Published 8/1/2009
Donna P. Phillips, MD

Speaking of children: Engagement is not enough

The importance of educating and enlisting children in their health care

Communicating with children and their families presents challenges that are different than those faced in interactions with adult patients. Physicians tend to do well engaging the pediatric patient initially, but frequently fall short when it comes to sharing information. In fact, studies show that less than 20 percent of the relevant information is shared directly with the child.

Communication in the pediatric setting may be challenging because physicians generally provide information to the parents and rely on them in decision-making, without involving the patient. To improve your communications with young patients, you need to understand and implement two important concepts: education and enlistment.

Educating pediatric patients
Successful patient education addresses the issues of health, including diagnosis, etiology, prognosis, and self-management. In speaking with children, talk about your findings, using vocabulary that is age appropriate.

All too often, this portion of the encounter is directed only to the parents, ignoring the presence of the child. How often have you caught yourself saying, “she has a broken wrist,” even though the injured child is sitting right in front of you? The parents will get the message, and you can convey the same information by telling the child directly, “you have a broken wrist.”

Children are able to understand more about concepts of health and illness than is generally assumed. Never underestimate what a child understands—but do find out how well the child understood what you said.

Say, “I just gave you a great deal of information. The only way for me to know if I was clear is for you to tell me what you understood. If I find I haven’t explained it well, I can try to explain it to you in a different way.”

A child’s concerns may be very different than a parent’s concerns. To find out what worries the child the most, encourage him or her to talk with your directly, and ask questions. If the parents take the child’s turn to talk, you should make an effort to allow the child’s voice to be heard. Only in this way can you make sure that your explanation was clear and understood. Use the patient’s language to clarify information.

Ask the child, “What questions do you have?” rather than “Do you have any questions?” The former invites additional questions and promotes further discussion; the latter can be answered with a shrug or a shake of the head. Allowing the child to ask questions will give you additional clues about his or her level of understanding and the impact of the injury or condition.

Getting enlistment
By definition, enlistment is an invitation from the clinician to the patient to collaborate in the decision making related to the goals and plans for treatment. It is an opportunity to discuss the pros and cons of each option for treatment with the children and parents. Children may be more likely to adhere to the treatment plan if they “buy into” the proposed treatment. For example, a child who understands the need for a brace and rest from sports for an overuse injury such as spondylolysis may be more accepting of not going to sports camp and limiting activities.

Children should, at an age-appropriate level, participate in decision making related to their health care. Remember that children are not incompetent, and they should be included in the discussions. A child who is involved in decision making is more likely to stick to the treatment plan, particularly if you are willing to make modifications, such as agreeing to remove a cast a few days early to accommodate a graduation schedule.

Children need to be convinced that the treatment is necessary and confident that they can carry out the plan. Your communication style and attitude should make it clear that the child’s input is important. Children will feel valued, involved, comfortable, and less anxious if they are part of the process. Regardless of the age of the patient, collaboration can improve outcomes.

Having a joking or cute relationship with the child is a good way to engage the child, but is not enough for educating and enlisting the child. Although communications clearly need to be modified depending on the child’s age, you shouldn’t assume that younger children do not understand what is being said about them.

In closing a patient session, make it clear that the interview is over. Anticipate and forecast the close of the visit. Summarize the diagnosis and plan. Explain what will happen next. Express your optimism about the response to the treatment, but be realistic. I give out stickers to age-appropriate patients, and sometimes even the parents, to signal that the encounter is over. Finally, say goodbye and smile!

Three “take-aways”
In summary, what can we do to improve our communication with pediatric patients?

Talk directly to children. Use their names and words that they will understand. The parents are still listening, and will appreciate that their child is being treated with respect. Ask the parents to allow the child to participate.

Modify your communications based on the age of the child. Younger children may not participate as completely as older children or teenagers, but they still have emotional and psychological needs that should not be ignored. Neither should parents be ignored; be sure to solicit and respond to their questions and input.

Take the time to educate both the young patient and his or her parents, as well as to enlist the child in the treatment plan. It will save time in the long run and lead to greater patient and physician satisfaction.

If we can successfully educate and enlist children as patients, the result will be contented parents and patients, improved understanding, better adherence to the treatment plan, and less anxiety for all.

Donna P. Phillips, MD, was a member of the faculty for “Communication Skills for Pediatric Orthopaedists—A Challenge,” a symposium presented at the 2008 POSNA annual meeting. She can be reached at donna.phillips@nyumc.org

Editor’s note: This is the third in a four-part series on the challenges of communicating with pediatric patients. Articles are based on a panel symposium held at the 2008 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).

The challenge of communicating with pediatric patients (February 2009; AAOS Now)

Engaging with younger patients (May 2009; AAOS Now)