Transcript Slide 1

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, panicstricken, 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.:
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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:
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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:
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reduced attentional ability
tendency towards social isolation and behavioral problems
Kids born to Bipolar Parents:
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↑ attentional and behavior problems, and subsequent
impairment of social and occupational functioning
↑ increased risk of suffering from affective disorder
Kids born to Depressed Mothers:
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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:
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associated with > attachment problems, esp. insecure
attachment and inhibited behavior
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↑ risk of lifetime anxiety-related disorders. (males>females)
Kids born to Mothers with Somatization D/O:
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increased rates depression and suicide
Kids of parents with Antisocial personality:
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↑ risk for oppositional defiant disorder and conduct disorder
Kids of parents w/ borderline personality
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↑prevalence of impulse-control disorders
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↑ features of borderline personality
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↑ 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, HelpRejecting, 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:
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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:
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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:
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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
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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
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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
SSRI’s Dosage
Fluoxetine
[Prozac] 10-60 mg/d
Paroxetine
[Paxil]
10-40 mg/d
Sertraline
[Zoloft]
25-200 mg/d
Fluvoxamine
[Luvox]
50-300 mg/d
Citalopram
[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?