Re-Calibrating Pediatric Counseling for the Millennial Parent

Editor’s note: This text-based course is a transcript of the webinar, Re-Calibrating Pediatric Counseling for the Millennial Parent, presented by Elizabeth Haley, AuD, CCC-A and Emily Jo Venskytis, AuD, FAAA.

Learning Outcomes

After this course, learners will be able to:

• Utilize statistical data from peer-reviewed publications, define millennial parents, and highlight differences between this group and other generational groups.
• Demonstrate the most appropriate counseling strategies when working with millennial parents of a child/children with hearing loss.
• Implement new best practices (i.e., social media interactions, appropriate use of language, and follow-up methods) in your pediatric practice to better attract and retain millennial parents.

Introduction

Dr. Emily Venskytis: Today, we will take a look at millennials from a different point of view and examine the differences that occur in this generational group when they become parents. Pew Research Center defines millennials as someone between the ages of 23 and 38 or born from 1981 to 1996 (Dimock, 2019). They can also be called generation Y and are considered less racially diverse than generation Z. Generation Z is the generation after millennials or anyone born after 1996. Because millennials grew up with the introduction of technology and saw it develop as they did, they have a unique exposure that they utilize.

Millennials as Parents

Up to 90% of millennials are new parents. If you work with pediatric patients in any capacity, you'll be seeing more parents coming into your clinic from the millennial age group, in particular, patients ages birth to three. Although they might be new parents, they are older than what you would previously consider as a new parent. The average age of a millennial having children for the first time is 26. This is a big jump from the data in 1970 when the average age of a new parent was 21 years old. One of our articles speculates that this is because millennials are waiting until they feel ready to be parents, as compared to conforming to a standard of age (Steinmetz, 2015). Millennials also don't think being married to someone means that they might be ready to have children. 61% of new millennial parents are married, there's still a large group that are unmarried that might be coming into your clinic (Gutting & Fromm, 2013). Therefore they don't conform to the relational standards you may be accustomed to for that age group of your patients. 

I like this quote, "self-centered millennials become selfless parents." There is a shift in this perspective that you want to keep in mind when they become parents. As millennial mindsets shift when they become parents, Gutting & Fromm wondered who they went to for information. They had several surveys and on a variety of options (e.g., daycare provider, mother-in-law, grandparents, sister). They were asked to pick the top three people that they go to for advice in regards to parenting. If you look at Figure 1, over 70% of people said their mother is one of the top three people they went to for advice. Over 40% reported a good friend was in that top three. Around 40% said the pediatrician, and a much smaller percent was the father.

Figure 1. The majority (>50%) of millennials utilize family members for childcare (Gutting & Fromm, 2013).

Gutting & Fromm also asked if they were to pick just one person that they may go to for advice, and the substantial majority said their mother. They emphasized that millennial parents might go to different sources for information, and then make their own choices. Additionally, there is a higher occurrence of millennial parents utilizing family members for childcare. That might not necessarily be their mother or a grandparent, but someone in the family, whether it's themselves or another relative, is caring for their child. I think this is important to consider when we're thinking about differences in millennials. They have strong influences from people in other generations, and that might carry over into the generation that you are working with.

"Drone parents." You might have heard of the term "helicopter parents" that was used to describe the parents of millennial children. When you are thinking about a helicopter parent, they're focusing on their child's achievement, and they're learning and controlling their child's moves. The helicopter parent has a strong influence on what their child's doing. However, Steinmetz thinks that when millennials become parents, they make the shift to what he called "drone parents." A drone parent is following and responding to their child's actions, rather than controlling them and focusing on their achievement (Steinmetz, 2015). They're allowing the child to have power over choice and they include the child in the conversation. There is a shift and focus in health care for family-centered care, and this is even more important to millennials compared to other generations. You should continue to focus on this, and highlight it in millennial care because family-centered care is crucial to them. Even when the child is very young, they want to feel like their child is being considered.

Millennials and Healthcare

Latest Technology

We are going to look briefly into the baseline expectations that parents have when they see a healthcare provider. Millennials expect that you have the latest technology and experienced staff with inclusion in the care process. Millennials want to make sure that you are keeping up with evidence-based practice.

