Stressful Parent-Staff Interactions: A Vignette-Driven Discussion

Dr. Shamina Henkel

Objectives:

• The participant will be able to identify several situations in which parental issues affect management of the hospitalized child.

• The participant will be able to identify at least three factors in parents that may impede patient care.

• The participant will be able to discuss at least two ways to help diffuse tense parent-staff interactions.

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Mindsets for Working with Parents:

Perception can be more powerful than reality

• Parents trust us with the most precious thing in their life – their child.

• Imagine finding yourself in an overwhelmingly stressful situation. Then imagine having no control over said situation. I have to keep this in mind each day that I venture to work and am faced with a difficult parent or family member. I am asking you to do the same.

Characteristics of Parents Who are Considered Difficult

• Described as demanding, hostile, intrusive insulting, anxious, irritable, controlling, uncooperative, panic stricken, unable to make decisions, and at times “hateful” • Poorer functional status .

• Feel mistreated and complain, Reduced satisfaction.

• May have a personality disorder .

• More likely to have a depressive or anxiety disorder.

• Social or financial problems: poverty, unemployment, abuse, divorce, lack of close social supports .

• Cultural differences.

Parental Anxiety:

• Parental anxiety and caregivers’ interpretation of parental expectations are important factors to take into account. • Remember that difficult parents are so because they are operating under stress within their own unique context (personal histories).

Parental Anxiety:

• Parents are attempting to gain assurance that their own limits of endurance will not be exceeded and that they will not have to face the event they fear the most, e.g.: – Death – Disability – Child dying at home – Child being in pain – Being abandoned by medical caretakers • Uncovering these stressors or fears allows you to isolate the factors motivating difficult behaviors.

Red Flags for Families at Risk for Struggles with Staff

1) Patient length of stay is greater than normal for diagnosis. Repeated child hospitalizations, inconsistent with what seems reasonable, esp. if multiple facilities.

2) Care conference on previous unit.

3) Conflict among providers with plan of care, unnecessary chaos surrounding the care of the child.

4) Patient not responding to treatment as expected, patient displays less distress than the parent.

5) Multisystem involvement for patient diagnoses: respiratory problems mobility, comorbidities, poor prognosis, and feeding difficulties or excessive involvement of individual team members.

6) Threatening, aggressive, or critical behaviors and/or absent family.

7) Nurses requesting not to take care of patient.

8) Cultural, linguistic and/or religious differences.

What makes a Parent Difficult?

1. Normal parents in abnormal situations 2. Parental Psychosocial Issues / Context in which the illness occurs 3. Parents with Mental Illness 4. Parents with Specific Personality Styles 5. Caregiver Factors

Vignette # 1

• NB is a 12 yo otherwise healthy male, who was admitted after a workup for concussion revealed disseminated medulloblastoma. He had resection of the tumor with resultant mutism and profound neurological deficits. According to the family patient was a very active healthy boy, who was into sports. He had been complaining of headaches for about 6 months prior to admission and they had taken him to chiropractor for treatment of these.

• Over the course of hospitalization the staff became concerned because family was constantly present and took it upon themselves to perform all of Ns care. The family took turns, however mother was noted to be overly involved in Ns care and rarely left his side.

Reactions of Normal Parents

• The immediate challenge in Pediatric physical illness for parents is to manage their own emotional reactions, while at the same time acquiring and integrating new information.

• Common phases in adjustment (Ravenscroft) to having a child with physical illness include: – Shock, denial and panic – Protest and regression – Oppositionalism – Mourning – Readjustment

Vignette #2

• TN is a 17yo AAM with no previous psychiatric or significant medical history, admitted to EG after found to be tachycardic and dehydrated at a psychiatric facility (GRN). Pt was admitted to GRN for treatment of one month of bizarre, hypereligious beliefs, isolation, decreased sleep, and refusal to eat for the week prior to admission. Because the patient refused to eat he was sent back to EG for treatment of dehydration.

• Pt stated on admission that he is in the hospital falsely, and that the original doctor he saw at the ED said "that my blood is fine. She said it was fine and that there's nothing wrong with me". He admits to not eating because God is telling him "the truth through my heart, I see it" and is communicating to him that he does not need to eat. Pt does not think this will cause him any harm, stating that God will protect him.

Vignette 2 continued

• In speaking with patient’s mother she states that their family is very religious, but pt had never spoken "of this God" before. She believes the reason for TN’s illness is that a false -God (pt calls him God, mother says it is a demon) "tackled" him while he was smoking marijuana and watching a movie. She thinks that after he got caught smoking marijuana, the "demon" told him to be good, and to change his ways.

