Autism Help Phils: Concerns About A Child

Concerns About a Child

Making Observations

If you have ever had concerns about your child’s development, you are not alone. Whether you’re worried about your child’s use of language, ability to relate to others, or any other developmental concerns, your child relies on you to share your observations with those who can help. Having occasional concerns is a natural part of parenting. But when these concerns persist, it’s time to take action.

Here, we offer parents and professionals important information about healthy development, how to monitor it, and how to know when a child has deviated from a healthy developmental path. We focus on the key social, emotional, and communication milestones and the red flags that may require an immediate evaluation. We try to help work through the range of concerns and realities that many parents face, and provide suggestions as to how parents, concerned friends, family members, and even healthcare professionals can describe their concerns to those who can help. Finally, we provide information about autism and other developmental disorders.

Being aware of what children do and learn as they develop sets the stage to let you know if they are on the right path. Physicians are essential to help determine this. By monitoring healthy (or typical) developmental milestones, parents and professionals must work together to promote healthy development and to recognize when a child needs an immediate evaluation.

Visit our developmental checklist on our Monitoring Development Web page to learn more about the key social, emotional, and communication milestones for young children (birth to age three). Also visit our Red Flags Web page, which describes the critical warning signs for when a child is at risk for developmental delays and disorders.

Parents are in the best position to observe and report what their child is doing. Be confident that you know your child better than anyone else. Trust your instincts. When you child’s development worries you, don’t be afraid to describe these concerns to your child’s physician. And don’t wait. Developmental delays only develop further. Remember, you are your child’s best advocate. By expressing your concerns to your child’s physician, you take an important step toward ruling out or in what your child may have. The sooner you can identify a developmental delay, the sooner your child can receive appropriate intervention to improve the situation.

Of course, some concerns may end up being nothing at all, even though you worried through many sleepless nights. Some concerns may be mild early signs of real problems that can easily be corrected if treated right way. Still other concerns may indeed be a more significant developmental delay or disorder for which early and intensive intervention is the key to a successful outcome.

Sharing Concerns Parent to Physician

Parents often have a difficult time sharing concerns about their child. The following outlines four crucial steps to follow with your child’s physician, and highlights the importance of a patient but persistent approach.

Be prepared
Express your concerns clearly
Ask questions
Follow up

Each well visit provides an opportunity for your child to receive a routine developmental screening; however, if you don’t ask, it may not be offered. Whether or not you have specific concerns about your child’s development, it is best to come to the doctor’s office prepared. Physicians rely on parents to provide information about their child. As a parent, you are your child’s best advocate and a “resident expert” about your child’s health and development. During a well visit, a physician usually sees a child for less than 15 minutes, even less if there has been an emergency that day. It is a challenge, for both the parent and the physician, to cover the wide range of issues related to a child’s health within a limited time.

If you have concerns about your child’s development, take the following four crucial steps: be prepared, express your concerns clearly, ask questions, and follow up.

1. Be prepared. Before you go to your next well visit, print out the checklist of developmental milestones and note whether your child has met each of the expected milestones. If you have questions or concerns, write down a few concrete examples that might assist your physician:

“My child doesn’t respond to my voice.”
“He spends so much time lining up his toys, he has no interest in other children.”
“She hasn’t learned a new word in months.”
“He doesn’t look at me—he never makes eye contact.”

Whether or not you have concerns, ask your doctor for a routine screening.

2. Express your concerns clearly. While this issue can be an emotional one, try to focus on your concrete concerns, such as developmental milestones. If your physician doesn’t want to perform a screening, or isn’t responsive to your concerns, be persistent. Ask why. And remember, “don’t worry” or “let’s wait and see” are not adequate responses. Schedule a follow up appointment, if necessary, or ask for a referral to a developmental pediatrician. Your child’s healthy development is your most important concern.

3. Ask questions. If there are terms you don’t understand, ask your physician to explain. After the screening, ask what the results show, and what they mean. Inquire about referrals to specialists. Ask what the next step will be.