Building Trust

Millennials want you to build trust with them. You must show your knowledge and include them in the care process. We know that if you are working with pediatrics, it can help to have a continuation of care with a provider. You want to work from the beginning to build trust with the parent. Otherwise, they might show up on anyone's schedule and see a different provider. Inconsistent providers will not benefit the patient as follow-up may vary. 

"Child-friendly office." One way that you can build that trust is by focusing on having a child-friendly office. They want you to talk to their children using language that's at their level. For example, get down to the child at their level, don't forget parents want them to be included in the care process. If you do work with pediatrics, you often may see siblings accompany them during the appointment. If the parent is the primary caretaker, they might not have childcare. Or the parent might want the primary caretaker such as a grandparent to come to the appointment. In your office, create a safe, but calming area with activities for all of the children, not just the patient.

This would also be of benefit to you while you are testing the child because they might have someplace to play. The parents wouldn't have to worry about managing everything, and they can focus on what's going on in the visit. Additionally, you want to make sure the personality of everyone they interact with is friendly and trustworthy; this also includes thinking about your front office staff. If you work in a private practice that might see children and adults, it might be beneficial to talk to your front office staff about communicating appropriately with children and parents that come in.

Earning Millennial Loyalty

Other ways to earn millennial loyalty include proving value in your service by providing evidence-based practice or providing them with unique and easy-to-digest information. Next, we will discuss how the internet influences millennials. As a provider, you want to provide patients with information to supplement what is already readily available on the internet. Millennials strive to get information from several different sources. It is important to include both the parent and the child in the decision-making process.

Parent groups. Parents may want to be included as "agents for change in the organization." Perhaps offer a group for parents with children with hearing loss or have an advisory board for your clinic. If you have a foundation that raises money, allow parents to be on that board, or have volunteer opportunities for them. Even if the parents don't join it, they know that it's available, and that might help create loyalty for your practice.

Online presence. Another way to attract millennials to your office is by actively engaging in an online presence. Being online can mean that they can access appointments and medical records. If you work at a hospital, you likely have a way for parents to access their files, try to access it yourself, and see what it looks like. You want to make sure your reports are reader-friendly, and they are easy for them to access, specifically your audiology reports.

Social media. Additionally, something you can do is utilize social media. Social media presence of an organization is essential today. I will discuss how social media impacts the millennial parents, their experiences online and how that experience shapes their perspective when they come to see you. When millennials are first looking for a specialist, what they're going to do is first look on the internet. "I have concerns about my child's hearing, what should I do?" They might have already looked at a whole list of providers. Then they will go to their pediatrician and say, "I have concerns about my child's hearing, and I found this audiology clinic, can you confirm that this is where I should go?" Previously what someone might do is just go to their pediatrician and say, "I have a concern about the child's hearing, where should I go?" But millennials often do their research first.

Accurate information. Aside from using social media to increase your brand awareness, you can also use it to post accurate online information. We already know that parents are out there online trying to find information. If you have a webpage for your practice, you can post something that you've reviewed and know it is accurate. As the provider, you can help them fulfill their need for finding information by providing accurate content. This is helpful because 58% of parents found the information available online to be somewhat to extremely overwhelming (Steinmetz, 2015). 

Social Media and Internet Searches 

The internet is one place that people look to for information. Millennials are more likely to look to the internet first for advice. Even after you have established a relationship with the parent or patient, they will still go on the internet and look online at different articles. You want to be aware of what is on the internet and what they might see when they're going to look.

YouTube. YouTube is now falling under various categories since you can watch shows and movies on there. However, it is still a form of social media. In a survey of moms aged 18 to 54, 83% of those moms searched online for questions they had about parenthood. Of that 83%, three out of five watched videos instead of other search options (Standford, 2016). YouTube has a strong influence because it is all video-based content.

Facebook. The Pew Research Center estimates that roughly 2/3 of U.S. adults or 68% report that they're Facebook users, and about three-quarters of those use Facebook daily. These patients use social media to interact with their peers because they feel a need to receive more information than what the medical provider tells them. Again, millennials are data gatherers, they're finding information from different sources, and social media has a significant impact on that.

