Communicating a diagnosis of developmental disability to parents: multiprofessional negotiation frameworks

Where are they now? An autism follow-up study

AIM

To explore the stability of diagnosis and the relationship between behavioural, adaptive and developmental skills in early to middle childhood in children with autism spectrum disorder (ASD).

METHODS

Fifty-four children recruited to the study were diagnosed with ASD before 42 months. Outcomes at follow-up after a mean interval of 64 months were measured using the Autism Diagnostic Observation Schedule, Vineland-II adaptive scale and Wechsler Intelligence Scale for Children and parental survey data. Scores before school were compared with follow-up data through descriptive, correlational and multiple regression analyses.

RESULTS

ASD was confirmed in all children at follow-up (mean age 10 years). Fifty-eight percent of children were enrolled in a supported educational class or school and 42% were taking a psychotropic medication. Adaptive function improved significantly in 19% of children. Developmental and adaptive behavioural scores before school correlated with cognitive, behaviour and adaptive assessments at follow-up.

CONCLUSION

At follow-up, the diagnosis was confirmed in all children. The children showed gains in their adaptive skills but and many required ongoing educational and behavioural support. Early developmental and adaptive assessments reliably predicted later educational support needs, cognitive and adaptive function and are a useful component of a diagnostic assessment.

Predicting Parent Reactions at Diagnostic Disclosure Sessions for Autism

Receiving a diagnosis of autism for their child can be a pivotal moment for parents, yet there is little research about how providers can predict parent reactions and adjust their feedback. We investigated factors related to parent reactions during the disclosure session using interviews with providers (n = 6), a parent focus group (n = 10), and a mixed-methods survey of parents (n = 189) of recently diagnosed children. Parents' prior knowledge of autism and anxiety about diagnosis predicted emotional reactions and readiness for next steps. Families anxious about receiving a diagnosis are most in need of information but may leave the session feeling lost and unprepared. Providers can promote positive emotional reactions for parents and prevent confusion by increasing their own positivity, warmth, respect, clarity, and confidence.

Family Sense-Making After a Down Syndrome Diagnosis

The script of parenting shifts when parents learn of their child's Down syndrome diagnosis. To build a theory of the diagnostic experience and early family sense-making process, we interviewed 33 parents and nine grandparents living in the United States who learned prenatally or neonatally of their child's diagnosis. The core category of rescuing hope for the future encompassed the social process of sense-making over time as parents managed their sorrow, shock, and grief and amassed meaningful messages that anchored them as they looked toward the future. Application of the theory to practice underscores the import of early professional support offered to parents at key points in the sense-making process: Early as they disclose the news of the diagnosis to family and friends, and later close friends and kin assimilate meaningful messages about what the diagnosis means as they recalibrate expectations for a hopeful future.

Communication of bad news in pediatrics: integrative review

OBJECTIVES

to identify the scientific evidence of the elements of communication in the process of communicating bad news in pediatrics.

METHODS

integrative review searched in the LILACS, PubMed and WoS databases. Primary studies in Portuguese, Spanish or English were included.

RESULTS

the evidence from the 40 studies were organized according to the elements of communication: sender (family and/or professional), receiver (family and/or child), message (bad or difficult news about diagnosis/prognosis; empathetically, honestly, objective, hopeful and available), channel (materials, quality, quantity and pace), context and effects (social and emotional changes), noise (feelings and language) and failures (silencing and misleading information).

CONCLUSIONS

there is a need to prepare the institution and team, as well as the family and the child, in order to promote co-responsibility in this process, to minimize suffering and communication noise and to avoid failures, recognizing the child's right to know their condition.

Parental perspective: Factors that played a role in facilitating or impeding the parents' understanding of their child's developmental diagnostic assessment

BACKGROUND

Full parental understanding of a child's diagnosis of a developmental disability is critical to be able to ensure the best health outcome for their child. Yet factors that parents perceived as influencing their comprehension during the final diagnostic meeting have not been well identified.

METHOD

This study used a qualitative interpretive description approach. Seventeen parents were interviewed who received a child's developmental diagnosis from one of the clinical multidisciplinary teams located in northern British Columbia. The interviews focused on the factors that played a role in facilitating or impeding the parents' understanding of their child's diagnosis, and on the identification of factors that influenced the way in which the child's clinical recommendations were pursued.

RESULTS

Two overarching themes with nine subthemes emerged from parents' reported experiences of receiving their child's developmental diagnosis. The themes and subthemes included (a) clinical encounter (including the subthemes structural considerations, professional diversity and new insights, questions regarding the assessment process, and validation) and (b) manner of the delivery of the diagnosis (emotional impact, impact on parenting practices, professionalism, professional language, and quantity of information).

CONCLUSIONS

Parents' accounts established and clarified the positive and negative parental determinants that aided or challenged their ability to understand their child's developmental diagnosis during the final clinical interaction with the multidisciplinary team.