Vignette 2 continued

• She noticed after that incident the pt was abruptly different- he began reading the bible, and "trying to act good so that I would let the demon in". She believes that pt is not himself right now, and that many of the things he is saying is the "demon talking, not TN". She wants to drive the demon out, and feels "deliverance" will help with this. Deliverance was defined by the mother as “like an exorcism.” Over repeated interactions with mother she agreed T was ill, and that the MDs had different explanation for TN’s illness. She was willing to try medications in the short-term to get TN better, but stated that she planned to “phase them out” as soon as she could.

Specific Mental Illnesses and Effects on Offspring

Kids born to Schizophrenic Parents: reduced attentional ability tendency towards social isolation and behavioral problems Kids born to Bipolar Parents: ↑ attentional and behavior problems, and subsequent impairment of social and occupational functioning ↑ increased risk of suffering from affective disorder Kids born to Depressed Mothers: Attention Deficit Hyperactivity Disorder Conduct Disorder Childhood, Early-Onset Depression Increased hospitalizations and presentations to EDs Eating disorders in teenage daughters

Specific Mental Illnesses and Effects on Offspring

Kids born to Parents with Anxiety Disorders: – associated with > attachment problems, esp. insecure attachment and inhibited behavior – ↑ risk of lifetime anxiety-related disorders. (males>females) Kids born to Mothers with Somatization D/O: – increased rates depression and suicide Kids of parents with Antisocial personality: – ↑ risk for oppositional defiant disorder and conduct disorder Kids of parents w/ borderline personality – ↑ prevalence of impulse-control disorders – – ↑ ↑ features of borderline personality risk of developing affective disorders

Vignette #3

• XY is a 15 yo WM with no prior psych history and no significant prior medical history. He presented to his PCP with a weight loss of 14lbs over 2 weeks and a total weight loss of 40 lbs in 4 months with a resting pulse of 45. EKG showed sick sinus syndrome and pt was immediately referred to Egleston. Pt was diagnosed with Anorexia Nervosa and had significant symptoms of food restriction, rigid rules about eating, calorie counting, began cooking for the family, excessive exercising (2 hours a day) and distorted body image. Both medical and psychiatric teams met with family to discuss diagnosis, immediate treatment plan and goals for discharge. • Over the course of admission the father was frequently noted to not follow treatment protocol as outlined by the team. HE questioned the team’s restrictions and limits stating “I can just monitor him myself.” The father was in school to become a nurse practitioner and seemed to want preferential treatment from staff throughout the visit, including trying to manipulate the team into giving a recommendation for a lesser level of care, although the patient was clearly in need of intensive treatment. The father also tried to split he the various teams involved, stating that the eating disorder “can’t be that serious if cardiology wasn’t concerned. So why is the psychiatry team so adamant about the need for intensive treatment.” The team became increasingly frustrated with family and a care conference was initiated.

Because he has … Personality

Parental Personality Disorders (PDP)

• Rates of parental personality disorders are no greater for parents of children with medical conditions than for parents of otherwise healthy children.

• PDPs self-focused, struggle to empathize with their children because they are focused on their own perceived unmet needs.

• Parents are more skilled than their children at getting attention, but in hospital child is focus of attention. PDP, may feel threatened if child is getting more attention.

• Need for attention by PDPs is thought to be very primitive and not responsive to logic and reason.

• PDPs struggle with maintaining appropriate “boundaries:” physical, psychological & social.

Difficult Parent Styles/Types

• Based upon a seminal paper from JE Groves, Taking Care of the Hateful Patient. New England Journal 1978.

• Groves notice that there we certain adult personality types that induce strong negative reactions among treating physicians.

• These are Demanding, Dependent, Help Rejecting, Denying, Hysterical, and Obsessive personality types.

Entitled Demander

• Make excessive, unreasonable demands, often for preferential treatment.

• Prone to be angry and never satisfied.

• Often use intimidation, devaluation, guilt and hostility to have their needs met: – GUILT: you guys are the doctors - why don’t you know what’s

wrong and how to fix it

• Often litigious, may be VIP’s.

• Strategies: – Never attack the entitlement, realize that the personality style is a defense against insecurity.

– Support right to finest medical care, but explain the limits of care that you can provide.

– Early psychiatric consultation to avoid perceived criticism.

Dependant Clinger

• Insecure, vulnerable parent who draws strength, emotional support, and stability from spouse, healthcare giver, or even the child.

• Seductive & grateful of medical staff, initially, but go on to have unending need for contact and support, insatiable.

• May view the child’s illness as a potential loss of “lifeline”.

• Their Children may present as: 1. “Parentified” – taking on a care giving role for the parent 2. Profoundly regressed, losing autonomous function. As if to “force” the parents to pay attention to him/her and break the dependency on the healthcare provider 3. Extremely Anxious and Guilty May blame themselves for the parent’s unraveling

Dependant Clinger: Strategies

• Avoid reacting with aversion and avoidance.

