Maternal distress, child behaviour, and disclosure of psychosocial concerns to a paediatrician

BACKGROUND: Despite the availability of effective screening measures, primary care providers continue to fail to identify and manage many children with psychosocial problems. One of the best predictors of identification by a primary care physician is whether mothers disclose concerns about their child's psychosocial functioning to their child's physician. This study examined if maternal distress and child behaviour predicted whether mothers had and discussed concerns about their child's behaviour and emotions with paediatricians. METHODS: Participants were 138 mothers who accompanied their 4-12-year-old children to a health supervision visit at an urban teaching hospital. Mothers completed a demographic questionnaire, the Pediatric Symptom Checklist, the Beck Depression Inventory, and an exit questionnaire. Results Logistic regression correctly classified 97.3% of mothers who did not disclose child problems. Only 34.5% of mothers who did disclose were correctly classified. CONCLUSIONS: The results supported the hypothesis that mothers' psychosocial functioning is significantly related to concern about child behaviour and disclosure of concerns to the paediatrician. The inability of child behaviour and maternal functioning to predict which mothers were concerned and disclosed concerns supports the hypothesis that disclosure and identification of psychosocial problems in primary care is complex and requires a multifactor model.     

Use of child reports of daily functioning to facilitate identification of psychosocial problems in children

BACKGROUND: Despite the availability of effective screening measures, physicians fail to identify and manage many children with psychosocial problems. Physicians are most likely to identify children with psychosocial problems when parents voice concerns about their child's functioning. However, few parents express concerns to their child's physician, and children's perspectives of their own functioning are rarely considered. This study evaluated the potential utility of children's reports of their own functioning. METHODS: The Child Functioning Scale (CFS) was completed by 107 parents and children and compared with the Pediatric Symptom Checklist (PSC) and physician reports on the psychosocial status of each child. RESULTS: Physicians identified 20% of the children identified by the PSC. Children's self-reported problems on the CFS would have identified 53.3% of these children. Additionally, 11.2% of children who did not meet criteria on the PSC self-reported problems in daily functioning. CONCLUSION: Collecting information about children's perceptions of their own daily functioning could provide physicians with an additional tool for the assessment of psychosocial problems.     

Use of information about maternal distress and negative life events to facilitate identification of psychosocial problems in children

BACKGROUND: Despite the availability of effective screening measures, primary care physicians fail to identify and manage many children with psychosocial problems. Physicians often have information about significant negative events in a child's life. The present study evaluated the potential utility of using information about negative life events to facilitate physician identification of children with psychosocial problems. METHODS: Negative life events, maternal distress and child psychosocial functioning measures were completed by 185 mothers of children, aged 4-12 years. Family physicians provided data about the children's psychosocial functioning. RESULTS: Mothers identified 15.1% (n = 28) of the children as having psychosocial problems. Physicians correctly identified 21% (n = 6) of these at-risk children. Physician use of negative life events would have led to the identification of 39.2% (n = 11) at-risk children. Information about maternal distress and negative life events would have resulted in an additional 18% (n = 5) of children identified by the physicians. Information about maternal distress alone would have resulted in an identification rate of 53.5% (n = 15). CONCLUSIONS: Using information about negative events in a child's life, physicians could improve their rate of identification of children with psychosocial problems. Children who have had more than two negative events in their lives are at increased risk for psychosocial problems.     

Psychosocial problem disclosure by primary care patients.