Social Media and Audiology

• The utilization of social media in the hearing aid community (Choudhury et al., 2017)
• Social media utilization in the cochlear implant community (Saxena et al., 2015)
• Tinnitus awareness and misinformation on social media (O’Brien et al., 2019)

These are three great articles that specifically looked at hearing aid, cochlear implant, and tinnitus patients, and focusing on social media and audiology. The hearing aid and cochlear implant studies are modeled after each other with a similar study design. In case you are not familiar with Twitter, Twitter is used for short blurbs of information that's posted in a feed. Facebook was designed to contain more content and intricacies, which includes pages and groups. According to Facebook, pages are designed to be the official profiles for entities such as celebrities, brands, or businesses. Facebook groups are the place for small group communication and for people to share their common interests and express their opinion.

Pages. If we're thinking about Twitter as a whole and Facebook Pages, these were designed for official profiles. These are the most commonly used medium by hearing aid and cochlear implant service providers. Manufacturers use Twitter and Facebook Pages. Dispensers and healthcare providers have a strong influence on Twitter and those different pages as well.

Groups. This is most commonly used by hearing aid and cochlear implant users. If a patient has a hearing aid, and they want to look for support on Facebook, they will join a hearing aid or hearing loss user group, rather than joining a page. Also, Facebook is used the most for brand discussions for cochlear implant manufacturers. If an adult is trying to decide which cochlear implant manufacturer they'd go with, they might have posted on a Facebook group.

Something I wanted to add is the presence of neighborhood-specific Facebook groups. On these groups, moms will post audiograms, stories, and recommendations that they received from a clinic, and ask for opinions or share advice. This has proven to be influential in our practice. That could partly be because we're the sole pediatric-only provider in the region. This is something you might consider when a parent is coming in. Parents are posting their child's audiograms or asking questions, and parents might come in with prior knowledge.

O’Brien and colleagues looked at misinformation on social media sites in regards to tinnitus. They defined misinformation on social media as something considered untrue, lacking peer-reviewed evidence, or uninvestigated at the time of the study (O'Brien, 2019). Facebook Pages were the ones that had the most sources of misinformation. We were typically thinking of Facebook Pages as related to being manufacturers or for practices. Facebook had a significant impact on misinformation on social media. Despite this, the authors of the article report that even though there's a lot of misinformation on social media, they would still encourage their patients to look on social media, as they might provide helpful information for their patients. 

Counseling Millennial Parents

Dr. Beth Haley: That information was excellent and will be echoed throughout our discussion of appropriate counseling for millennials. We know that our patient's parents have likely sought out information about our evaluations in advance. Many have done this through social media. Rather than trying to limit or block this practice, we need to understand that this provides benefit, not just for our patients, but for us. To truly understand it from a parent's perspective and give us a deeper meaning to what they're going through. 

As we know, it is not only within the scope of practice in audiology for us to infuse interactions with families with emotional support, but in fact, it is essentially a required part of the process. Now, I appreciate ASHA's usage of the word infused because, in busy clinics, we can't always set aside 10 minutes just for counseling. Our goal here is to integrate counseling seamlessly into our practice so that our patient's parents know that they're able to ask questions and feel comfortable reaching out about any information that might be causing them distress or confusion throughout the diagnostic and treatment process.

I'm going to describe overarching aspects of counseling, one being more informational counseling (i.e., how to read an audiogram, what educational options are available) — advocating, helping to provide information for families to make educated decisions about their child's hearing healthcare. Also, we need to think about supportive counseling. We know that there's a great deal of anxiety and stress for many parents at the diagnosis of a hearing loss. We have to help these parents develop both realistic expectations of how their child can benefit from things like hearing aids, or what to expect from their child in terms of educational goals and capabilities. We also have to enforce coping mechanisms with families that hopefully will lead to higher engagement of the whole family. These two aspects are highly integrated in medical practice, but certainly in audiology. I chose to present them as a Venn diagram in Figure 2; there's a lot of overlap here that we will see.

Figure 2. Informational and supportive counseling (Glade, Bowers & Baldwin, 2018).

Pediatric Audiologists Surveyed 

Fortunately, pediatric audiologists find that supportive counseling is important for managing expectations and perceptions of hearing loss. Interestingly, fewer audiologists felt that is was very or extremely important to talk about technical information from hearing aid components (Munoz, Price, Nelson & Twohig, 2019). I think that this is an interesting measure of our field's adaptation to millennial parents because we know that a lot of these parents are going to be less distressed by actually managing the technology that we're giving them. They may be more distressed by some of the emotional and social factors that come up concerning using hearing aids or going through this process in general.

