Medication recommendations supported by parent/child preferences

Excerpt 3: Third follow-up visit with Anna.[1] [2] [3] [4] [5] [6] [7] Doctor is recommending an increased medication dose, but Mother is reluctant.

Parent and child preferences were given equal weight to observable symptoms and side effects as reasons to change or maintain a dose. By explicitly referring to a parent (or child's) worries, the doctor turns her professional recommendation into a collaborative decision where the parent's input has equal value. This strategy can be effective in defusing disagreements if parents’ preferences contradict medical best practice, and can open the door to conversations about how to adjust medication recommendations to address parents’ concerns.

In this example, rather than contradicting Mom’s factual understanding of how titration works, the doctor first addresses the underlying reason for her reluctance and reassures her that they both share the same priority: neither of them wants to alter the child’s personality, they want her to stay her happy, engaged self. By emphasizing these shared goals, the doctor tries to allay the parent’s resistance to her recommendation. Near the end of same visit, the doctor returns to the topic and says she would like to “try a higher dose’’ (see excerpt 6) and the parent eventually agrees.

Eliciting children's preferences

Younger children in our study were not heavily involved in medication decision-making; indeed, doctors sometimes had trouble getting clear responses from a young child about “how the med feels” or “what it’s helping you with”. However, older children did understand and could participate in the conversation by describing side effects or school successes or by stating their own concerns. (See Travell and Visser, 2006, for more about the importance of including the perspectives of youth in ADHD medication treatment.)

The following two excerpts follow Keith, who has just begun a medication that is effective in controlling his symptoms but also causes problematic headaches. We see how psychiatrist and mother both use inclusive language to validate Keith as a participant in the decision-making process.

Excerpt 4: First follow-up. Mother relays Keith’s preferences to Doctor.

  • 1. MOM: When I ask him, you know, "Okay if the medication's making you feel this way, do you want to continue to take it?"
  • 2. I'm like "Mommy's not gonna force you to take it" .
  • 3. DOC: Mhm?
  • 4. MOM: And he was like "No, I'll stay on it". And I said "Okay".
  • 5. Cuz I've asked him on numerous occasions, у'know, how he' s feeling?
  • 6. DOC: Yeah?
  • 7. MOM: Urn, у' know "Do you want to continue with the medication?"
  • 8. DOC: Yeah.
  • 9. MOM: He says he don't wanna stop.
  • 10. DOC: Okay. ((to KID) ) You - you like what it' s doing for you then?
  • 11. KID : ( (nods) )
  • 12. DOC : Overall you like it. Okay. Well we ' re gonna help you try to see if we can deal with some of the - some of the side effects, okay?

In a situation with the potential for a very imbalanced power dynamic (one child speaking to two adults) mother and doctor both work to make sure Keith’s perspective is included and respected. Keith is a quiet child who says very little during appointments. Here, his mother voices his concerns and preferences by relaying conversations she had with him in private. Afterwards, the doctor addresses Keith directly to confirm their accuracy (lines 10-12).

Excerpt 5: Second follow-up. Doctor discusses with Mom the possibility of a higher dose now that Keith’s headaches have decreased.

  • 10 DOC ((to Kid)) : What do you - I know you mentioned that that's was something you'd be okay with, what do you think, Keith?
  • 11 KID ( (looks up) ) : Urn.
  • 12 ((pause while DOC looks at KID))
  • 13 KID: Uhhh, yeah?
  • 14 DOC: Would you be - Urn. I was wondering if you' d be okay with maybe, trying a higher dose of the medicine? To see if it might help you focus more.
  • 15 KID: ((nods slightly)) Yeah.
  • 16 DOC: Would that be something you'd be open to trying?
  • 17 KID: ((nods a bit more vigorously) )
  • 18 DOC: Cuz, we could try it and then you could let us know what you think.
  • 19 KID: ((nods))
  • 20 DOC: Okay?
  • 21 KID: ((nods again, smiling))

Similar to Excerpt 2, the doctor uses inclusive we- and yrw-focused language, check-in questions, and mitigating hedges (we could, would you be okay with) to include Mom and Keith in both the decision-making and the treatment implementation. Additionally, by repeatedly using the verb “to try” (lines 14-16), she presents the medication change as a temporary experiment that can be stopped at any time, not as a weighty final decision. Keith appears to not be paying attention at first, but soon agrees with nods and smiles (lines 17-21).