4. Follow up. For most parents, routine screenings indicate that a child is following a typical development pattern. Screenings at well visits in the future will help to confirm that. For other parents, who learn from the screening that their child may be at risk of a developmental delay, follow up is crucial. Children at risk of atypical development are routinely referred to Early Intervention for a closer look by a developmental specialist. You also may want a referral to a developmental pediatrician, a psychologist, a neurologist, a psychiatrist, or a specialist for further evaluation.

Through all four steps, some parents may stumble or falter. Grief and disbelief can prove to be great hurdles. Parents may fear the worst and not move forward. Other parents may feel uncomfortable questioning their physicians. Proceed with confidence, as parents know their child best. Only by pursuing your questions and concerns, forming a sharing relationship with your child’s physician and then by following up with him/her, can you ensure the best possible outcome for your child. Be patient with yourself and persistent for your child. Get the help your child needs.

“Pediatricians are the only professionals with knowledge of development who are in routine contact with the families of young children. Parents turn to their pediatrician for information about development, for assessment of whether their children are doing all right or not. If pediatricians don’t know or aren’t sure or don’t have the appropriate tools, the children with delays or disorders are missed.

Sharing Concerns Physician to Parent

Physicians may also find it challenging to identify children at risk for developmental delays and disorders and difficult to express their concerns about a child's development with parents or caregivers. No doubt about it, these are critical life-changing discussions that require time, sensitivity, honesty, planning, and follow-through on your part. Here are some suggestions as to how you can handle this process successfully with your patients.

Listen to parents

In recent years, parents of young children have become increasingly aware of the need to monitor traditional developmental milestones at each well visit prior to age three, due in large part to the popularity of the What to Expectseries, the Touchpointsbooks, and other baby books currently available. Parents expect to have a dialogue with their child’s physician about development, though even these highly regarded books do not cover social, emotional, and communication milestones well enough. Nor do they address behavioral problems.

A recent national survey of parents with young children indicated that they want more information and support on childrearing and developmental concerns, yet pediatric clinicians often fail to discuss non-medical concerns with them .Moreover, detection rates in primary care show that 70% of developmental disorders and 80% of mental health problems are not caught.These discussions could yield developmental concerns early, since parent report has been shown to be highly accurate and indicative of a true concern

Because parents are with their children around the clock, they are well positioned to be valid reporters about their child’s development. This, combined with routine observations and comparisons of other children is very powerful. This cuts across all populations: income, education, social level, culture, etc. A physician can make great use of these observations at a well child visit where the average time for a professional to observe a child is only 15 minutes on average. Thus, a collaborative parent/physician relationship is critical to the continued healthy development of a young child.

When you have concerns about a child, remember, this is a family you anticipate having a professional relationship with for the next 18 years. It's important to develop the ability to say, 'Okay, this is a problem you're experiencing, I'm going to take it seriously. I may not agree with you that it's developmental; I may think this is more of an emotional or family problem, but you're telling me it's a problem, and I'm going to do something about it.”

Understand that early identification and intervention are essential

Early intervention’s positive outcome has been well-documented in the literature and goes far beyond IQ. In the short term, it improves the quality of life and functioning for the child and for the family. In the long term, early intervention’s impact extends into such key developmental areas as prevention of secondary emotional/behavioral issues, reduction in teen pregnancy, increase in high school graduates, increase in employment, and reduction in the crime rate.

Pediatric clinicians are in a unique and central position to identify developmental concerns early and refer children at risk on for further evaluation and treatment. Parents depend on pediatric clinicians for advice, guidance, and support. They need healthcare professionals who can speak the language of development with them and work with them to keep their child on a healthy developmental path.

"I would advocate a preliminary developmental screening for all children. And if a parent comes in and has concern about a child, there should be an immediate discussion about it. If the pediatrician doesn't have time, it would be well for him to either have a person to whom he refers the family or for one of his staff to be able to sit down with the family for 15 minutes and make them feel heard. The risks of not doing that are enormous in that the first few years of life are the period of the greatest neuroplasticity and the greatest rate of change in brain development. This is a critical period. If we miss this critical period, we could miss the boat on helping a child to develop to his or her fullest potential.