Parental Perceptions of a Comprehensive Diagnostic Evaluation for Toddlers at Risk for Autism Spectrum Disorder

Parent satisfaction with neurodevelopmental evaluations may influence the pursuit of intervention. Parent satisfaction with a neurodevelopmental evaluation for toddlers at risk for autism (n = 257; 128 with autism) was examined using the Post-Evaluation Satisfaction Questionnaire, which collected quantitative and qualitative information. Fewer ethnic/racial minority than non-minority parents returned the questionnaire. Factor analysis indicated a one-factor model, Total score, which did not differ significantly by diagnosis, autism severity, child's cognitive or adaptive delay, family race/ethnicity, maternal education, family annual income, or parental stress. Examination of 24 individual items showed a race/ethnicity difference for only one item; minority parents scored the evaluation as meeting their needs less. Qualitative data stressed the importance of fully explaining diagnoses/recommendations and providing direct and clear feedback.

Impact of Diagnostic Practices on the Self-Reported Health of Mothers of Recently Diagnosed Children with ASD

Objectives: Obtaining a diagnosis of an Autism Spectrum Disorder (ASD) for a child is a pivotal point in developing the treatment plan for the child but can also be regarded as highly stressful by parents. The current study examined the impact of different aspects of the diagnosis process on the self-reported mental health of mothers of children undergoing a diagnosis for ASD in a cross-sectional cohort design. Methods: One-hundred-fifty-eight mothers of consequently diagnosed children with ASD participated. The severity of the children’s ASD and their intellectual functioning was assessed within twelve months of the diagnosis, and the mothers completed a psychometric assessment battery including the Hospital Anxiety and Depression Scale, General Health Questionnaire, and Questionnaire on Resources and Stress. Results: The actual time from first reporting a problem to obtaining a diagnosis, and the speed of the diagnostic process from first to last appointment, were both negatively related to patenting stress. In contrast, mothers’ perceptions of the speed and helpfulness of the process were negatively related to levels of anxiety and depression. The number of professionals involved in the process and the perceived coherence of the diagnosis were also negatively related to aspects of mothers’ functioning. Conclusions: Care is needed to help mothers through the diagnostic process with regard to their own functioning. Providing information and help sources throughout the process, while keeping the number of professionals involved to a minimum, may improve the parent perception of the process and reduce the negative impacts of the diagnosis on the family as a whole.

Diagnosis of pervasive developmental disorders: when and how? An area-based study about health care providers

BACKGROUND

Pervasive developmental disorders (PDDs) can be very difficult to diagnose in children and to communicate such a diagnosis to their parents. Families of children with PDD learn of their child's diagnosis long after the first symptoms are noted in the child's behavior.

METHODS

An area-based survey was conducted to assess all social and health care providers taking care of patients with PDDs in the Veneto Region (North-East Italy).

RESULTS

Only 28% of health care providers arrived at a definite diagnosis when the child was in his/her first year of age, 51% when the child was 2-3 years old and 21% from age of 4 years and up. On average, the latency between the time of the diagnosis and its communication to the family was 6.9 months. However, a number of families did not ever have a diagnosis communicated to them. Sometimes, 68% of the providers did not communicate a PDDs diagnosis to patient's families, and 4% of them quite commonly.

CONCLUSION

The well-known delay in making a diagnosis of PDDs has two distinct components: one relating to the difficulty of confirming a diagnosis of PDDs, the other, hitherto unrecognized, relating to the family being notified.

'One wants to know what a chromosome is': the internet as a coping resource when adjusting to life parenting a child with a rare genetic disorder

The internet has democratised access to health and diagnostic information, enabling patients to mobilise social support from peers and advocate their interests in encounters with medical personnel. Research has shown that these possibilities are particularly important for patients and caregivers confronting a rare medical condition. However, little research has focused on how the act of searching for and accumulating information via the internet can be important for coping emotionally with a situation characterised by uncertain prospects and inadequate information from health personnel. This paper explores the experiences of 10 Norwegian parents whose children have different rare genetic disorders and who used the internet as a resource. The analysis draws on the theoretical framework of the medical sociologist Aaron Antonovsky, who emphasises people's inherent ability to manage extremely stressful life experiences. Analysing the process of adjusting to and coping with life parenting a child suffering from a rare genetic disorder, this study shows that becoming knowledgeable about a child's condition is essential for gradually comprehending and managing a situation that initially seems unmanageable and distressful. It also suggests that as parents adjust, so do the frequency and purpose of their internet searches.

The autism diagnostic experiences of French parents

This survey focused on French parents' views of the diagnostic process relating to their child with autism. Data were collected on the age at diagnosis, the time taken to obtain a diagnosis and the difficulties encountered. Questionnaires filled in by the parents (n = 248) and in-depth interviews (n = 43) were analyzed in order to obtain quantitative and qualitative results. The ages of the children ranged from 4 to 45. This approach enabled us to compare the practices of professionals now and in the past. The mean age of diagnosis was 10 ± 8 years from 1960 to 1990, 5 ± 3 years from 1990 to 2005 (3 ± 1 from 2003 to 2005). The results showed that the mean delays between first consultation and diagnosis were reduced. Regarding the way the diagnosis was announced, 63% of the parents of children with autism and 93% of the parents of adults with autism were dissatisfied. We discuss the parents' reactions and the changes in the diagnostic process.

