which a new medication is gradually administered in order to determine the ideal dose needed by the child. While these strategies can be used more generally, it is important to note the ways in which medication titration differs from other forms of mental health treatment (such as therapy):
1 Providers can face resistance from parents to the idea of a long-term prescription medication, including concerns about side-effects, addiction, or having it become a gateway to illegal drug use later in life. For psychotropic medications, there are additional fears of personality changes or distrust at “fixing” a behavioural problem with chemicals. In our interviews with families for this study, a common theme that emerged was parents’ concerns that the medication would suppress the child’s natural enthusiasm or reduce them to a listless “zombie” state (see also Bussing et al., 2012: Hansen and Hansen, 2006: Travell and Visser, 2006). 2 Most of the treatment process occurs outside the psychiatrist’s office. The parent bears the primary burdens of administering daily medication, closely monitoring the child for bad reactions, and making immediate decisions if these occur. While some parents may prefer to have the child’s welfare in their own hands rather than that of a stranger, others may feel they are being given a medical role for which they are untrained.
Despite these differences, we anticipate that the strategies and tips we present here are also useful for other types of child treatment, particularly cases where there is strong fear or stigma, or where a caregiver is required to implement treatments between clinic visits or track the child’s condition on a daily basis.
The significance of parent/provider communication: Context and literature review
Across multiple care settings, family perception of good communication and rapport with the child’s provider are connected with other positive outcomes such as greater engagement in treatment, increased therapeutic alliance, better adherence to medication and treatment, higher parental satisfaction, and increased comfort discussing psychosocial concerns, all of which lead to better mental health care outcomes (Schoenthaler et al., 2009: Hart et al., 2007; Nobile and Drotar, 2003; Tarn et al., 2006; Wissow et al., 2010). For minority and immigrant families, good “cultural congruence” (shared cultural understandings between provider, patient or parent, and interpreter if there is one) is also key to successful communication, and can increase the likelihood of positive treatment outcomes for Latinos and Hispanics regardless of language fluency (Costantino et al., 2009; Villalobos et al., 2016).
In contrast, when parent feel that communication with their provider is poor, there is an increased likelihood of treatment drop-out, low medication adherence, misinformation, or mental illness stigma (Arcia et al., 2004; Bussing et al., 2007; Yeh et al., 2005; Zima et al., 2010). This effect becomes exacerbated for parents from racial or ethnic minority backgrounds (Arcia et al., 2004; Bussing et al., 2007), where differing paradigms of illness, caregiving, or even normal child behaviour may cause conflicts between family and provider (Ojeda et al., 2011) and lead to reluctance to seek out institutional care, especially if parents feel social stigma from medical authorities (Yeh et al., 2005).
Good communication is not always achieved, however. In an examination of US acute care visits, only one-third (32%) of providers even attempted to elicit other concerns patients might have apart from their initial complaint. Those providers who did so were more likely to receive a response if asking early in the appointment rather than at the end (Robinson et al., 2016). In medication titration visits, eliciting other concerns is important for two reasons. First, seemingly unrelated physical or behavioural problems may actually be side effects (e.g., insomnia) or indicators of medication ineffectiveness. Second, medication treatment is only part of the provider’s larger goal to improve the child’s quality of life. In addition to focusing on medication, the providers in our study would often also advise parents on other problems, such as creating effective homework or bedtime routines.
Importance of good communication in medication treatment
Positive medication outcomes over time depend on two factors: continuing to use the prescribed medication regularly (medication adherence) and continuing to meet with a provider to monitor changes or problems and receive refills (clinic attendance). Both factors are almost entirely in the hands of primary caregivers.
The degree to which patients and family are open to or resistant toward medication treatments varies cross-culturally even within a shared language. For example, Stivers and colleagues found that UK patients are more resistant to prescription medication, while US patients are more likely to expect prescriptions (Stivers and Barnes, 2017), and that providers frame recommendations accordingly, with UK providers using more inclusive language (offers or proposals, rather than authoritative pronouncements) to elicit patients’ agreement (Stivers et al., 2018).