In CHS’s Bright Start nurse-family visitation program, one of the hardest tasks when supporting clients can be letting them “drive the bus”—even when the bus is headed in the wrong direction.

Bright Start’s Betty Peterson, RN, experienced this recently. She began working with a family when their son Jackson, was several months old. “My client and her husband both worked full time, opposite shifts so that they would not have to take their son to outside daycare,” she says. The father also attended school.

Due to their busy schedule, the family wanted to meet monthly, rather than every two weeks, which is more typical.

Falling Behind

“As I did the Ages and Stages Assessments on Jackson, I began noticing he was falling behind in the areas of communication and fine motor,” Betty says. “I discussed this with my client and offered her activities she could do with her son to help him in these areas.”

But when Betty would follow up at the next meeting, the client would say that she didn’t have time to work with her son on the activities and that she was tired from her job. 

Delays become more apparent as a child becomes older and doesn’t meet milestones. When Jackson reached 24 months, Betty’s assessment indicated that Jackson should be referred for screenings and therapy.

“My client refused, stating that her son would get there in his own time and that she felt he was fine,” says Betty. Motivational interviewing, such as asking the client if she wanted to make sure her son was ready for kindergarten, wasn’t working either.

Walking a Fine Line

This put Betty in a difficult position. “I could have sent a referral,” she says. “They would have contacted mom. But if she’s not on the same page as us, she’s not going to agree to having an evaluation. And she might feel it’s an intrusion and she might cut ties with me.”

“It is a fine line when you have a situation like that,” Betty says. 

Betty let it go but encouraged her client to bring Jackson to his 24-month check-up with his doctor. “I knew the doctor would see this and then I would have some support.”

Unfortunately for the client, the physician was very blunt. “The doctor was the one who brought up the autism word and wanted her to go to Birth to Three and Lifescape. And that’s when she really fell apart,” says Betty.

“My client called me immediately and was crying, upset by what the doctor had said,” Betty explains. “I was able to calm her down and help her process what was happening with her son by validating her feelings, addressing her fears, and confirming the doctor’s assessment with my assessment without labeling it with a diagnosis of autism.”

“Through motivational interviewing I offered my client another way of looking at the situation and helped her accept the referral screenings the doctor wanted and the referral I wanted to make to the Birth to Three program. Because of my experience, I was able to talk my client through the process and what to expect from the referrals made. She was calm and hopeful at the end of our conversation.”

Next Steps

After the wake-up call with the physician, Jackson’s mom quit her job and began to focus her attention on her son.

“After the screening with occupational therapy, my client called and excitedly told me the screener said her son was a fast learner and that he caught on quickly,” Betty says.

The last time we talked, she said she said she still couldn’t think of him as autistic but she was open to reading information I was going to send her about signs that a child might have autism. It’s a big spectrum,” says Betty.

“I know they started therapy at Lifescape for speech and occupational therapy. He’s been going there for probably three months. They also dove in and got all of these educational things and turned their kitchen into a space where they can work with him. So I know they’re doing everything they can,” she says. Betty doesn’t know if Jackson has actually been diagnosed as autistic or not.

The client told Betty that Jackson likes occupational therapy the best. Speech therapy is more difficult and not as fun. Betty is waiting to hear from the therapists who are working with him on what the evaluations have indicated, what they’re working on and whether he’s made progress. 

“It’s important to have sharing between the nurse, the client and the therapist, for instance,” Betty says. “For example, the mom might not be comfortable sharing something with the therapist, while I could ask if there’s a way to make speech therapy more fun.” Working together is another key to getting the best results possible for the child.

Walking Alongside the Client

Betty prioritized the relationship with her client, because maintaining the connection to the family was ultimately the most important goal.

“As a nurse-home visitor, it was difficult to accept my client’s initial decision to refuse my help and referral,” Betty says. “But my role is to support my client and let her ‘drive the bus.’”

“You can’t push and yet you want to walk beside them,” she says. In Jackson’s case, Betty was fairly sure his developmental delays would be spotted by the physician.

“I am thankful for the outcome with this client in terms of her coming back to me for support, guidance, comfort and hope, and for her commitment as a parent to helping her son,” Betty says. “As I continue to provide encouragement, support and a listening ear, I am hopeful her son will improve or at the very least will get the help he needs at an early age because of our program.

“There are few things in life more rewarding than knowing you have made a difference in the life of a child and family,” she says.