How should we persuade children – particularly those with communication challenges – to co-operate during ophthalmic examinations? Light for Sight’s new Procedure to Increase Compliance may hold the answer
You can’t just put a child in front of an ophthalmic instrument and expect everything to go smoothly. Even for adults, measuring IOP with air-puff tonometry feels like being poked in the eye! Imagine what it’s like for children – no wonder they are reluctant to repeat the experience contralaterally. And when children have imperfect communication skills – for example, because they are very young or have autistic traits – it is almost impossible to persuade them to go through that kind of procedure again. Unless, of course, you know how.
In our experience, the key is to educate the child about what they should expect. For this, it is essential to adopt a communication style appropriate to the patient in question; remember, youngsters – especially autistic children – are often very visual. In most cases, using complicated language or medical jargon to explain what we’re going to do, and what we need them to do, is futile. But how do we know what communication style will work best for a given patient? In brief, we must do our homework and ask questions about the child well in advance of conducting any examination.
For example, what do they like and not like? Are there particular triggers that upset them? Is there any specific past experience that we should know about? Critical to this information-gathering phase is our specially designed questionnaire; by completing this standardized form prior to the consultation, carers provide us with the information necessary to ensure that we adapt our style and environment to suit the child.
We have worked with the charitable foundation, Light for Sight to develop a checklist (see box, “The Art of Persuasion”) that standardizes our approach. Armed with the information it provides, everyone here at ELZA can prepare themselves and the environment to be as reassuring as possible for the child. That includes modulating our communication style as necessary; for example, for children who are very visual, we have 360º photos of the ELZA Institute, images of all our instruments, and videos of how they work. These are tremendously helpful for ensuring that the children – and their carers – understand as much as possible about the procedure, and why it’s important to ‘play along’ with us. When kids can see what the room looks like and what the procedure involves, they’re much less likely to be scared of it when they come to have the tests performed for real. Overall, we do whatever we can to de-stress the situation – for example, if white coats are a problem, we won’t wear them, and if professional titles and unfamiliar names might be an issue, we’ll just call the surgeons by their first names.
The Art of Persuasion
Getting children to co-operate is complicated – but you can increase your chances by application of a simple process. The Procedure to Increase Compliance (PINCO) acknowledges that every child is different and that each may respond optimally to somewhat different communication styles. Very often, information is best conveyed visually – for example, by pictures or videos. The PINCO system is designed to ensure that each child receives optimal eye care in an environment that matches their needs as close as possible, and includes the following key steps:
- The child’s carers complete a pre-consultation questionnaire
- From the questionnaire responses, we establish:
- factors that may trigger unwanted behavior
- methods that may enable positive enforcement of desired behavior
- This information permits:
- modification of the clinic environment per the child’s specific needs
- communication with the child using the most appropriate media: oral, written or visual (for example, PECS – picture exchange communications system)
- Consequently, the child always knows what will happen next – no surprises!
We all know how important it is to educate patients about their procedure; not least because things are more likely to go smoothly when the patient knows what tests will be done, what the operation will entail, and what they must do to support their recovery. When the patient is an adult who understands you, that’s fine. It’s not fine when the patient is an easily terrified child – and that’s where we all need to do better. The good news is that we only need to slightly tweak the skills we use every day with adult patients. Above all, we should remember that these children have a right to receive decent eye care – none should miss out; it’s up to us to meet this challenge in the best way we can. With PINCO, I believe we at ELZA are doing exactly that.
Professor of Ophthalmology at the University of Geneva, Switzerland; Research Group Leader at the CABMM of the University of Zurich, Switzerland; Chief Medical Officer of the ELZA Institute, Zurich, Switzerland; Adjunct Clinical Professor of Ophthalmology at the USC Roski Eye Institute, Los Angeles, USA; and Visiting Professor at the Wenzhou Medical University, Wenzhou, China