Counseling Relationships

Having both this aspect of informational and supportive counseling is important, but the counseling relationship itself is what's central to any interaction that we have with a parent. We need to help parents develop their insight and knowledge. Not necessarily what we would like them to think or know, but to feel free to explore how they feel about these processes, developing their insights. Sometimes this leads to talking about specific problems, making specific decisions, or coping with crises. Other times it's a more general feeling of engagement and rapport with our patients. Fortunately, there's been quite a bit of research into counseling relationships. The more that we can increase our millennial parent self-knowledge, the more that they're able to grow, develop optimal personal resources, and ultimately have a greater emotional acceptance of hearing loss, or really whatever the case may be.

Counseling, not parenting. Most importantly, we need to avoid parenting millennial parents. Counseling is not necessarily about telling them how to feel or what to think, but it's giving them feedback about their thoughts and encouraging effective behavior, for example, adequate hearing aid use. This involves presenting information without judgment. Fortunately, Millennials do recognize that professionals have knowledge that cannot necessarily be learned in school or from the internet. The more we approach an interaction with parents in a very non-judgmental manner, the more that they'll be willing to tap into our expertise and something that we spent a lot of time and energy learning.

Domains of Education (Gowin, 1987)

Educational studies can provide us with great information about how to counsel millennial parents. I wanted to highlight these domains of education proposed by a researcher, Gowin, in 1987, but still very much prevalent in modern-day times.

Governance. This is not controlling or telling our patients or parents how to feel, but more in sort of setting the tone. We are creating a balance between what we want from our patients and their parents and  the level of support that they want. Sometimes this even can cross over in an educational setting to teachers and considerations of how teachers work with their students more effectively. I just want to highlight the point that audiologists are the narrator of this story. We're setting the tone that influences how the rest of the message will be received. To that effect, there's a different meaning or sense that we want parents to leave with when we're having an interaction with them. These tones can vary from appointment to appointment. But it's essential to keep in mind the tone that we are setting.

Curriculum. This is central to any educational plan. Sometimes this requires some innovation, utilizing the tools that Emily spoke about in terms of social media. We must remember that millennial parents are already relatively informed consumers of medical practicing counseling. While audiologists may need to communicate about their rationale for using specific tools, we need to hold to a high standard for our curriculum and content that we're providing.

Teaching. Teaching is very central to learning. In the context of counseling, we want to be using our available materials and understanding of our parent's personal experiences to create a shared meaning or social construction of information. We want to be on the same page about these concepts and meaning that we're kind of simultaneously making with parents. This can involve using reflexive dialogue and experiential activities to promote collaboration and mutual meaning-making.

Learning. Ultimately, we hope through the use of these three domains, that we engage our parents. For someone to learn, there's a certain sense of responsibility and ownership of the process and the knowledge, and we want our parents to feel that they can then advocate for themselves, as opposed to merely regurgitating information that we have provided them with. This can be helpful when we're repeating the process over and over.

One way to practice these skills is to use reverse mentoring, so having the parent show you a skill versus you demonstrating a skill for them. This has been shown to encourage cross-generational relationships.

Perceived Barriers to Counseling

There are a lot of boundaries and barriers to counseling. We need to assess how the parent is feeling at a specific time, knowing how to connect with families. I think one of the biggest barriers can be finding the time to address emotional needs specifically.

Tips for Facilitating Counseling (Roberts, Newman & Schwartzstein, 2002)

Researchers talked about different tips for facilitating counseling, and I won't go in-depth about all of these tips. I do suggest that you review these and educate yourself not only about the generational differences but how you can call out and identify your philosophy. In the future, whoever you are working with at any given time understands where you are coming from. This will ultimately serve to encourage collaboration between yourself and these parents.

Millennials appreciate the value of not just what is presented, but how it's presented. Think about using additional technologies in your clinic (i.e., iPads) as an engaging tool in guided education. Hopefully, this will lead to just encouraging curiosity and exploration from our parents.

What Matters to Millennials?

