Supporting medication recommendations: Research findings
In this chapter, we examine strategies that child psychiatrists use to encourage parent engagement and buy-in toward medication recommendations, and illustrate how parents, psychiatrists, and sometimes children, discuss and make decisions about necessary changes in medication such as increasing a dose or switching to a new prescription. We particularly highlight ways doctors strategically set up their recommendations to give parents active power in the decision-making process and provide a non- judgmental space to express fears and concerns.
The transcripts presented in this chapter are from video-recordings of child psychiatry appointments for children diagnosed with attention deficit/ hyperactivity disorder (ADHD) starting on first-time stimulant medication (see inset). We examined the first three follow-up appointments after initial diagnosis as this is the crucial early stage when groundwork for the psy- chiatrist/parent/child relationship is developed and when parents’ and children's concerns about medication are most apparent. Data were collected for a feasibility study of an ADHD medication titration web app designed to help improve communication between parents and providers about children's symptoms and side effects (Mikesell et al., 2018; see Box 7.1).
Presenting the medication recommendation
In these appointments, providers are negotiating three main goals:
- 1 To provide quality evidence-based care for the child;
- 2 To engage the parent as an active participant in the decision-making process; and
- 3 To allow parents room to express fears or concerns and acknowledge these in a non-judgmental fashion.
In some cases, these goals may appear to be in conflict. For example, if a parent’s fears about medication are based on misinformation, the provider
Box 7.1 Web App Feasibility Study
- • Site: Two child psychiatry clinics in Los Angeles, California, USA, serving low-income, primarily minority families
- • Research Participants:
о 21 English-speaking parents of children aged 5-11 years о Child is diagnosed with ADHD and prescribed stimulant medication for the first time
• Data Collected:
о Video recordings of the first 3 appointments after receiving the prescription
о After-visit questionnaires about medication acceptability, parental confidence, and satisfaction with treatment о Open-ended interviews with parents and providers, and ethnographic observations of clinic workflow
- • Goals: To test the feasibility and acceptability of a web app designed to track parent/teacher reports of symptoms and side effects and to assist parents and providers in discussing them during medication titration visits
- • See also: Mikesell et al. (2018) will typically focus on building rapport and addressing the parent’s concerns (goal #3) before correcting their misinformation (goal #1). We therefore provide some practical tips in Box 7.2.
Four types of support for a medication decision
When presenting a medication recommendation, doctors frequently offered some fomi of support for their decision. In our research, these fell into four categories:
- • Observations of symptoms and side effects, based on parents’ or teachers’ reports. (Less frequently, doctors may cite their own observations of a child’s behaviour during the appointment.)
- • Parent or child's preferences or dislikes, for example a parent not wanting a high dose or a child not liking how the medication makes them feel.
- • Hypothetical future scenarios in which doctors describe different possible ways a dose change might play out (e.g., “if we see improvement, then ... otherwise ...”)
- • Expert medical knowledge about ADHD or stimulant medication.
Each type of support can be used strategically to include parents as partners in the treatment process, making them active collaborators in decisionmaking and creating a non-judgmental environment where their concerns and fears can be addressed.
Medication recommendations supported by parent observations
Excerpt 1: First follow-up visit.
1. DOC : The other thing is . since she' s been more irritable on the weekends, I would just keep the Concerta [medication] going. On the weekends.
Because ADHD symptoms occur in a variety of contexts, providers heavily depend on the observations of adults who spend lengthy periods of time with the child, such as parents and teachers. When making recommendations about dose changes, providers often reference parents’ own reports (e.g., more irritable on the weekends). Building on information presented by the parent adds strength to the provider’s recommendation. Such repetition also emphasizes the key role the parent plays in the treatment process as the person in charge of monitoring the child’s status.
Box 7.2 Practical tips
Practical tips for improving communication during treatment recommendation
- • Throughout the entire process, create opportunities for shared treatment decision-making with the parent.
- • When giving your recommendation, explicitly show that it is consistent with the parent or child’s preferences and concerns, or that it is based on information they provided (e.g., reports of symptoms).
- • Depending on cultural and class factors, parents may feel uncomfortable contradicting an authority figure even if they disagree with you. Frame the interaction as an equal partnership by using:
о inclusive ire and vow-focused language (we can decrease the dose rather than I can prescribe a lower dose). о mitigating phrases (/ think; maybe we can; let's try), rather than authoritative ones (you need to). о check-in questions to see how parent and child feel about each step (how does that sound? are you okay with that?)
• If parents are uncomfortable with a best practice treatment recommendation:
о Don't dismiss their fears as “wrong” or unrealistic. Instead, emphasize your shared priorities as a team (see above) and work together to address their concerns (see below), о Focus on the source of the parent’s discomfort: can you plan in advance or safely change the recommendation to alleviate it? (e.g., if the parent is worried about accidental overmedicating, suggest a very gradual titration), о Offer clear strategies for addressing different future scenarios (e.g., “we'll go back to the lower dose if the stomachaches don’t go away after three days”), especially for scenarios that the parent is worried about.
о Empower the parent in this process: remind them that they know their child best, that you’re relying on them to make the in-the-moment decisions if any problems emerge (e.g., whether to skip a dose when the child is ill), and how they can contact you if they have questions.
Excerpt 2: Mother and son’s second follow-up visit. Mother has just finished describing problems the child is having with distractibility during homework time.
- 1. DOC: I see, okay. So sounds like, um, um, maybe we could do better medwise -
- 2. MOM: Mhm.
- 3. DOC: - as far as, um, you know, helping with focus and attention, and - helping him to be less distracted.
- 4. MOM: Mhm.
- 5. DOC: Um, I wonder if . You know we could try a higher dose
- 6. the reason we didn't do it last time is cuz
- 7. we were concerned about side effects
- 8. he was having those headaches and stuff?
- 9. MOM: Mhm
- 10. DOC: But now that he's not having them. You know, I think -
- 11. It sounds like - you know we COULD go that way.
Rather than repeating the parent’s observations as in Excerpt 1, this doctor begins with the referential phrase sounds like, to tie her upcoming recommendation to the information the parent has just given her. She also strategically uses language that encourages Mom to become an active decisionmaker. Repeatedly using we rather than / frames her recommendation as a joint decision (ire could, we were concerned). She also downplays her position of authority by using hedge words - mitigating modifiers that make one’s speech sound less assertive and more hesitant: I wonder if, it sounds like, we could.