The vast majority of psychologically distressed primary care patients present exclusively somatic concerns at the outsets of their visits. However, it is not known how often such patients subsequently disclose psychosocial problems to their primary care physicians (PCPs) and what variables predict such disclosures. Our objectives were to measure, among psychologically distressed primary care patients, the frequency of disclosure of psychosocial problems (disclosure), the effects of prior psychosocial inquiry (prior inquiry) by PCPs and various patient variables on disclosure, and the effect of disclosure on mental health problem recognition (recognition) by PCPs. The study was based in the practices of 69 community-based PCPs and involved 308 adult patients with 28-item General Health Questionnaire scores of 5 or greater, indicating significant psychological distress. Disclosure occurred during 51% of visits overall and 67% of visits with prior inquiry. The odds of disclosure were increased by prior inquiry (p < 0.001), greater physician-patient familiarity (p < 0.001) and greater severity of patient psychological distress (p < 0.001). Prior inquiry and physician-patient familiarity had a negative interaction (p < 0.05) of smaller size than either variable's main effect, so that their combined effect on disclosure exceeded the effect of either variable alone but was less than multiplicative. The estimated odds ratio for recognition given disclosure was 24.13 (95% confidence interval, 11.28-51.63) after adjustment for the effects of significant covariates. We conclude that if PCPs inquire, most psychologically distressed, somatically presenting patients will disclose psychosocial problems. Inquiry is particularly productive with unfamiliar patients. PCPs can engender a substantial increase in psychosocial disclosure simply by adding one or two questions about mood or interpersonal problems to their clinical interviews.     

Parental vaccine safety concerns. The experiences of pediatricians and family physicians

OBJECTIVES: Recently several concerns regarding vaccine safety have received significant media attention. Primary care physicians are the most common interface for parents with the immunization delivery system and are likely to have the greatest opportunity for exposure and experience with parental vaccine safety concerns. METHODS: Mail survey study of a national random sample of 750 pediatricians (PDs) and 750 family physicians (FPs) was conducted in 2000. Outcome variables of primary interest included the number of parental vaccine refusals in the past year, frequency of specific parent vaccine safety concerns, and actions taken by physicians when parents refused a vaccine. Chi-square analysis was used to determine the significance of the association of each outcome variable of interest with physician specialty, frequency of vaccine refusal, and the demographic variables. Multivariate analysis explored the potential for independent predictors of physicians who experienced increases in vaccine refusal. RESULTS: The response rate was 70%. Overall, 93% of PDs and 60% of FPs reported at least one parental vaccine refusal in their practice in the past year. PDs also were more likely than FPs to report an increase in the number of vaccine refusals over the past year (18% v 8%, p =0.01), while FPs were more likely to report a decrease in vaccine refusals over the same time period (18% v 11%; p <0.5). PDs were more likely than FPs to provide additional information regarding vaccines to parents who refused vaccines and/or to discuss the issue at later visits. The most common concerns of parents were related to short-term reactions and pain from multiple injections. CONCLUSIONS: While almost all PDs and most FPs experienced at least one vaccine refusal from parents in the past year, far fewer physicians of both specialties observed an increase in their occurrence. Physicians must work to be consistently well informed of both the benefits of immunization as well as the issues of parental concern regarding vaccine safety.     

HIV-negative children’s experiences and opinions towards parental HIV disclosure: a qualitative study in China

In HIV/AIDS research, few studies to date have evaluated ways to improve parental HIV disclosure practices using feedback from HIV-negative children who have recently experienced this event. We conducted semi-structured in-depth interviews with 20 children (aged 6–15) who were partially to fully aware of their parents’ HIV status in rural Guangxi, China. Of the 20 children, eight children who were of older age (11.38 years in average) endorsed parental HIV disclosure, five discouraged it and seven expressed uncertainty. Children’s different experiences and attitudes towards disclosure were seen to be associated with their family dynamics (especially the parent–child relationship), social support and care, experiences of stigma and discrimination, psychosocial suffering, comprehension of the disease and the children’s age. Our study contributes to building a child-centered comprehensive understanding for Chinese parental HIV disclosure. It is imperative that counselors and community advocates assess and help parents achieve optimal readiness preceding disclosure of their illness to their HIV-negative children.     

Disclosing HIV diagnosis to infected children: A health care team's approach

Abstract

Telling children that they have HIV is a one of the most difficult psychosocial issues for parents and professionals caring for children with HIV. The literature presents three primary reasons for this: concerns for children's emotional well-being, fear that children will not be able to keep the secret within the family and maternal fear of blame when the virus is transmitted from mother to child. Through research and clinical experience, our HIV team has developed strategies for balancing the needs of parents and children through the three major stages of disclosure: pre-disclosure preparation; the disclosure event and immediate support; and post-disclosure: ongoing assessment, support and information. Before children are told about their HIV, we provide them with health information through partial truth-telling, building gradually upon their knowledge about their health while supporting their parents as they move towards disclosure. We provide support and information during the disclosure event, as planned with parents, and ongoing support after disclosure, as children gain knowledge and understanding of their health and HIV issues. We discuss issues such as multi-disciplinary communication and delayed disclosures.     