These are some things that will likely come up in our interactions as we counsel. While millennials may not be as willing to sacrifice personal time for their career, in the context of our interactions with them, they're going to be very focused on the importance of family life. How do they find creative ways to work with their children and their child's hearing loss? For us, this is nothing but a strength. We're able to use these characteristics to our benefit and our patient's benefit ultimately.

Figure 3. What matters to Millennials (Newman, 2014; Ristow, 2015).

Impressions of Disability

Millennials are also considered to be on the front lines of social progress and acceptance. These are some overarching themes and ways that we can develop not only our patient's and our parent's understanding of disability. Also, take their own implicit emotions about disability, things that may often be based on minimal information, and expand on that so that we can recalibrate the impression that they make of individuals with a disability. We're in a very fortunate perspective because we know that millennials are very open-minded to people that are different and to diversity.

Figure 4. Millennial impressions of disability (Kinley, Strübel &  Amlani, 2019).

Hearing aid effect. Essentially what we're finding is that this stigma, judgment, or perception that some generations in the past have placed on individuals who wear hearing aids is slowly falling away. The stigma associated with hearing aids has reduced over the past several decades. This is in part due to the discreet nature of some modern hearing aids, but also the changing views about visible devices. Millennials are not as bothered by these devices. 

Case Study A

Dr. Emily Venskytis: That was a wonderful look at different counseling strategies that you can use. I'll be touching on some of those as we go on to these first two case studies. My first case study came to me when he was about five years old, scheduled as a hearing aid evaluation. He had been monitored through our ENT clinic for some time and was coming in to discuss hearing aids. He came to the appointment with his mother who is was part of the millennial generation. She came in and the first thing she said to me was my child and I have been talking, and he decided that he would like to try a hearing aid for his hearing loss. That really struck me because she wanted this to be his decision, he was the reason that we were here today. As we discussed earlier, where the parents want them to feel involved in the conversation, and they clearly had thought a lot about this before they came in to see me. They wouldn't have come in to get this hearing aid if their child wasn't on board, and his opinion was important.

You can see in Figure 5 he has a conductive hearing loss on his left ear. He has a history of fusion of his malleoincudal joint and ossification of his ligaments. He also has abnormal soft tissue. He did have ossicular chain reconstruction in 2016; however, that minimally improved his hearing loss. Our ENT believes that part of the reason for this is because he does have a stenotic ear canal and small space on that side. They are planning on performing more revision surgery. However, they wanted to wait a few years before they would try this again. I think that also makes it a little bit more unique into why there were talking with the family. The hearing aid might be considered a more temporary solution because our ENT is pretty optimistic that the hearing will improve. We wanted to do something in the meantime, even though this patient was in a small Kindergarten classroom in a private school, they were noticing that he was becoming frustrated in loud or noisy places. He plays soccer and baseball and was having a hard time hearing his teachers. We decided to fit him with a ReSound Up Smart hearing aid because we were able to get a mini mic with it. He could use that for soccer and baseball and hear his coaches better.

Figure 5. Audiogram for case study A.

Case Study B 

This young patient had a bilateral grade II microtia and atresia, and mucous cleft palate. He's working with genetics right now; it can take a while in Pennsylvania for genetics approval from insurance. We don't quite have a genetic diagnosis for him yet, but they are expecting one. Figure 6 shows a natural sleep ABR, so that's why there's some limited information obtained. We did not fit him with bilateral BAHAs until eight months of age because he was lost to follow-up for some time. At nine months, during his one-month follow-up appointment, we obtained an audiogram show in Figure 7. 

Figure 6. Audiogram for case study B.



Figure 7. Follow-up audiogram for case study B.

You can see in Figure 7 that the bilateral BAHA significantly improved his aided performance. He was accompanied to the follow-up appointment by his mom and grandma. His mom is of the millennial age group. She reported good use of the BAHA. His mother works full time, and grandma is his primary caretaker. From the beginning, they were both on board with the BAHA. The mother is from that generation where needing these devices is not a stigma. They are supportive and not concerned with looks, they want to be able to help their child hear better, and are open to this technology. However, grandma is the primary caretaker, and she seemed more hesitant about his BAHA.

