What’s behind ‘No!’?
Here’s another (most likely familiar) clinical vignette: A parent of an 8-year-old child enters the office giving the PNP a note from the teacher, and before the provider can read it, the mother states, “I am not putting my child on any medication.” A quick read of the teacher’s note, a brief discussion with the parent, and a 5-minute observation of the child in the office who is “opening every drawer within reach, jumping on and off the scale, pulling the paper off the exam table, and ignoring his mother’s attempts to stop these behaviors,” leads to a differential diagnosis of attention-deficit/hyperactivity disorder (ADHD) as top on the list of potential diagnoses.
Silently, the PNP wonders what would make this mother walk in refusing medications when she is dealing with similar behaviors at home all the time? Of course, as healthcare providers, we cannot always say what we think. So, this is where the “rubber meets the road.” How do we approach this common scenario and ascertain the health literacy and informed decision-making capacity of a resistant parent?
In this instance, the PNP began by identifying direct observational behaviors present in the office, a rather easy task as the child was somewhat destroying the office at that moment. Next, the PNP posed a question to the mother: “What makes you immediately say, rather firmly, no medications?” This question addressed the mother’s tone and may have, for the first time, permitted her to reflect on her beliefs, concerns, or fears related to medication management. The mother’s answer led the PNP to start the process of determining if, when, and how maternal behavioral change could take place.
The mother was in a state of resistance and would not even consider changing her position on medication management. The PNP provided scientifically based information to the mother, in particular, parental resources on ADHD from the Centers for Disease Control and Prevention (CDC). The child was referred for an evaluation and for talk/play therapy. A primary care behavioral health follow-up appointment was scheduled with the mother and child in 1 month. In the interim, the mother received a reminder via e-mail (her preference, however, texting is good, too!) with the ADHD resource links, and was asked if she had questions. This strategy placed the mother in control of the problem and afforded her the opportunity to make an informed decision.
At the follow-up visit, the mother’s readiness for behavioral change was reassessed. The PNP asked questions pertinent to the health literature that had been referred to the mother to read. The outcome? The mother consented to medication management and talk/play therapy. Three months later, the child arrived at the primary care office for a follow-up visit. His behavior had improved both at school and at home. He related: “I have 2 friends and I got an A in math.” Both the mother and the PNP were very proud of this little boy!
Ask your way to patient comprehension
Since the 2004 Institute of Medicine Report (IOM) on health literacy,7 the definition of health literacy has evolved from the “degree to which individuals can obtain, process, and understand the basic health information . . . to make appropriate health decisions” to higher order, abstract thinking in which “individuals have the knowledge, motivation and competencies to access, understand, appraise, and apply health information in order to make judgements and decisions in everyday life concerning healthcare, disease prevention, and health promotion . . . to improve quality of life.”1,8
Indeed, this high-level definition requires healthcare providers to question themselves about ways they can enable pediatric and adolescent patients—as well as their parents—to accomplish this level of critical thinking concerning patients’ personal healthcare needs and the long-term healthcare outcomes that their decisions will yield.
1. Bröder J, Orkan O, Bauer U, et al. Health literacy in childhood and youth: a systematic review of definitions and models. BMC Public Health. 2017;17(1):361. Erratum in: BMC Public Health. 2017;17:419.
2. Perry EL. Health literacy in adolescents: an integrative review. J Spec Pediatr Nurs. 2014;19(3):210-218.
3. Ormshaw MJ, Paakari LT, Kannas LK. Measuring child and adolescent health literacy: a systematic review of the literature. Health Educ. 2013;113(5):433-455.
4. Glick AF, Farkas J., Nicholson J, et al. Parental management of discharge instructions: a systematic review. Pediatrics. 2017;140(2):e20164165.
5. Morrison AK, Myrvik MP, Brousseau DC, Hoffman RG, Stanley RM. The relationship between parent health literacy and pediatric emergency utilization: a systemic review. Acad Pediatr. 2013;13(5),421-429.
6. Hallas D, Koslap-Petraco M, Fletcher J. Social-emotional development of toddlers: randomized controlled trial of an office-based intervention. J Pediatr Nurs. 2017;33:33-40.
7. Institute of Medicine (IOM) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004.
8. Sorensen K, Van den Broucke S, Fullam J, et al; (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80.