Parenting Stress, Difficult Child Behavior, and Use of Routines in Relation to Adherence in Pediatric Asthma

The main purpose of this study was to evaluate the role of child behavior problems, parenting distress, and child routines in relation to children's adherence to daily medication in pediatric asthma. Participants included 45 asthmatic children and their families. Assessment included questionnaires, a medication dose-count monitor, and a brief telephone interview with the parent. Significant negative correlations were found between child care routines and both parenting distress and difficult child behavior. Medication adherence was significantly and positively correlated with both parental distress and difficult child behavior but was not significantly related to parent use of routines.     

Validation of the Pediatric Symptom Checklist in HIV-infected Batswana

OBJECTIVE: To determine the validity of the Pediatric Symptom Checklist (PSC), a brief measure of psychosocial health, for screening HIV+ Batswana children. METHOD: Setswana versions of the parent and child PSC were administered to 509 HIV+ Batswana children (age 8-16) and their parents/guardians. Test properties were evaluated and cut-off scores were derived using receiver operating characteristic curve analysis. Scores on the parent-completed PSC and the child-completed PSC-Y were compared to parental and clinic staff reports of concern about the child's psychosocial health and to scores on the Children's Depression Inventory and the Revised Children's Manifest Anxiety Scale. RESULTS: The Setswana PSC has high internal consistency (Cronbach's alpha 0.87 for the parent-completed version). Comparing PSC scores to parental reports of concern and child-reported depression symptoms, a cut-off score of 20 on the PSC and PSC-Y maximised the sensitivity and specificity. CONCLUSIONS: The PSC performed well in Setswana-speaking children and is a promising screening tool for paediatric psychosocial problems in busy clinical settings. Screening with the PSC may allow for early detection and treatment of psychosocial problems. This is likely to be of particular value for HIV+ children for whom HIV treatment non-adherence may result from untreated psychosocial dysfunction.     

The role of parental presence in the context of children's medical procedures: a systematic review

BACKGROUND: There are conflicting views and practices regarding whether or not parents should be present at the time of their child's medical procedure. A systematic review was conducted to assess the effects of parental presence in the paediatric treatment room on child, parent and health professional outcomes and to synthesize this body of literature. METHODS: Based on a comprehensive literature search, studies investigating parental presence in the paediatric treatment room were included in the review if they had a concurrent control group (i.e. a parent-absent group). RESULTS: A total of 28 studies met inclusion criteria, which included 1256 children with a parent present and 1025 children without a parent present. There were mixed findings regarding the effect of parental presence on measures of child distress and affect, however, studies of lower levels of evidence were more likely to report significant results. Parents who were present during their child's medical intervention were either better off or no different from parents who were absent with regard to their levels of distress and satisfaction. There was no evidence of increased technical complications nor elevated staff anxiety for health professionals attending to children with a parent present as compared to attending to children without their parents. DISCUSSION: Although parental presence may not have a clear, direct influence on child distress and behavioural outcomes, there are potential advantages for parents. It seems appropriate that clinicians provide parents with the opportunity to be present during their child's painful procedure.     

Provider recognition of psychosocial problems in low-income Latino children

The purpose of this study was to determine the frequency of identification of psychosocial problems in Latino children by primary care providers (PCPs). This was a cross-sectional study of 269 low-socioeconomic status (SES), Latino children, ages 2-16 years, seen at a community clinic for well-child care. Primary care providers completed a World Health Organization checklist, which organized provider assessment of child psychosocial problems. Clinicians identified one or more psychosocial problems in 39.8% of children. Clinicians recognized only 20% of children with clinically significant aggression symptoms, 18% of children with clinically significant attention/hyperactivity symptoms, and none (0%) of the children with clinically significant anxiety/depression symptoms with clinical data from parent-completed child-behavior checklists used as the benchmark. Despite high rates of identification of psychosocial problems in a low-SES, Latino population, PCPs still miss symptoms of mental health difficulties, especially anxiety and depression. Since symptoms of anxiety and depression are likely to be more pronounced in Latino populations, there is a continued need for improvement in detection of mental health concerns among these children.     