Consider the prevalence of developmental delays and disabilities

Prevalence studies indicate that autism spectrum disorders are dramatically on the rise with the CDC citing 1 in every 166 children on the autism spectrum and developmental disorders representing 17% of young children.

Thus, every pediatric professional can expect to see at least one patient in his/her practice (if not more) that lives with these concerns. This makes it essential for medical practitioners and clinicians to understand the key social, emotional, and communication milestones and to have a firm grasp of red flags.

"The findings now from very large prevalence studies show that 16 to 18% of children have developmental problems. That's one in every five patients or so, especially if you include the more serious mental health problems. One out of every five patients that you run into will be experiencing a developmental problem...it's a huge concern. It's probably the biggest single issue that you encounter in pediatrics and, yet, it is just a fraction of pediatric training”

Heighten your “index of suspicion

Simply by making developmental surveillance a regular part of every office visit, you can sharpen your observations, elicit better information from parents, and heighten your index of suspicion.

Suspicions are eliminated or confirmed through the screening process first by using a broad-based developmental tool and then, if concerns persist, by narrowing the focus through a level-two tool (e.g., autism or Asperger screen). Pediatric physicians’ observations enhance and strengthen the accuracy of screening tool measures. Physicians can use the developmental surveillance and screening processes to increase the chance of detection during very early development and provide a clear compass for referral and treatment if a concern is flagged. By listening closely to parent report during the surveillance process, physicians may be prompted to start the developmental screening process at any time a concern arises as a result.

"Physicians need to have an index of suspicion. And they need to listen to parents. Even when I was a resident back in the dark ages...there was this whole idea about being an overanxious mother. I don't think I've ever seen a mother that I thought was overanxious. You're usually anxious for a reason and if there is a reason, you need to know what that reason is. So if they've got a busy schedule, it would be appropriate when Mrs. Jones comes in to say, 'Mrs. Jones, I really don't have time today, but let's make an appointment, I'll stay late on Thursday, why don't you drop by and let me hear more about that problem.' The parent needs to be validated, and you, the physician, need to hear the story in more detail. Without that, I don't think you have a clue, frankly”

Make each well-visit an opportunity for screening and surveillance

In response to the increasing number of young children affected by these disorders, leading medical organizations have issued policy statements that provide specific guidelines toward the routine screening and surveillance of developmental delays and disorders, including autism. By making routine screening a regular part of pediatric practice, physicians can channel parent concerns efficiently, reduce over or under referrals, and accurately validate reported concerns and observations.

"Ask the parent how little Johnny or Susie lets them know what they want and listen carefully for the explanation. If at 12 or 14 months little Johnny or Susie simply cries or wants the parent to guess what he or she wants, but can't use purposeful signaling, such as taking them by the hand or pointing to indicate wants or desires, that's a warning sign. Also, observe yourself. Try to observe a few minutes of free play. You don't have to make a diagnosis, you just want to be alert”

Create a screening training and implementation plan

To make screening and referral a routine part of pediatric practice, it will require planning, training, and implementation. First, if you have someone on staff who is already a champion for children with special needs, get that professional involved in creating an atmosphere of enthusiasm and excitement as an advocate of positive change. Train all staff members, including front office staff. Not getting all suitable staff on board can make or break a program. Host a meeting with local service providers and office staff to build relationships and establish collaborations. Plan and implement a smooth office process for storing, disseminating, tabulating, and replenishing screening questionnaires and referral notes. Arrange to have trained staff available who can interview or interpret questionnaires for those parents who cannot fill out the forms without support. Stock exam rooms and the front office with patient education materials related to these disorders for easy access. Keep contact information on hand for quick referrals to local service providers and diagnostic services.

Lastly, look at how other model pediatric programs are meeting this challenge. One excellent example is the Health Steps program, an approach that designates a trained staff member to be a developmental “Healthy Steps” specialist who regularly addresses issues around child development and behavior. To be sure, innovation can lead to a successful implementation of a screening and referral program. But plain old-fashioned planning and execution can be all that is necessary to get started.