Medication recommendations supported by hypothetical futures

In contrast to behavioural observations or preferences, a third strategy used by the child psychiatrists is to describe alternative scenarios that could result from a dose increase. These hypothetical are often presented as pairs of if/ then/else statements, contrasting good and bad futures, as we can see in the following conversation, which revisits the family from Excerpt 3:

Excerpt 6: Third follow-up. Anna is responding well to the medication.

  • 1. DOC: Well, the reason I wanna try it is just to see.
  • 2. So we would try the 27 [mg dose]
  • 3. and if you say - if teacher says "Wow she ' s doing so much better even
  • 4. MOM: ( (nodding) )
  • 5. DOC: And there's not any side effects
  • 6. then we say "Okay maybe we should try this dose" .
  • 7. Cuz, urn, if you're saying "Noo there's not an improvement" , and there ' s more side effects?
  • 8. We would go back down. To the other one.
  • 9. We would know in a couple days.
  • 10. MOM: Mm.

In this excerpt, the doctor presents two possible futures, each with a medication plan:

• Future #1 (lines 3-5): Parent and teacher see improvement, no side effects.

о Medication plan (line 6): Continue with the higher dose.

• Future #2 (line 7): No improvement, more side effects.

о Medication plan (line 8): Go back to the lower dose.

By presenting both possibilities at the same time, the parent is not pressured to make a high-stakes decision about her child’s well-being - both paths remain open to her even after the child starts on the higher dose.

Interestingly, the doctor’s description of these two futures relies on data to be collected by the parent herself (either through direct observation or talking to the teacher), thereby placing Mom in charge of the experiment: she will talk to the teacher and see if the new dose is effective, she will monitor the child for side effects, and, if there are problems, she has the authority to say “Noo there’s not an improvement” (line 7) and reverse the decision. With all these verbal framings, the doctor sets herself up as an advisor supporting the parent.

rather than as the medical authority in charge. Mom retains responsibility and control over what’s best for her child.

Medication recommendations based on medical knowledge

Excerpt 7: First follow-up. Parent and child have been describing child’s improved school performance.

  • 1. DOC: So you feel like you - how do you feel the medication helps?
  • 2. KID: A little bit good.
  • 3. DOC: A little bit good? What do you notice? You' re the expert.

Medical expertise was the least frequent reason doctors used to support a recommended dose change. Even though they have superior knowledge about ADHD treatment and stimulant medication, they actively found way to diminish the potential imbalance in authority, positioning parents (and older children) as equal collaborators or sometimes even as the final decision-makers. When doctors did cite medical expertise, it was typically in an educational fashion, giving parents more information about ADHD or the medication so they can make better decisions.

Excerpt 8: First follow-up. Doctor and parent have been talking about child’s school performance and relationship with siblings.

  • 1. DOC: We can make this decision over time
  • 2. But у'know some kids do end up needing a second dose as the day wears on.
  • 3. Because you know their teachers are noticing in the afternoon they're not as focused, they're having hyperactivity.
  • 4. So there's certainly room to make adjustments like that.
  • 5. Urn, are you noticing that by the time she's home she's more hyperrr is there anything?
  • 6. MOM: Yes.
  • 7. DOC: Okay.
  • 8. MOM: I notice that by the time she's home, she's ((hand gesture)) - off . I noticed it because of the weekend.

Here the doctor presents background information about ADHD medication to help contextualize what the parent and child have noticed. However, she quickly turns the conversation back to the parent’s own observations (line 5).

  • [1] DOC: But it - you know, um, but you're seeing benefits ((nodding)) from the medication.
  • [2] MOM: ((nods)) Yes.
  • [3] DOC: But you're afraid to go up too high cuz you don'twant it [her personality] to completely change, yeah.
  • [4] MOM: Yeah.
  • [5] KID: Change what?
  • [6] DOC: And we, we don't want that either. We want her tostill be engaged and -
  • [7] MOM: And happy.
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