• Appreciate parent’s insecurity and need for closeness.

• Set clear firm limits on the role and availability

of staff.

• Relate to the parent as an adult, emphasizing

the value of being a parent.

• Define clear, concrete tasks defining the role of

parent.

• Enlist other family members for support.

• Early social service or psychiatric referral.

Manipulative Help Rejecters

• Not grateful or appreciative, often appear angry at one caregiver or another.

• Pessimistic: nothing will help, and therefore, often noncompliant.

• Often viewed by caregivers as willfully obstructing treatment.

• Question the competency of caregivers and frequently “tests” reliability, worthiness, and knowledge of patient history etc.

• Strategies: – Identify feelings of self-doubt, guilt and resentment.

– Empathize with parent around distrust.

– Frequent contact.

– Never make promises that cannot be kept

Self-Destructive Denier

• Uses denial to cope with stress, manage unbearable fears, and sustain hope.

• Fails to listen to explanations and instructions, or may occasionally refuse use of medications and treatments. • Remember: Extreme denial is usually a desperate measure that may not be under conscious control.

• Strategies: – Acknowledge the difficulty of having a sick child – Avoid emotionality – Provide reading material on child’s illness. – Encourage speaking with parents of other children with similar illness.

Obsessive Parent

• Emotionally constricted, rigid, and dogmatic.

• Focus attention on fine details, losing sight of the big picture.

• Feel compelled to make the “right” decision based upon “the facts,” leading to poor ability to make prompt decisions.

• This style defends against uncertainty and

intolerable anxiety.

• Strategies: – Be patient and tolerant – Answer questions directly – Redirect attention to the “big picture” and the parent’s value in emotionally supporting the child

Hysterical Parent

• Opposite of obsessive parent, hysterical parent tends to be impressionistic, making overgeneralizations based on intuitions or anxieties.

• Highly dramatic, overly sensitive and emotional; tends to overreact to many situations. May be flirtatious & seductive .

• Often seems as though these parents “just don’t get it” as information given to them seems to go unheard, unintegrated and often lead to emotional overreactions.

• Strategies: – Allow frequent short meetings.

– Use calm, repetitive rational discourse. Quell the flood of emotions.

– Explain the value of being calm and focused.

– Utilize less hysterical relatives to contain emotionality.

– Use calm sympathetic confrontation about the effect of the parent’s behavior on the child

Caregivers:

• Countertransference – when feelings of the caregiver are reflections of earlier experiences the caregiver has had with persons of similar traits and behaviors • Remember: Always check your own pulse first!!!

General Principle for Improving Relationships with Families

• Increase Empathy – “You seem quite upset. Could you help me understand what you are going through right now?” • Improve Listening and Understanding – Interrupt less – “What I hear from you is that … . Did I get that right?” • Revise expectations as needed – “I wish I (or a medical miracle) could solve this problem

for you, but the power to make the important changes is

really yours.”

General Principle for Improving Relationships with Families

• Offer explanations using appropriate language for the parent’s literacy level and cultural background.

• Facilitate “Partnership” with Family – “How do you feel about the care you are receiving from

me? It seems to me that we sometimes don’t work

together very well.” • Improve skills at expressing negative emotions – Decrease blaming statements.

» “It’s difficult for me to listen to you when you use that kind of language.” – Increase “I” messages. » “I feel …” as opposed to “You make me feel …”



Always try to improve your listening and understanding skills

– increase your empathy – be patient . 

Make the effort to maintain the attitude you probably had when you decided to enter this field—you wanted to help people



Remember, it's easier to change yourself than a difficult person, because you can only control yourself.

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Pediatric Depression:

Diagnosis and Management Before the Psychiatrist Can See the Patient

Shamina J. Henkel, MD

What not to do …

Depression Children and Adolescents

• 9/1000 preschool children • 20/1000 school-age children • 50/1000 adolescents • Cumulative incidence by age 18 years: 20% • 1:1 female/male ratio until puberty then 2:1 • Depression is apt to remit spontaneously over 6-12 months with recurrence rates at one year about 40% and over a lifetime >50% • Since 1940, each successive generation at higher risk for MDD

Depressed Mood is central to:

Major Depressive Disorder

– 2 weeks pervasive mood change: sad or irritable – 5+ of SIGECAPS criteria (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor state, Suicidality)

Dysthymic Disorder

– depressed mood most of the day for more days than not for at least 1 year – 2+ (inc/dec. Sleep, low Energy, poor Concentration/ ability to make decisions, Appetite, low Self-Esteem, feelings of Hopelessness)

Bipolar Disorder

– Will also have manic or hypomanic episodes

Assessment:

• Look for behavioral indications of depression like irritability, social withdrawal, apathy.

