Successful Transitions: Give Some Independence, Gain Some Cooperation

Up until now, in this series on transitioning from the pediatric to adult medical systems, we have focused on defining transition and why it matters.

Now, we are going to start looking at how to start the transition process at as young an age as possible. In fact, the transition to responsibility starts when kids are old enough to spit peas from the high chair!

First, let's briefly discuss the concept of “control.” Control is a basic human need just like food and water. When humans feel like they have no control, they do some pretty crazy things to get control including things that may be self-destructive. And when children have special medical needs, there are times when they have little or no control over their bodies. So much in their lives can feel out of control! And when they feel out of control, they can act out, misbehave, and cause all kinds of trouble. So, Love and Logic® teaches us to share control as much as possible.

 

1. The easiest way to share control is with choices. Rather than telling a child what to do and when to do it, use choices. What happens when we say to a child: “Come here and take your medicine!”?  Power struggle, arguing and complaining, right? Instead, try: “Would you like to take your pills with apple juice or grape juice?” or “Are you planning to do your medical treatment before or after soccer practice?”  Give choices as much as possible in all areas of life including food, homework, chores, and medical requirements. The more control is shared, the less the likelihood of control battles.

2. Replace statements with questions. Here's what Jim Fay, co-founder with Dr. Cline of Love and Logic, says about this: "How can we make sure that our kids are doing their fair share of the thinking? How can we keep ourselves from getting pulled into working harder on their lives than they are? How can we help them become prepared for a world full of decisions and consequences? Replace statements with questions.”

Some of the most powerful moments come when we empower kids by asking them what they plan to do about various situations instead of telling them what they need to do. The implied message we send says, "You are smart. You can come up with the answer." Children who are given this gift are far more likely to succeed in school and in life. On top of that, the human brain has a hard time ignoring the questions. It automatically searches for the answers - it just can't help itself.

What a gift we give kids when we encourage them to think rather than telling them what to do. A child who is redirected with the question, "Are you sure this is the right place for that behavior?" will respond much more thoughtfully than the child who is told, "Stop that!" One method invites thinking; the other invites resistance and battles for control. Which do you prefer? In either case, we are enticing young brains to do lots of thinking by simply asking questions rather than stating "how it is." So, do your kids' brains a favor and feed them a steady diet of questions." 

Some questions you might ask your child with special healthcare needs are:

"What kinds of foods can you eat today to get the proper nutrition?" 

"What do you think might happen to your body if you forget your medication?" 

"What is the best choice for your body?" 

 "Have you thought about what might happen if you don't listen to the doctor?" 

“What is your plan for getting your medical treatments done on time today?”

Give choices and questions a try especially if you are experiencing power struggles with your children. You’ll be amazed at how well they work to reduce power struggles and give your children the opportunity to do more of the thinking than you. 

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Foster W. Cline, MD is a child psychiatrist and co-founder of Love and Logic^®. Lisa C. Greene is a parenting educator and mom of two children with cystic fibrosis. Together they have written the award-winning book “Parenting Children with Health issues."  For free audio, articles and other resources, visit www.ParentingChildrenWithHealthIssues.com. 

©Copyright by Foster Cline, MD and Lisa Greene. All rights reserved. 

Endless Parenting Struggles: When adult children rebel

A new question popped up recently from a concerned parent regarding her newly troubled adult son. Dr. Foster Cline gives his expert advice in regards to helping these parents deal with the situation.

Photo by Photostock

Question:
I have a 21 year old son.  His dad and I have not been together since he was 3.  He has always been a good boy and respectful. Now that he is living on his own, he is very verbally abusive. He does not want anything to do with his dad or I.  We have tried everything to get him to let us help him.  But he is just so mean and hateful. I feel he is crying out.  But will not let us do anything except he wants money from us.  Please help us help him. Kim

Successful Transitions: It All Starts with the Toddler Years…..

This is Blog # 4 in our Transition series. The last three blogs discussed what transition is and why it matters. This week, we start looking at parenting strategies for raising children with special healthcare needs who are responsible, independent, confident and prepared for the transition/ transfer into the adult medical system.
Raising Responsible Children

All children must make a shift from parental to personal responsibility. All children must learn to make good choices which are independent of active adult involvement. And when a child has special healthcare needs, there is the additional process of shifting the medical tasks and responsibilities.

The challenge is, telling our children to simply “Be responsible!” doesn’t work. It is ineffective to demand, “Do your homework, take your medicine, and make good choices." Responsibility is something that has to come from inside the child- not from parents trying to force it from the outside.  And taking responsibility starts early. In fact, learning about responsibility and making good choices starts when children are old enough to throw peas from the high chair!

This brings us to a critical subject: Parenting Skill Training. This includes how to talk and work with children: what to say and do when they are resistant, how to avoid power struggles in the first place, what responses work and don't work, and how to structure a home environment in such a way that best promotes responsibility, positive attitudes and a desire to make good choices. Research shows that parenting skills, responses, and disciplinary styles have a significant impact on all of this. 