Deliver difficult news to parents with sensitivity and understanding

We have provided links to many excellent journal articles that discuss how to deliver difficult news to parents in our Reference section below. In addition to these sources, we have provided our own advice for how to approach the difficult conversation of delivering bad news. It is important to remember that positive outcomes of these discussions between a physician and parent will set the tone for how the parent views their child in the future, how satisfied they are with the physician/patient relationship and how positively they view their roles as parents in the years to come.

1. Set the stage for a successful conversation.

Often, these difficult conversations take place in the physician’s office immediately following a screening. However, if your schedule does not allow adequate time to hold this conversation, schedule a follow-up visit as quickly as you can. Choosing the right time and place for a conversation to share your concerns is very important. And allowing sufficient time with no interruptions is critical. Understand that emotions may be unpredictable. Be ready to listen and offer help through the referral process.

2. Start with parent observations, questions, or concerns.

It’s important to assess where a parent stands in relation to understanding his/her child’s development before sharing your own professional concerns. The parent may already sense a problem and just not have the words to articulate it. Gently probe and ask questions that will allow a parent to share their own observations, questions, or concerns first. Then share your own observations and screening results in a very neutral manner. By doing so, you will open an exchange and may even validate a parent’s hidden concerns and fears.

3. Put yourself in the parent's shoes. Be supportive.

Some of the most memorable conversations that parents of children with special needs report are those that take place at the critical moment a first concern is expressed. An empathetic approach goes much further in establishing trust and understanding than a clinical or professionally-detached one. Your tone and manner should be open and available. Whatever the outcome, in the long run, the parent will remember and appreciate your discussion if it is framed in a caring way.

4. Focus on the need to "rule out" anything serious.

By referring for further evaluation, it opens up the opportunity to “rule out” as well as “rule in” the concern. If concerns are ruled out, parents can rest easy. If concerns are confirmed, then seeking help through evaluation and referral will help to get the child back on a healthy developmental path. No harm can be done by checking out concerns. Things can only get better.

5. Refer parents and caregivers to other resources. Some parents need to come to this understanding on their own.

It is also a good idea to give the parent something descriptive to read about the disorder in the quiet of their homes. Seeing disabilities described in writing, whether through literature or on the Web, allows a parent to make the match with his/her own child’s behaviors and needs. It provides an objective description of common features and allows the parent to come into recognizing developmental concerns at their own pace. Often, when a parent is in denial, reading something that describes their own child’s behaviors closely can be the catalyst for progress.

6. Emphasize the importance of early identification and intervention.

One way to look at developmental concerns is that if a child had signs of a serious and persistent physical illness, like asthma, you would want to get it checked out as soon as possible to rule it out. If there really were a problem, it would only make it worse by not doing so. Developmental delays are no different. By not receiving timely interventions for concerns around language, behavior, and social connectedness, the problems will not go away, but will worsen over time. And what’s most hopeful is that early intervention works, improving life in the long and short term for both the child and the family. So life will get better once interventions are underway.

7. Be confident that sharing your concerns is always the right thing to do. The hardest part is finding the right words to get started.

Try role playing what you will say first. Express what you have observed that gives you concern in a caring and supportive way. By doing so, it may lower your own anxiety and give you the confidence to have a heart-to-heart with a positive outcome. Do not be afraid about hurting the relationship with the family. If you present your concerns in a positive and caring way, you will build trust. The bottom line is that the earlier a developmental concern is identified and treated, the better the outcome.

Narrow the gap between knowledge and behavior

There is much currently being published in medical literature about the gap between knowledge and behavior in practice. Physicians are more knowledgeable than ever about autism due to increase in awareness campaigns, media attention, and funding for research studies. So why is there still a gap between knowledge and practice? And why don’t many physicians screen?

