The MI process strengthens the trust in your relationship with the parent, starting with reflecting on the issue (“It sounds as though you don’t always feel safe at home”), empathizing (“That must be really scary. I am sorry you are going through that”), and assessing (“May I try to help you with this?”).
After collecting the pros and cons for making a change, either in the interview or via the screening tool SEEK Plus in CHADIS, your job is to help the parent weigh them (“On the one hand you love him and need his income, but on the other hand you are so afraid that you can’t sleep and your children are too nervous to concentrate in school.”) Then you need to elicit what would be enough to move them (“How will you know when it is time to act?”) and to assess readiness to change (“What kinds of help would you be open to?”), then offer that kind of help (“I would like to connect you to a professional who has a lot of experience helping people in your situation. Is it okay if we call her right now?”). Provide written contact information, of course, but actually assisting by calling the appropriate resource or even doing a “warm handoff” in person is more effective.
Obviously, to make an effective referral, we need resources assembled in advance for the most common issues. UnitedWay.org is a good place to include on your list.
Our job, however, is not over with an “accepted” referral. Most referrals are not kept, help is never received, and risk to the child is not averted. There are many potential barriers to families’ accessing help – time off work, money, transportation, or child care – but difficulty generating the courage to change is understandable and may resolve only gradually with your work and support. It is wise to tell the parent that “I (or someone on your staff) will check in on how this goes, okay?”
Making a follow-up appointment with you is important, even if you feel helpless to do more than refer. Why? A return visit is a chance to show that you care, to be sure they went, and to get information on the quality and appropriateness of the care provided so you can support it or refer elsewhere. Perhaps most importantly, it shows that you do not reject them for revealing what they may see as personal failure or immoral behavior so that you can continue caring for and monitoring their at-risk child.
What if they decline help, no resources are to be found, or the damage has already occurred? You still have valuable help to provide. Our goal is to ameliorate the impact of the stressors on the child now and in the future. Just as relational factors can stress the child, improving supportive relationships is key to reducing their effects. Parents with ACE risk factors are often self-absorbed in their pain, using smoking, substances, or alcohol to dampen it and moving from one troubled relationship to another in response to past trauma; thus they are emotionally unavailable to the child.
You can help them by focusing on the wonders of their child, encouraging daily individual time for play, and modeling Reach Out and Read as a supportive, calm activity they can do even when stressed. You can encourage the practice of mindfulness – an exercise of letting thoughts pass over them without judgment while breathing rhythmically – for stressed parents and school-aged children. It has been shown to be an effective intervention for recovering from past as well as current stress. Children also should receive any needed mental health care.
An emotionally available, supportive, nurturing parent is the most important protective factor for the child’s development of emotion regulation, resilience, and the ability to cope with adversity throughout their life. Referring parents to services such as home visiting, Healthy Steps, or parent-child therapy to build these skills has evidence for improving relational health. Helping the parents avoid ACEs for their children and assisting them in ameliorating them, if they occur, are important investments in long-term health that you can provide.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.