Seeing the post-fitting audiogram eased their worries. When I was counseling about daily use with the family, the mother reported he wears it all the time. However, data logging showed only two hours of use per day. I decided to bring it up with the mom and grandma gently. I said, "I'm getting this information that says that our patient here is wearing it only two hours per day. Maybe I can help you, are you having some trouble? Is the battery dying earlier than you'd expect? Are you not putting the batteries in the correct way? Is there something that might be going on that's having a barrier to your use? Because this patient does have a significant binaural hearing loss." As soon as I brought that up, mom was surprised and upset. She looked to grandma and asked, "what's going on here? I thought he was wearing it." This opened up a difficult but necessary conversation that we had with grandma. I think this is an excellent example of the multigenerational influence, but also the importance of learning the different care providers.

Future Directions

As we are thinking about millennials as parents, we would like to see how millennial parenting is shaping our pediatric patients. We know that the generation of parents is changing. Therefore the children that are coming in might be shifting as well. Other things that we would like you to do is consider new counseling strategies that are consistent with millennial attitudes and beliefs. Additionally, we would like to see more qualitative and quantitative research into additional methods for improving these parent and practitioner relationships.

Summary of Millennials

Dr. Beth Haley: We want to consider millennials defined by their own unique characteristics and beliefs. They are distinctly different from other generations. We need to appreciate and face that head-on. We know that millennials will seek out information via social media. We know that they prioritize interpersonal and familial relationships. They also use a lot of individualism and creativity when parenting. Many millennials face different challenges than other generations. Again, facing that head-on really is the best way to address these differences and challenges. Millennials respond to guided and cooperative counseling. They're compassionate, open-minded, and can appreciate the diversity that comes along with our patients. I liked the distinction that Emily made and the difficulty she expressed in working with this family, where grandma is approaching the scenario one way, and mom is approaching the scenario another way. Always remind yourself that welcoming that discomfort and thinking about why we're uncomfortable in a given situation, and what we can do to just promote better care, is never going to be a bad thing. It's always a great learning experience.

References

Choudhury, M., Dinger, Z., & Fichera, E. (2017). The utilization of social media in the hearing aid community. American Journal of Audiology, 26(1), 1-9.

Dimock, M. (2019). Defining generations: Where Millennials end and Generation Z begins. Pew Research Center, 17.

Fromm, J., & Read, A. (2018). Marketing to Gen Z: The Rules for Reaching This Vast--and Very Different--Generation of Influencers. Amacom.

Glade, R., Bowers, L., & Baldwin, C. (2018). Incorporating Informational Counseling in Treatment for Individuals With Hearing Loss and Their Families. Perspectives of the ASHA Special Interest Groups, 3(9), 13-26.

Gowin, D. (1987). Changing demeaning of experience. Empowering teaching and students through Vee Diagrams and Principles of Educating to reduce Misconceptions in Science and Math. Educational Strategies in Science and Mathematics.

Kinley, T., Strübel, J., & Amlani, A. (2019). Impression Formation of Male and Female Millennial Students Wearing Eye Glasses or Hearing Aids. Journal of Nonverbal Behavior, 1-23.

Koltz, R. L., Smith, A., Tarabochia, D. S., & Wathen, C. C. (2017). A pedagogical framework for counselor educators working with millennial students. The Journal of Counselor Preparation and Supervision, 9(1), 6.

Munoz, K., Price, T., Nelson, L., & Twohig, M. (2019). Counseling in pediatric audiology: Audiologists’ perceptions, confidence, and training. Journal of the American Academy of Audiology, 30(1), 66-77.

O'brien, C., Deshpande, A. K., & Deshpande, S. (2019). Tinnitus Awareness and Misinformation on Social Media. The Hearing Journal, 72(1), 18-20.

Roberts, D. H., Newman, L. R., & Schwartzstein, R. M. (2012). Twelve tips for facilitating Millennials’ learning. Medical teacher, 34(4), 274-278.

Saxena, R. C., Lehmann, A. E., Hight, A., Darrow, K., Remenschneider, A., Kozin, E. D., & Lee, D. J. (2015). Social media utilization in the cochlear implant community. Journal of the American Academy of Audiology, 26(2), 197-204.

Steinmetz, K. (2015). Help! My parents are millennials. Time, 186(17), 3843.