• Somatic complaints are also common.

• Ask parent and child about depression. Young children will need more concrete questions. • Go through SIGECAPS sx with parent and child. • Ask specifically the context, duration, and severity of symptoms in order to determine whether the behaviors may be within the “normal” range.

Treatment of Depression: Back to the Basics

• • • • •

Sleep Exercise Diet Light Eliminate Drugs & Alcohol

Treatment of MDD in Children & Adolescents

• Psychotherapy is effective for mild to moderate MDD • Antidepressants are useful for moderate-severe depression, kids with lower verbal ability, or younger ages • Due to psychosocial context, pharmacotherapy alone may not be effective TADS: Combo of CBT and SSRI, offered highest treatment response rate. Fluoxetine alone had a significant response rate, whereas CBT alone did not TORDIA: Switching to another ssri, did not improve the response rate, whereas the addition of CBT did

Antidepressants: Adverse Events

• Discontinuation Syndrome: Abrupt discontinuation with SSRI’s with shorter half-lives may induce withdrawal symptoms that mimic MDD • Serotonin Syndrome: SSRI’s interact with other serotonergic medications (MAOI’s, ultram, linezolid, dextromethorphan, hydro/oxycodone, amphetamine, triptans) to induce serotonergic syndrome (agitation, confusion, hyperthermia) • Drug-Drug Interactions: SSRI’s inhibit metabolism of some medications metabolized by hepatic enzymes (P450 isoenzymes)

Potential Induction of Mania

• In susceptible individuals • Often have a family history of Bipolar Disorder • Most commonly seen in first-fourth weeks of AD therapy • SSRI’s may induce mania, hypomania, behavioral activation (impulsive, silly, agitated, daring) • Early indicators include elated mood, decreased need for sleep, grandiosity, hypersexuality, racing thoughts, pressured speech

Suicidality/Black Box Warning

• Possibly linked to behavioral activation or akathisia (first reported 1991) • Retrospective look at 24 studies found increase from 2-4 % for reporting suicidal ideation or behaviors with kids on antidepressants (AD) • TADS showed decrease in suicidal ideation from 29% to 10% with treatment • No completed suicides in >4000 pediatric subjects on ADs (2200 w/ ssris)

Treatment con’t.

1. Start Low and Go Slow – start at half of adult smallest dose 2. Raise to full adult starting dose after 1 week, if no significant side effects 3. Clear benefits only occur after 2-4 weeks, at adequate dose 4. Because kids metabolize medications more efficiently, be sure to raise dose as needed for partial responders

Fluoxetine

SSRI’s Dosage

[Prozac] 10-60 mg/d Paroxetine [Paxil] 10-40 mg/d Sertraline Fluvoxamine Citalopram [Zoloft] 25-200 mg/d [Luvox] 50-300 mg/d [Celexa] 20-40 mg/d Escitalopram [Lexapro] 5-20 mg/d

Treatment con’t.

5. Continue same dose for 6-9 months to prevent relapse (there is extremely high rate of relapse/recurrence in kids as high as 70%) 6. If no response to adequately dosed AD, switch meds after 8-10 weeks or if partial response can try augmentation strategies, e.g. second AD, thyroid hormone, stimulant, buspar, lithium, antipsychotic 7. Discontinuation of medication should be scheduled to minimize disruption and avoid confusion.

Educate Parents to CALL you for:

 New thoughts of suicide or a sudden worsening of suicidal thoughts  Any attempts of your child to injure him or herself in any way  Increased motor restlessness  Increased agitation or irritability  Increased rapid and constant talking (mania or hypomania)  Increased activity level, extreme hyperactivity  Worsening symptoms of depression  Increased or new symptoms of anxiety and/or panic attacks  Difficulty sleeping

Prognosis

• In one study, 85% of depressed adolescents had a full spontaneous remission within 12 months, but of these, 40% had another depressive episode within 1 year • 50/70/90 rule • The extent to which depressive episodes interfere with other developmental tasks, greatly affects ultimate outcomes for these kids.

Depression Clinical Pearls

• SSRI -> SNRI switch may be helpful, particularly if patient is an adolescent • Paroxetine and fluvoxamine are not the best choices for depression due to shorter half-lives lending to greater withdrawal symptoms and poorer compliance. (Paxil is also relatively commonly found to cause akathisia) • Fluoxetine has the longest half-life and so may be ideal for the adolescent with questionable compliance, however has significant p450 interactions and is a potent inhibitor of 2D6 so may have greater drug-drug interactions.

• Citalopram and Escitalopram have limited p450 interactions • Mirtazapine – no evidence in depression • Buproprion –usefulness in adolescents with depression with comorbid ADHD, obesity, and OSA

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Questions?