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Communicating bad news in pediatric practice and its impact on child behavior

Hesham, Mohameda; Mansour, Manalb; ElWan, Amanya

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Medical Research Journal: June 2011 - Volume 10 - Issue 1 - p 5-8
doi: 10.1097/
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Breaking bad news is a difficult task frequently performed by doctors in most specialties. The needs of children and the difficulties that healthcare professionals face when breaking bad news, as well as the effects of training sessions on communicating skills have been the areas of interest for research during the last decade [1]. Key communication skills considered to be important in the context of breaking bad news have been identified and there is increasing evidence that skills necessary to break bad news in a patient-centric manner can be acquired from courses using experiential teaching methods. In addition, data from clinical studies indicate that good communication skills can contribute significantly to the health and satisfaction of both patients and healthcare professionals [2]. Recommended communication behaviors for physician to proceed intervention are to find a private setting for discussion and decision making, to use language the family can understand, to use visual aid if possible, to pace the information by providing it in logical sequences, to recognize emotional distress, to discuss indications, risks, benefits, and all reasonable alternatives, to personalize the information rather than giving it as a speech, to avoid last-minute surprises when feasible, and to ask parents and children to repeat what they understood in their own words [3]. Communication with patients is generally acknowledged as an essential part of patient care. In pediatrics, healthcare doctors' communication tends to be directed more toward the parents than toward the child; in addition, the first studies on doctor–patient communication focused exclusively on the communication between pediatricians and parents. Thus, the nature of communication with children remains unclear. In fact, a lot of medical recommendations have to be performed by the parents. However, a lot of school children are quite capable of providing relevant information and feedback about their complaints and seem to be able to understand a lot of medical information. Furthermore, taking children's view into consideration seems to contribute to the effectiveness of the therapeutic relationship in terms of satisfaction and compliance [3]. Chronic illness increased the stress on the child's parent. Children with chronic condition have twice the risk of developing mental health disorders than in healthy children, and three times the risk if they have an accompanying disability. Warning signs of distress in children include problems at school or in social relationship and low self-esteem [4]. The most common psychological problems associated with chronic diseases are internalizing problems such as anxiety, depression, fear, loss of control, and frustration. In addition, externalizing problems are also reported, such as aggression, noncompliance, and substance abuse [5]. Behavioral disorders in epilepsy may precede, occur with, or follow a diagnosis of epilepsy and differ between children and adults. Specific childhood comorbidities include attention-deficit hyperactivity disorder, autism, and developmental disabilities. Some comorbidities such as depression and anxiety are present both in children and adults with epilepsy [5]. The most common psychological problems with diabetes are depression and low mood, aggression especially when blood glucose increases, fear of dying, altered body image, altered role in family, and alteration of relationship [6].


This study was conducted at the Cairo University Children's Hospital's Diabetes and Neurology Clinics after gaining written consent from parent. One hundred mothers and their children and 50 junior physicians participated in this study. Pediatric symptom checklist was conducted in children. Two questionnaires in Arabic (one for mothers and the other for physicians) were completed. The development of parents' questionnaire was based on review of studies with regard to informing the diagnosis of chronic diseases [7]. The questionnaire was modified by adding some questions related to evidence-based recommendation of breaking bad news, which was found in the doctors' questionnaire [7]. Personality assessment sheet pediatric symptom checklist contains items in which the children had to respond by themselves through three alternatives, that is, rarely, sometimes, and often.

Educational evaluation was carried out using mother's and father's education with score 1, 2, 3, and 4 denoting illiterate, primary school, high school, and university education.

Statistical analyses

Univariate statistical analysis using the χ2 test and Pearson's correlation was used to assess the strength of relation. All statistical calculations were done using computer programs Microsoft Excel 2003 and SPSS version 15 (Chicago, Illinois, USA) for microsoft windows.


Table 1 shows the education of mothers. Twenty percent had a university degree, whereas 34% had high school education, 24% attended primary school, and 22% were illiterate.

Table 1:
Shows sample characteristics

Table 2 shows the item content of parent questionnaire. Sixty percent of mothers stated that the physician's explanation included medical terms that they were unable to understand, whereas 40% of mothers stated that they had been encouraged to pose questions.

Table 2:
Shows the items content of parent questionnaire

Table 3 shows the threatening thoughts of the parents described in counseling. Forty-four percent of parents were stressed about the future, 15% were unable to think, and 14% thought that the child will suffer pain.

Table 3:
Shows the threatening thought of parents described in counseling

Table 4 shows physician questionnaires in which 50% of physicians did not know that their hospital had guidelines for breaking bad news.

Table 4:
Shows the association between the length of discussion and the ability of the parents' to answer and ask questions and follow physicians' explanation

Table 5 shows the association between fear sensation of the mother and the child behavior.

Table 5:
Shows the association between fear sensation of the mother and the child behavior

Table 6 shows the items content of physician questionnaire

Table 6:
Shows the items content of physician questionnaire


Breaking bad news is an important and difficult skill. The way in which bad news is broken can have a significant impact on the recipient's long-term psychological adjustment and compliance with medical management [7]. Consensus guidelines have been drawn up to aid this process. Parental dissatisfaction with the process of breaking bad news is common. Use of a protocol for breaking bad news can substantially improve the experience [8]. In this study, an attempt was madeto link the bad news event with later psychological distress in parents and children, although parents were observed to retain vivid memories of the interview and were sometimes still distressed with it many years later [9]. Two Arabic language questionnaires were developed, one for the parent and the other for junior doctors. A necessary modification was performed to match our social and cultural background. This study investigates the mother's experiences when hearing the diagnosis of chronic disease by using a written questionnaire. The study also analyzed the emotional function of children with chronic disease. The purpose of the questionnaire was to find out parents' views of counseling. Seventy-one percent of parents in this study reported that the informing professionals spent little time in conveying the diagnosis during first interview. This was found in another study, which reported that 64% of parents believed that informing took little time [10]. In this study, most physicians communicate the diagnosis orally without any written illustration; this in contrast with other studies in which providing parents written illustrations about their child's condition was better for understanding [11]. Eighty-six percent of parents in this study lacked prediagnostic knowledge of the disease at the first counseling, Parents' estimated of understanding about (25–50%) of information about the disease and reflect reasonable comprehension. After discussion with pediatrician whether the disease is curable or not. A considerable proportion of parents (46%) had difficulty in comprehending medical terms and only 40% reported that they were able to follow physician instructions. This result was similar to another study of studying parents' recollection at initial setting [12]. On asking parents to report their feeling during the informing interview, they reported fear 87%, crying 31%, relief 3%, guilt 3%, despair 3%, and resignation 3%; these emotions are also described in another study [12]. We found that 25% of children had internalizing behavior, 1% had externalizing behavior, and 1% had inattention behavior. These psychological problems are related to chronic illness, stress, and burden on family. This is in accordance with another study in which children with chronic disease had high depression and anxiety symptoms. Chronic disease causes a permanent effect on cognition and emotional development of children [13]. Significant correlation was found between mother's fear during counseling and child's behavior (P=0.04) and this was also found in a similar study in which the emotional state of mothers had a direct effect on child's behavior, as a child learns more from their mother's reaction and behavior than their words [14,15]. In this study, junior physicians had received recent training in breaking bad news (42%). There is growing interest to improve doctor–parents relationship and medical care in children with chronic disease.


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child behavior; communicating bad news; pediatric symptoms chick list

© 2011 Medical Research Journal