Childhood depression: an overlooked problem in family practice

To investigate the incidence and correlates of childhood depression in a family practice clinic, Kovacs Childhood Depression Inventory (CDI) was administered to 64 patients, aged 6 to 12 years. Accompanying parents completed the short form of Beck's Depression Inventory (BDI) and reported on the children's behavior problems. One half of the children studied scored within the depressed range on the CDI. Thirty-nine percent of the parents scored at least mildly depressed on the BDI. Depression appeared to cluster in families. Every parent who scored in the severe depression range was accompanying a child who rated himself or herself as depressed. All parents who scored above the cutoff for mild depression rated their children as having behavior problems. Children's self-reported depression was also related to negative parental rating of the children's behavior.     

Psychosocial Services for Children and Adolescents With Hemophilia and Their Families: Result of a National Survey

Seventy-one providers at 53 hemophilia treatment centers were surveyed concerning their patient populations, types of problems encountered, type of psychosocial services provided, and obstacles to service delivery. Respondents, who were social workers, nurses, and psychologists, reported that they spent more time providing direct services for illness-related problems compared with general psychological problems. The most time-consuming problems included problematic child-adolescent adjustment to hemophilia (21.6%), parental adjustment to hemophilia (20.5%), child-adolescent adjustment to HIV (17.4%), and parental adjustment to HIV (14.0%). Practitioners utilized a wide range of services to address clinical problems, such as providing information and support to parents; assessment of child, parent, and family adjustment; psychotherapy for children and parents; and identification of community services and referral contracts for families. The families' distance from the center was rated as the most significant obstacle to delivery of psychosocial services. Findings have potential implications for planning for psychosocial services for children with hemophilia and their families as well as for support and education of service providers.     

Why do physicians think parents expect antibiotics? What parents report vs what physicians believe

OBJECTIVE: To examine the relation between parent expectations for antibiotics, parent communication behaviors, and physicians' perceptions of parent expectations for antibiotics. STUDY DESIGN: A nested cross-sectional study with parallel measures of parents presenting children for acute respiratory infections (previsit) and physicians (postvisit) and audiotaping of the encounters. POPULATION: Ten physicians in 2 private pediatric practices (1 community-based and 1 university-based) and a consecutive sample of 306 eligible parents (response rate, 86%) who were attending sick visits for their children between October 1996 and March 1997. OUTCOMES MEASURED: Communication behaviors used by parents expecting antibiotics and physicians' perceptions of parents' expectations. RESULTS: Parents' use of "candidate diagnoses" during problem presentation increased the likelihood that physicians would perceive parents as expecting antibiotics (from 29% to 47%; P=.04), as did parents' use of "resistance to the diagnosis" (an increase from 7% to 20%). In the multivariate model, parents' use of candidate diagnoses increased the odds that a doctor would perceive a parental expectation for antibiotics by more than 5 times (odds ratio, 5.23; 95% confidence interval, 3.74-7.31; Plt.001), and parents' use of resistance to a viral diagnosis increased these odds by nearly 3 times (odds ratio, 2.73; 95% confidence interval, 1.97-3.79; Plt.001). CONCLUSIONS: Parents perceived as expecting antibiotics may be seeking reassurance that their child is not seriously ill or that they were correct to obtain medical care. Physicians were significantly more likely to perceive parents as expecting antibiotics if they used certain communication behaviors. This study revealed an incongruity between parents' reported expectations, their communication behaviors, and physicians' perceptions of parents' expectations.     

Problems and hopes perceived by mothers,fathers and physicians of children receiving palliative care

Background

The quality of shared decision making for children with serious illness may depend on whether parents and physicians share similar perceptions of problems and hopes for the child.

