Parental non-compliance - a paediatric dilemma. A medical and psychodynamic perspective

Considerable resources have been directed towards the recognition and manag ement of child physical and sexual abuse and/or neglect. However, the issue of parental non-compliance is less well defined and under recognized. Whil e outwardly seeking advice, non-compliant parents, especially if anxious, a re unable or unwilling to comply with the recommendations made. Conflicts o f interest between the parent(s)' and the health professionals' perceptions regarding the best interest of the child may arise. Parental non-compliance is centred around the parents' perception of the ch ild's current problems and its relationship to past problems. Such noncompl iance may reflect ignorance or misunderstanding of the clinical situation. Ignorance may be readily addressed if the parents are receptive and trustin g. However, non-compliance more commonly arises from the parents' inability to cope emotionally with the stresses surrounding the recommended treatmen t. Parents may be vulnerable to psychological reactions which inhibit ratio nal thinking. Parental anxieties are best understood in terms of psychologi cal constructs, including 'defences' such as 'denial' and 'splitting': 'rep etition compulsion' and the need to 'work through' psychological barriers s o that the child's best interest is served. Parental non-compliance can ser ve to protect the parents from overwhelming fears and anxieties, which if a ddressed may transform parental defensiveness to co-operation. Extreme pare ntal non-compliance may represent a special form of child abuse where, due to parental psychopathology, parents are unable to consider the child's bes t interest. Clinical vignettes arising from a consultant private and hospital ambulator y setting will focus on management strategies for successful outcomes. Reco mmendations offered on ways to reduce the risk of parental nan-compliance i nclude building trust, eliciting the aid of a parental partner, and organiz ing a second opinion, thereby improving the chances of a successful outcome .