Guidance for evidence-based practice

To provide quality evidence-based care, providers must not only apply their own medical expertise about best practices, but also build parent trust and openness. As we emphasized earlier, good treatment outcomes depend on parents being actively on-board: they are the ones scheduling therapy or doctor’s appointments, administering medications, monitoring the child, and other tasks such as therapy “homework”.

Building such trust requires giving parents a non-judgmental setting where they can express concerns and fears without feeling like they are dumb or silly, even when such concerns seem irrelevant or medically inaccurate (e.g., believing that ADHD medication is a gateway to illegal drug use). In some cases, parent resistance may stem from outside sources: cultural or community norms, or the conflicting views of other family members. Building this safe space of trust will allow parents and providers to work together to address such sensitive issues (see also Smoliak et al., this volume).

The provider’s goal is to secure parents’ uptake, engagement in treatment, and sustaining treatment after the initial learning phase ends (e.g., continuing to give the medication after titration or to use the cognitive behaviour therapy (CBT) techniques after the training class ends). Here are five practices to assist in developing those goals: / Clarify your reasons for making a recommendation

Although it may seem redundant, reiterating what a parent has told you will make transparent the logic behind your decisions and emphasize the parent’s role in the decision-making.

Explicitly cite the parent's input

“Referential phrases” indicate the source from which you learned a fact (for example: the teacher said or what I'm hearing from you). Whether you are citing a behavioural observation or a parent preference, using referential phrases to explicitly highlight the parent/child as the information source helps emphasise that your own recommendations are consistent with their experiences. [1]

Engage the parent as an active collaborator in solving these future problems

Child ADHD treatment relies heavily on observations from parents and teachers who see the child’s everyday life outside of the psychiatrist’s office. When providers present hypothetical future scenarios (see above), they give parents the major role of on-the-ground observer, collecting the data on the child’s status that will determine the final medication decision.

Also apply these strategies to include older children as decisionmakers

Requesting the child’s input helps them learn to be more aware of how the medication affects their mind and body. Encouraging them to ask questions can decrease fear of trying a new dose by reassuring the child that both doctor and parent will take their concerns seriously if anything goes wrong. (For example: one child worried that the medication would cause her to gain weight.)

In the next section, we examine the reasons and rewards in building professional relationships with families from the clinician’s perspective.

Reflections of a child psychiatrist: Engaging with parents and children over time

The essence of practicing child psychiatry is the therapeutic relationship between the practitioner and both the child and the adults who are influential in his or her care over time. Like our colleagues in paediatrics, we aim to maintain relationships with the child and their family that last across developmental phases, that change as the child grows, and that may last through adolescence and into adulthood. Some of my patients continue to return to me well into college. They make appointments for when they are home during spring break or Thanksgiving, rather than seeking out a new adult psychiatrist, because this clinic is their home and we are part of the family. Watching these children excel and grow and celebrating their successes with them is one of the great rewards of my profession.

As child psychiatrists, we are often the “last stop” for parents with concerns about their child’s mental health. Many parents who come to us are reluctant about long-term medication or worry the child may be labelled as “defective” if they are receiving psychiatric care. For this reason, it is crucial to start building trust from the beginning. If the first appointment doesn't go well, the parent may never return.

There is often a “tipping point” for parents that stimulates recognition of a problem that requires seeking care outside their usual support networks. It typically occurs around 9 years of age, because academic demands increase in fourth grade when application of basic reading and math skills begins. In the case of very young child with developmental delays or symptoms across the spectrum of autism, contact may be sooner. Tipping points can also occur later in life, for example the transitions to middle school, high school, preparing for standardized tests for college, or transition to college. For older children, the stronger relationship may be between psychiatrist and child rather than psychiatrist and parent.

  • [1] Use future hypothetical to acknowledge different problemsthat may occur and how they will be handled Doctors in our study used if-then-else scenarios to assure parents that therewould be a plan in place for dealing with future problems. Quite often, theplan for the “negative” future was to revert to a previous dose. Emphasisingthis option ahead of time decreases the sense of risk parents may feel intrying a higher dose in the first place.
 
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