Objective

(i) Describe the problems and hopes reported by mothers, fathers and physicians of children receiving palliative care; (ii) examine the observed concordance between participants; (iii) examine parental perceived agreement; and (iv) examine whether parents who identified specific problems also specified corresponding hopes, or whether the problems were left ‘hopeless’.

Method

Seventy‐one parents and 43 physicians were asked to report problems and hopes and perceived agreement for 50 children receiving palliative care. Problems and hopes were classified into eight domains. Observed concordance was calculated between parents and between each parent and the physicians.

Results

The most common problem domains were physical body (88%), quality of life (74%) and medical knowledge (48%). The most common hope domains were quality of life (88%), suffering (76%) and physical body (39%). Overall parental dyads demonstrated a high percentage of concordance (82%) regarding reported problem domains and a lower percentage of concordance on hopes (65%). Concordance between parents and physicians regarding specific children was lower on problem (65–66%) and hope domains (59–63%). Respondents who identified problems regarding a child's quality of life or suffering were likely to also report corresponding hopes in these domains (93 and 82%, respectively).

Conclusion

Asking parents and physicians to talk about problems and hopes may provide a straightforward means to improve the quality of shared decision making for critically ill children.     

Parent stress and child behaviour among young children with type 1 diabetes

Background Parents of young children with type 1 diabetes (T1D) are responsible for executing a complex daily management regimen and are at risk for elevated levels of stress. Normative misbehaviour during the preschool years can complicate T1D management, and interpretation of behavioural concerns may vary because of child health status and parent stress. Within a paediatric transactional model framework, child characteristics (e.g. behaviour problems, metabolic control) and parent functioning (e.g. parenting stress, anxiety) likely impact one another. Methods Parents of 2‐ to 6‐year‐old children with T1D completed self‐report measures, including the Pediatric Inventory for Parents (PIP), State‐Trait Anxiety Inventory (STAI), Eyberg Child Behavior Inventory (ECBI), and 24‐h Recall Interviews. Medical data were obtained by parent report and medical record review. It was hypothesized that greater parent stress and child blood glucose variability would be significantly associated with greater parent‐reported child behaviour concerns. Results Moderate levels of parent stress and child behaviour problems were endorsed; however, parents perceived children's misbehaviour as problematic, particularly with relation to tasks relevant to diabetes management (e.g. bedtimes and mealtimes). Structural equation modelling indicated that greater general anxiety and paediatric parenting stress was associated with parent report of more problematic child behaviour. Blood glucose variability did not significantly contribute to this relationship. Conclusions The stress experienced by parents of young children with chronic illness appears to relate to their perception of their children's behaviour problems. Parents' experiences with developmentally normative misbehaviour may interfere with disease management and exacerbate parents' stress and the subsequent impact on well‐being. Implications for supporting parents and children with T1D are discussed.     

Post-Injury Medical and Psychosocial Care in Children: Impact of Traumatic Stress Symptoms

This study examined after-hospital medical and psychosocial care parents sought for their child following an injury and how this was affected by parent and child traumatic stress symptoms. Whereas the majority of parents (> 70%) reported seeking after-hospital pediatric medical services, less than one-third sought psychosocial assistance. More severe child or parent acute traumatic stress within the first month post injury was associated with a greater number of subsequent outpatient medical visits. Level of child or parent acute stress was also related to the type of psychosocial help sought. Results support trauma-informed care and symptom screening in children and parents post injury.     

Parents experiences of the care provided by medical services whilst looking after a chronically ill child

Fifty-eight parents of a child with liver disease completed the Survey of Parental Satisfaction (Dare & Hemsley, 1986). Prior to admission to hospital, many parents expressed dissatisfaction with their emotional care, the information given, and speed of referral on. As Inpatients, parental dissatisfaction was associated with distress not being noticed or responded to, lack of discussion of the child's prognosis and development, inadequate recognition of pressures imposed on marriages and the emotional/behavioural problems shown by siblings. As outpatients, 40% were dissatisfied with the emotional care given and 36% with the amount of information provided. Methods for reducing parental distress as well as the importance of auditing services in identifying unmet parental concerns are discussed.