Physicians cite many challenges that may influence their decisions on whether or not to screen routinely in practice. Among these are:

Lack of training
Lack of time
Lack of reimbursement by insurance companies
Physician perceptions about fears and benefits of screening
Breaking bad news to families
Concerns about over referrals
Lack of confidence in results of early intervention

However, in spite of the perceived challenges of screening, two conditions have been shown to influence a physician’s willingness to act when a developmental concern is indicated: a sense of urgency and a level of certainty

If one considers the latest information about early brain plasticity and the very powerful influence of early intervention on the developing brain, a sense of urgency is an absolute must whenever a parent expresses a developmental concern. The use of validated screening tools in practice strengthens a clinician’s level of certainty by providing a measure of confidence to make the referral for further evaluation.

Follow up with referrals; Progress can be made

It is important to have on file contact information for local agencies, services, and specialists where families can go to for help during the referral process. Oftentimes, physicians may not know of local resources that are available or may not be satisfied with the caliber of these services. Take the time to find out for the future of your patients. Once you have made the appropriate referrals, be sure to follow up with families to see how they are doing. Progress will be made with the proper supports and services in place. The process starts with you.

"One of the greatest joys out of all this is the day that the child shows up— you've delivered the bad news six months ago and the family's done what you've told them to do—they come back in and you've got a child who's looking at you. Now he's developing words and play skills are beginning to expand. The parent looks terrific and the kid looks terrific and you're saying, 'wow, this is terrific, this is really great stuff'.">

Sharing Concerns Parent to Parent

Many friends, relatives, or caregivers may have concerns about a child’s development, but are unsure of how to raise the issue with the parents. It is crucial to pursue any concerns, to ensure early and appropriate interventions; however, it can be difficult to do so.

Drawing on the experience of parents, this essay also provides a list of Do’s and Don’ts, such as:

Listen to the child’s parent, start with their observations or concerns
Always be supportive, never judgmental
Avoid jargon, labels, and terminology
Keep it positive; emphasize ‘ruling out’ anything serious

No parent wants to hear concerns about a child, particularly regarding a child’s development. All parents naturally want to protect their child. But, if a child isn’t meeting developmental milestones, or is exhibiting one of the absolute indicators or “red flags,” it is crucial that the child be properly screened. In order for this to happen, many friends, grandparents, and clinicians find themselves in the unenviable role of having to discuss developmental screenings with a parent.

Developmental delays and disorders are still poorly understood by much of our society. Few people understand the range of developmental disorders, let alone the opportunities for treatment and intervention. Many of us may recognize the differences in the physical features of children with Cerebral Palsy or Down Syndrome; however, we often aren’t aware of more subtle “hidden disorders” such as autism and how they present themselves in babies and toddlers.

The lack of knowledge about developmental disorders is further compounded by stigma. Sadly, what is not understood is often feared. This fear may prevent a parent from pursuing questions or concerns about a child’s development. This fear may also prevent those close to the parent—caregivers, grandparents, or friends—from sharing their concerns.

Some caregivers, and even clinicians, may have concern about “labeling” a child. A diagnosis doesn’t have to be a “label” —an appropriate diagnosis may describe a child’s challenges, but should never define a child. If a child is experiencing developmental delays, the specific diagnosis enables that child to have access to the most appropriate educational programs and therapies, such as occupational, speech, and physical therapy.

Early identification and intervention complement the core values of parenting: to seek to understand each child as a unique individual and to meet each child’s distinct needs in order to prepare them for adulthood. A child, who is more fully understood, with respect to his/her individual strengths and weaknesses, will have a better quality of life. The goal is simply to help every child reach his or her fullest potential.

If you are concerned about a child’s development, and want to bring it to the attention of the child’s parent, here are a few Do’s and Don’ts:

DO:

1. Set the stage for a successful conversation.

“My mother invited me to go for a long walk to tell me what was concerning her about my child. It confirmed my own suspicions. After, we had a long cry for ourselves over it.”

Choosing the right time and place for a conversation to share your concerns is very important. Try to speak in person at a time when there will be no interruptions. Arrange to meet in a private setting. Dedicate as much time as you need to have a full conversation. Understand that emotions may be unpredictable. Be ready to offer help.

2. Start with the observations, questions, or concerns of the child’s parent:

“It is critical to respect a parent’s perspective; begin with a clear understanding of whether or not they may have concerns, and what those might be.”