If a child won't get their shoes on without arguing, brush their teeth without nagging, and pick up their belongings when asked, how can they be expected to do their medical treatments? Or, from an article called Take as Directed: Improving Adherence in the Primary Care or Specialist Care Setting by Edward Christophersen Ph.D. and Susan Mortweet VanScoyoc Ph.D.:

"In the area of pediatrics, an often overlooked but important part of the medical adherence equation is that of the general behavioral compliance of the child. It is unrealistic to expect a child who will not follow the directions of her parents on anything else to follow the directions of her parents with respect to medical regimens. Often, failures with complicated regimens like Type 1 diabetes could have been predicted by the parent's prior lack of knowledge of strategies for addressing general compliance issues."

So the big question is: How do we raise kids with special healthcare needs who are respectful, responsible and prepared for the real world?  Next week, we'll start to answer this question.

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Foster W. Cline, MD is a child psychiatrist and co-founder of Love and Logic®. Lisa C. Greene is a parenting educator and mom of two children with cystic fibrosis. Together they have written the award-winning book “Parenting Children with Health issues."  For free audio, articles and other resources, visit www.ParentingChildrenWithHealthIssues.com. 

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Successful Transitions: Medical professionals share perspective and adviceSuccessful Transitions from Pediatrics to Adulthood: A Matter of Life and Death?

This is Blog #3 in our Transition series. The last blog discussed what patients have said about their transition experience. This week we'll discover what the medical professionals have to say.

Current research shows that an organized, methodical approach to transition is crucial. A. Kennedy et al. states: "Increasing evidence shows that adverse health consequences occur when inadequate transition arrangements are in place. Poor transition processes are increasingly recognized to have a significantly negative effect on morbidity and mortality in young adults."

Research also shows that starting the transition process early is essential. Research by Hewer and Tyrrell recommends that a formal "transition process should start from 11 to 13 years of age."

Unfortunately, this isn't happening in a majority of cases (in the cystic fibrosis community). In 2008, research of 87% of all US CFF-accredited programs shows that: "Although transfer of care in CF occurs at a median age of 19 years, initial discussion of transition does not occur until a median age of 17 years, leaving a limited amount of time for patients, families, and care teams to delineate and foster key self-care skills. In fact, an international survey of individuals with CF found that only 10% reported introduction of the concept of transition before the age of 15 years." (McLaughlin et al.) 

Researchers may recommend that the formal transition process start in the preteen years but child development experts recommend that a developmentally-based transition process ideally starts much younger.

Preschoolers can learn to label medical equipment, body parts and medications. They can help count out pills, push buttons on medical equipment, and answer basic questions about why they take medication. In our Transition Blog #1, we showed a simple transition plan for PKU starting at about age four.

Children in elementary school can start to take the responsibility for some aspects of their care with the watchful support of adults. Examples for cystic fibrosis might include independent management of pancreatic enzymes, initiating breathing and chest therapy treatments, and cleaning and properly storing medical equipment. These are all examples of transition tasks that can be, and should be, purposefully shifted much earlier than the preteen years.  

Transition is a cumulative process meaning that all of the little things we do over the years as a parent will "add up" and help our children be ready (as young adults) to successfully move into the real world. For our children with special healthcare needs, this includes the adult medical system.

Clearly this is a critical area that needs to be addressed by both parents and medical professionals. As parents, we must be proactive about initiating an effective transition process with our child even if our medical clinic lacks a formal one. So let's discuss the transition experience and examine ideas about how it can be most effectively accomplished from a parent's point of view.

The transition process really consists of two parts: the shifting of medical tasks and the shifting of personal responsibility in general. There is certainly some overlap but the personal responsibility piece encompasses a whole lot more than the medical tasks.

Generally speaking, if a child is responsible around schoolwork, chores, money, and basic self-care issues (like personal hygiene), then the child will be responsible around the medical tasks as well.  This is great news for us parents because general personal responsibility can be learned much earlier than medical tasks and around less risky issues.

Parents must focus their attention on two primary areas: Responsibility Training and Medical Task/ Disease Knowledge.  We will discuss these important areas over the next few weeks with this blog series on transition.

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Foster W. Cline, MD is a child psychiatrist and co-founder of Love and Logic®. Lisa C. Greene is a parenting educator and mom of two children with cystic fibrosis. Together they have written the award-winning book “Parenting Children with Health issues."  For free audio, articles and other resources, visit www.ParentingChildrenWithHealthIssues.com. 

Transitions from Pediatrics to Adults: A Brave, New World

After beginning our Transition blog series, we received a question from a reader telling us about her experience going from a pediatric clinic to an adult clinic. This patient explains to us her common concern that so many others experience - Lisa Greene responds with some very helpful advice.

