On Call Magazine
March 2001

By Helen Osborne, M.Ed., OTR/L
President, Health Literacy Consulting

Health providers who work with children and teenagers need to be well versed in anatomy, physiology, and child growth and development. But they also need to be fully informed about who’s who on “Sesame Street,” what’s new in the world of rock music, and what’s hot in fashion and belly-button rings.

Jessica Hennessey RN, CPNP, founder of Pediatric and Adolescent Health Associates and a Leadership Education in Adolescent Health (LEAH) Fellow at Children’s Hospital, treats children and teenagers in both inpatient and outpatient settings. Over the years, she has learned that the most effective way to communicate is to first understand “where the child is in life.” This means understanding more than bio-psycho-social and moral development. It means knowing what is important to the child, and making the effort to frame health information in a manner that the child can understand and accept.

Hennessey offers some helpful tips that health providers can use to communicate with children, teenagers, and their families about health and illness concerns.

Establishing a Friendly and Cooperative Relationship

• Talk to the child about health. Hennessey says that when a child is an active participant in the exam, he or she is likely to be cooperative and to give honest information. So she usually speaks directly to the child, inviting the parents to “chime in” as necessary. In a well check-up, for example, Hennessey might ask Johnny if he wears a seat belt “all of the time” or “some of the time.” While the parent might insist that he always wears a seat belt, Johnny might admit that he sometimes forgets to buckle up when going to the store. Hennessey takes advantage of such a response to talk about the importance of consistent seat-belt use.
• Prepare the child for medical procedures. Communication can be difficult when a child is sick. Not only does the child feel ill, but he or she might also need to have an unpleasant medical procedure performed. When this is the case, Hennessey uses humor and real-life examples to help prepare the child for the procedure. When Mary needs a throat culture, for example, Hennessey might first show her what a swab looks like and let her feel the soft tip. Sometimes she might even let Mary try to take a culture on a doll.
• Appreciate developmental differences. Even children who are the same age can vary widely in their learning skills and communication abilities. Amanda, for example, may be a fluent reader at 5 years old, while David at the same age does not yet know his alphabet. Hennessey suggests tailoring your exam to the particular child’s skills and abilities. When asking children to read an eye chart, for example, you might ask Amanda to tell you which way the letter “E” is pointing while you might ask David to show you with his hands which way the shape is leaning.
• Encourage laughter. Laughing often breaks down communication barriers and can go a long way toward relaxing children and their parents. Engage children in conversation by talking about their favorite TV character or pop singer. Try to play games or use puppets as part of an exam. When listening to a child’s breathing, for example, you can ask a child to blow on a pinwheel or pretend to blow out candles on a birthday cake. By encouraging laughter, Hennessey says, “I get what I need and the child is having fun.”
• Pay attention to appearance – theirs and yours. Appearance can be very important to children, especially to teenagers. It is quite likely that adolescent patients spend considerable time and effort getting ready for their appointment. Find something to compliment in their appearance – be it their clothes, nails, hairstyle, or even belly-button ring. Your appearance is also important. Hennessey, for example, often wears brightly colored clothes and sometimes adds a light-hearted touch to her wardrobe, such as wearing a pin that squirts water. By dressing this way, she finds she can gather far more information than she might when she is wearing a traditional lab coat.

Handling Special Problems

• The unwilling patient. Despite your best efforts to put a child at ease, some children just do not want to be examined. When this is the case, Hennessey says, work quickly and save your conversation for after the physical exam. Then you can follow-up with the parent when the child is calm and playing in the waiting room.
• A child who is easily distracted. Some children, such as those diagnosed with attention deficit hyperactivity disorder (ADHD), may have a difficult time focusing during the medical exam. To engage the child, you can speak directly to him or her and make the exam as participatory as possible. You can, for instance, ask 4-year-old Samantha to help you figure out who is hiding in her ears. When you do, stand close to her so that you, rather than other objects in the room, are her primary visual focus.
• A child who does not communicate well. When a child cannot speak for himself or herself, regardless of the reason, you need to find other ways to communicate. One way that Hennessey recommends is to use visual tools that can make a connection between you and the child, such as happy or sad faces. You can also ask parents how they learn what their child is thinking and feeling and work from the same cues and nonverbal approaches they use for communication.

Working With Parents

Not only do children bring a range of communication needs to a medical appointment, but so do their parents. While some parents may lack the literacy or language skills they need to understand complex medical terminology, others come to appointments with journal articles and research findings. Regardless of the parents’ education or vocation, make sure they understand what you are saying. When talking about dehydration, for example, confirm that they know that dry skin or dry diapers can be warning signs that a child needs further medical attention. When you need to deal with a controversial issue, such as whether children should  receive the chickenpox vaccine, write a handout that clearly outlines the perspective of your healthcare practice.

Parents sometimes bring in information they find on the Internet. As a health professional, you may feel uncomfortable talking about an article you aren’t familiar with. When you are uncertain about the credibility of new information, ask to read the material. Then follow up with a phone call to the parents a few days later. You can deal with Internet information proactively by distributing lists of Web sites you can recommend because you find them credible. Keep up-to-date with what’s new on these sites, and share the information with both the children and their parents.

How to Find Out More

Jessica Hennessey, RN, CPNP, is founder of Pediatric and Adolescent Health Associates, located at: 290 Baker Avenue, 217 North, Concord, MA 01742.