An experimental investigation of the dilemma of delivering bad news

OBJECTIVE

This randomly controlled experiment tested a theory of how experienced physicians solve the dilemma of communicating bad news by using implicit language.

METHODS

8 physicians delivered both bad and good news to 16 analogue patients. Microanalysis of their news delivery reliably identified departures from explicit language.

RESULTS

As predicted, the physicians used implicit language at a significantly higher rate when delivering bad news than good news. For bad news, they tended to use alternative terms for the diagnosis, to qualify their evaluation, to underemphasize certainty, and to subtly separate the patient from the disease. The evidence both within and after the interview indicated that recipients still understood the bad news.

CONCLUSION

(1) The skilful use of implicit language is a solution to the dilemma of honest but not harsh communication of bad news. (2) Experimental methods can complement surveys and qualitative studies for investigating bad news delivery by providing a theoretical foundation and controlled conditions.

PRACTICE IMPLICATIONS

Physicians can deliver bad news honestly without being blunt by skilfully incorporating implicit language. The theory, data, and examples presented here provide insights into the nature and functions of implicit language, from which students and practitioners can develop their individual styles.

Sugar-coaters and straight talkers: communicating about developmental delays in primary care

OBJECTIVES

The goals were to investigate parents' and early intervention (EI) specialists' beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS

Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N = 46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS

Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred a more direct style, including the use of labels to help them understand their child's development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS

Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers' approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays.

Parents' perceptions of communication with professionals during the diagnosis of autism

In order to obtain the views of parents concerning their perceptions of the process of getting a diagnosis of an autistic spectrum disorder (ASD) for their child, 15 focus groups were conducted across a range of locations in England. These groups were split into parents of preschool-, primary- and secondary-aged children who had recently received an ASD diagnosis. At the time of diagnosis, most of the parents wished for a quicker and easier process. In particular, they would prefer the procedure to have a more coherent structure and content. They also requested greater professional training about ASD, in particular, regarding the information that professionals possess, and the interpersonal skills of some professionals. The idea of broad information sheets to be provided to parents at the time of diagnosis would be of value, especially to combat negative information provided from other sources.

The importance of physician knowledge of autism spectrum disorder: results of a parent survey

BACKGROUND

Early diagnosis and referral to treatment prior to age 3-5 years improves the prognosis of children with Autism Spectrum Disorder (ASD). However, ASD is often not diagnosed until age 3-4 years, and medical providers may lack training to offer caregivers evidence-based treatment recommendations. This study tested hypotheses that 1) children with ASD would be diagnosed between ages 3-4 years (replicating prior work), 2) caregivers would receive little information beyond the diagnosis from their medical providers, and 3) caregivers would turn to other sources, outside of their local health care professionals, to learn more about ASD.

METHODS

146 ASD caregivers responded to an online survey that consisted of questions about demographics, the diagnostic process, sources of information/support, and the need and availability of local services for ASDs. Hypotheses were tested using descriptives, regression analyses, analyses of variance, and chi-squared.

RESULTS

The average age of diagnosis was 4 years, 10 months and the mode was 3 years. While approximately 40% of professionals gave additional information about ASD after diagnosis and 15-34% gave advice on medical/educational programs, only 6% referred to an autism specialist and 18% gave no further information. The diagnosis of Autism was made at earlier ages than Asperger's Disorder or PDD-NOS. Developmental pediatricians (relative to psychiatrists/primary care physicians, neurologists, and psychologists) were associated with the lowest age of diagnosis and were most likely to distribute additional information. Caregivers most often reported turning to the media (i.e., internet, books, videos), conferences, and other parents to learn more about ASD.

CONCLUSION

The average age of ASD diagnosis (4 years, 10 months) was later than optimal if children are to receive the most benefit from early intervention. Most professionals gave caregivers further information about ASDs, especially developmental pediatricians, but a sizeable minority did not. This may reflect a lack of training in the wide range of behaviors that occur across the autism spectrum. Parents turned to outside sources to learn more about ASD. We recommend that all physicians receive specialized training about ASDs to improve upon early screening and diagnosis, and then advise caregivers about empirically-supported services.

Exploring diagnostic processes: social science perspectives

This review explores social science analyses of diagnosis of childhood neurological disabilities. The paper moves through three sections, which capture the historical and conceptual trends within the literature. The first focuses on work identifying the need to communicate effectively with parents when giving a diagnosis, the second explores the role parents can play as "partners" or contributors to diagnosis, and the final section goes further in exploring the social complexity of diagnoses in order to examine the embedded nature of social practices, power relations and hierarchies, and institutions in the diagnosis encounter.