Question 3 - Gina
Shmaya and
colleagues (2015) discussed increased nutritional risks for ASD populations in
the second supplemental article cited below. Considering the challenges and
stresses (to both child and caregiver) associated with potential child behavioral
reactions to changes in diet and routine, how would you counsel a caregiver who
is resistant to your recommendations for dietary changes?
posted by Unknown @ 8:06 PM
10 comments
10 Comments:
Like any resistant patient, I think it is important to gauge the person’s personality and needs. For example, a caregiver who provides their child with a gluten free diet might become defensive if we, as dietitians, were to talk to them as if we are criticizing their nutrition decisions for their child. I think the best method with resistant parents is to let them do a lot of the talking at first and gather as much information about them as you can. Parents with ASD children are already under a tremendous amount of stress and the last thing they want is to feel as if a dietitian is criticizing what they are doing as a parent. After listening to the information they are willing to provide, I might ask some of the questions provided in the Academy article from this month, depending on some of the GI symptoms that the ASD child has. If the caregiver expresses great resistance, I would probably present them with some information about the increased prevalence of nutrient deficiencies and overweight in ASD children so that they are at least aware of their child’s risk. At that point, it really becomes the parent’s choice as to whether they will follow the advice that I have provided to them. I certainly would not want to come across as too pushy with the information and advice I am providing.
When talking with any patient and/or caregiver, I find it very important to start initial contact by building rapport and showing a genuine interest in the patient and his/her care. It is amazing what you can learn by taking the time to listen to the patients, whether it be related to their health or just a story from their life. Taking this time starts to build trust in the relationship, which could be highly beneficial in the caregiver accepting recommendations and being open to try new foods/methods.
As with any patient, we as RDNs, have the capability to offer information and recommendations, but in the end it is not in our power to force these suggestions onto our clients. I would probe the caregiver to see if there was any flexibility in trying anything new with the care and diet of the child, and focus on baby steps with what he/she was comfortable with from there. I would offer my contact information for support and likely set-up a follow-up call to touch base if any new questions/concerns arose.
I think it is first important to listen like both Jenn and Amanda said, but then I think it is even more important to make the parents feel good about their decisions. Validating parents and telling them that you are aware they are trying to provide the best care for their child will not only make them feel good, but might make them more willing to hear what you have to say because they will feel less attacked. I would start by suggesting small changes and gradually try to make more changes as the parents feel comfortable. I agree with Jenn that taking time to build trust with these parents is crucial for the success of the meeting and hopefully later intervention. Through out the whole meeting I would constantly be asking the parents for permission to try and implement intervention so the parents feel they have complete control. Even if the parents decide to take none of your advice at least you were able to educate them on their options and who knows maybe they will come back at a later date and be more willing once they have had time to process the information.
Amanda brought up a great point that many parents with children with ASD are under a tremendous amount of additional stress and just validating that stress might help the parents feel more comfortable opening up to you. I also think presenting very resistant parents with facts might sway the parents into listening to what you have to say.
On a counseling level I think just being there and listening to the caregiver’s issues and stresses could be a step in the right direction. I was recently reading a book that was explaining the different approaches doctors take when delivering tough news to patients. A large percentage of the patients felt better if the doctor simply listened to their thoughts, concerns, and worries when it came to treatment options, regardless of the patient’s prognosis. I think it just goes to show the value of listening.
Once you’ve made listening the foundation of the counseling session, I think one way to help the caregiver avoid stressful issues would be to first help them consciously establish what the child likes (what works for the child). After you both know the starting point (what works) I think a tag team brainstorm of areas of improvement (how can we make what works better) in the child’s diet would be a good idea. Once you’ve both agreed on a good single starting place for change (making only one change at a time could be a good way to ease the child in to a new routine) helping the caregiver learn how to make tiny baby step changes would be a good next step. Hopefully taking small (maybe even un-noticeable to the child steps) will help to avoid overwhelming the child.
I think listening, agreeing on the intervention strategies, and working together to come up with interventions that best fit the child and caregiver’s life would hopefully give the caregiver ownership of the change process and would hopefully help to curb any resistance to recommendations.
Asking permission to give advice can make a caregiver or client so much more receptive because it makes it their choice to grant you permission to go on. Listen does make a huge difference. Does anyone have thoughts on how they might present the evidence for nutritional risks to the caregiver? Approaching and transitioning into that conversation can be a very touchy subject depending on the language and word choices used. How can we make ourselves more convincing?
Like all patients, we need to treat each case individually and take many things into consideration. I think it is extremely important to try to put ourselves in the caregiver’s shoes. Like Amanda said, they are under a lot of stress and big health and diet changes could add to that stress level. I used to work with a lady who has a nonverbal disabled child, and I gained insight of some of her challenges. The mom was an advocate for her child and was persistent when she thought something was wrong even when doctors disagreed with her. Building a relationship with the child and the caregiver is essential and could help reduce some of the resistance. Also listening to them and their situation is very important too.
I believe the most important thing regarding a resistant caregiver is gaining their trust. In order to deliver appropriate care it is crucial to individualize your treatment, as Abby stated, and that includes considering the factors influencing the patient/client like their caregiver. I mentioned this in the previous question, but I think an interdisciplinary team can be used to help individualize treatment and gain the trust of a resistant caregiver. In an interdisciplinary team other professionals can back up your recommendations and help establish your credibility.
the first step is to build rapport before casting any judgment or forcing our views onto the caregivers whom are already stressed and frustrated. I have learned and seen the importance in building rapport with caregivers during my internship at WIC. Gathering information is possible while building rapport. We can gather a lot of information about the caregiver's habits, opinions and why they may be resistant to something by talking to them. If they are unwilling this time, we can understand why and then encourage the caregiver to come back next time and hope they will be less resistant in the future as we build rapport with them. Telling a caregiver they're caring for their family member or a friend wrong is the fast route to have them shut down on us. Communication is very important for us!
To answer the questions Gina posed, I think one way to present evidence for nutritional risks is in the form of a handout that includes visuals. Throwing a bunch of information verbally at the caregiver may not be effective for many people. It may help for them to be able to see and read what you're talking about. It also helps for them to refer to some resources after speaking with them. It may take some time for them to let the information sink in, so they can review what was discussed at a later time. It may also be more convincing for them to read it on paper with some additional references to use if they want to. Of course this conversation needs to be started after building rapport instead of jumping right into that topic.
This makes me think back to an undergrad lab class where we were given scenarios and were asked to assess the patient's 'readiness to change,' which I have found through rotations is a great skill to be able to identify this in your patient. I would start by providing them with all of the necessary information needed for them (the child and caregiver) to understand the risk factors associated with malnutrition. From there, take it step by step and set slow goals for change following at their pace. As Vivian mentioned, jumping in too quickly could overwhelm them and turn them off from the idea entirely.
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