Question:

"I was 19 when I transitioned and it was a huge shock. My peds doctors were amazing, my mom was usually with me but even then my peds doc spoke directly to me and helped prepare me for what was coming. She took so much interest in my life outside of CF (cystic fibrosis) as well (she knew that what was going on at home affected my CF).

Transitioning to the adult clinic was awful. I felt that my new doctor didn’t care about me as a person and that I was just another patient to her...I’m naturally a shy person and after that first disaster of an appointment, I just retreated into myself. After a few more appointments, we have slowly started to get to know each other and I’ve relaxed a bit more, but its still not the same. I still have the feeling that I’m such an inconvenience to her...and it really kills me every doctor’s appointment. My peds docs were like family...and I was hoping that my adult doctor would be the same, especially since I’m always up there and always having to deal with them. Any advice? "

Successful Transitions: Patients share the significance of Transition

This is Blog #2 in our Transition series. In our first blog, we learned, "What is Transition?". This week we'll start to discover why Transition matters.

Transferring from pediatrics into the adult medical system is a big step for families. The medical care models are very different. Even prepared parents and young adults express shock at how different the two systems are. It's like jumping into a cold swimming pool. You might be mentally ready for cold water because you dipped in your big toe but when you jump in, there's still a shock to your system. Some people appreciate the shock and call it "invigorating" while others can't wait to jump back out at the first possible chance!

Here are some comments from adults with cystic fibrosis about their experiences with transitioning from pediatrics to adult-oriented medical care: 

I had a hard time at first transitioning from the pediatric to the adult clinic because I find it really difficult to adapt to new doctors. It didn't last long before I felt comfortable with my adult doctor because naturally, there are more adult health concerns that need to be discussed and somehow it's just easier talking to an "adult" doctor about "adult" problems. The one main difference I noticed from the pediatric clinic is that the doctor I switched to is more blunt, to the point, and speaks directly to me. One of my parents has always come with me to clinic but once I was transitioned, my parents stopped coming in to see the doctor with me. They would still take me to clinic but they just stay in the waiting room. When they were in the room with me, it seemed as though the doctors forget I'm there. They would talk about me to my parents, I never felt like I was being addressed. They way I'm spoken to in the adult clinic is very different... because apparently they think once you're 21, you don't want to talk about your "poops" any more.  - female age 21

In my personal opinion, the courtesy with the patients changes. They assume that because people are older, they can handle the info that's given to them with no problem, which I agree to a certain extent; but what they're forgetting is normally it's bad news and is still a lot to take in for some people. MY advice... stay a kid.  - male age 25 

Was I ready? I think as far as being in control of my own heath I was. I was 19 when I transitioned to the adult clinic. I was pretty independent; I was living on my own, engaged, going to college, etc. But the reality of insurance and bills still wasn't there. I learned pretty quickly how to manage the medical bills and how to understand insurance. The pipe dream of going to college full time and working part time was just that. There would have been no way to afford insurance working only part time. How is it different? I think I have to be more aware of my own health and speak up when something is not right. - female age 23 

The transition from the Ped's to the adult clinic is all going to depend on the medical team and the patient. I think I'm healthier than most CFers so I was less dependent on the Ped's clinic which really helped with my transition. I went to school with another CFer and CF had a major impact on her. She actually passed away about a year ago. I know that she had a very difficult time transitioning from the ped's to adult. I think it is all very situational. - male age 25 

I transitioned at 16. My pediatricians had prepared me for the transition. They always talked directly to me. At the age of 12, I would go to the exam room by myself and mom would stay in the waiting room. They wanted me to learn how to interact with doctors and advocate for myself. I think they did a great job.  Honestly, when you are an adult, you need to see a doctor who is used to dealing with issues that adults face. - female age 40

This small sample demonstrates that there can be a wide variety of transition/ transfer experiences. The quality of this experience has a critical impact on how young adults adapt to dealing with their healthcare choices that can span across their lifetime.

Interestingly, research shows that parents have a harder time with this process than their adult children. Being well-prepared will help young adults and their parents to have a successful transition/ transfer experience.

So, this is what young adults have said about why transition matters. Next week, we'll discover what the professionals say. 

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Foster W. Cline, MD is a child psychiatrist and co-founder of Love and Logic®. Lisa C. Greene is a parenting educator and mom of two children with cystic fibrosis. Together they have written the award-winning book “Parenting Children with Health issues."  For free audio, articles and other resources, visit www.ParentingChildrenWithHealthIssues.com.  

Successful Transitions: Moving from Childhood into Adulthood and from Pediatrics into Adult Care

Happy New Year! A new year is about looking ahead, making changes, and moving forward. It’s about transitions! We are excited to start a brand-new blog series about the subject of transition. In this first blog, we discuss “What is transition?”