It’s important to assess where a parent stands in relation to understanding his/her child’s development before sharing your own concerns. The parent may already sense a problem and just not have the words to articulate it. Gently probe and ask questions that will allow a parent to share their own observations, questions, or concerns first. Then share your own observations. By doing so, you will open an exchange and may even validate a parent’s hidden concerns and fears.

3. Put yourself in the parent’s shoes. Be supportive, not judgmental.

“If you want to talk to a parent, please say it in a loving way. It might be good to begin by making a positive comment about the child’s strengths and by reinforcing the parent’s skills, love, and dedication to the child.”

Some of the most memorable conversations that parents of children with special needs report are those that take place at the critical moment a first concern is expressed. An empathetic approach goes much further in establishing trust and understanding than a judgmental or emotionally-closed or -charged one. Your tone and manner should be open and available. Whatever the outcome, in the long run, the parent will remember and appreciate your discussion if it is framed in a caring way.

4. Focus on milestones, absolute indicators, and the need to “rule out” anything serious.

“It is such an emotional subject, with so little that made sense. Milestones made sense to me.”

Give the parent something positive to read (see our developmental checklist of hallmark milestones and red flags). The checklist gives parents something to think about and consider, but never puts a label on it. It gets the conversation started with the child’s physician and provides specific information about strengths and areas of challenge.

5. Refer parents and caregivers to other resources. Some parents need to come to this understanding on their own.

“I remember seeing a Web site that seemed to describe many of my son’s unique and, frankly, troubling behaviors. As much as I wanted it to be wrong, the more I read the better I understood that something was going on.”

Seeing developmental disorders described in writing, whether through literature or on the Web, allows a parent to make the match with his/her own child’s behaviors and needs. It provides an objective description of common features and allows the parent to come into recognizing developmental concerns at their own pace.

6. Emphasize the importance of early identification and intervention.

“Early intervention is the key. Tell the parent that the earlier you catch a child, the easier it is to help the child...if you let it go too long, it just takes that much longer for the child to gain ground.”

7. Be confident that sharing your concerns is always the right thing to do. The hardest part is finding the right words and getting started.

“When my son was 18 months old with no language, a friend said that I should march him right down to the pediatrician’s office. I have to admit I was a bit offended but when I found out her advice was right, I thanked her. Most people would just sit back on their hands and not say anything. Her delivery lacked some tact, but she got me going.”

Try role playing what you will say first. Express what you have observed that gives you concern in a caring, supportive way. By doing so, it may lower your own anxiety and give you the confidence to have a heart-to-heart with a positive outcome.

8. By sharing your concerns, you may help to validate what a parent is afraid or unable to express.

“I felt comfortable in my denial. I just thought ‘oh, this too shall pass.’ But when my sister expressed her concern, it articulated what I was too afraid to say. Every now and then I need someone to shake me out of my comfort zone and get me moving.”

Often a parent may have a nagging and persistent subliminal fear that something is indeed wrong developmentally, but they may be afraid to say it out loud. All they may need is to hear the same concern from someone else to confirm their suspicions. These outcomes are usually described by parents as bringing them relief. Now they don’t feel so alone. It provides the impetus to take the next step for their child.

DON’T:

1. Don’t dismiss a parent’s concerns.

“Just listen and observe. Take the time to listen to the parent and observe the child before you do, or say, anything.”

If a parent shares concerns with you directly, you have a unique opportunity to help them. Listening is often all that is needed to help parents channel their concerns into words and actions.

2. Don’t compare one child to another. Each is unique.

“I’ve heard the story about how a child had no language and then one day, started to speak in volumes, almost miraculously. I’ve heard about Einstein being a late talker as another way to comfort me. Although well-meaning tales, they did nothing to help me move forward to help my child. They only prolonged my self-doubt.”

Often family and friends will share a story meant to give comfort to a parent that gives an anecdote of someone else who struggled with early developmental concerns, only to outgrow them in a dramatic or famous way. Instead of having the intended effect of providing comfort and ruling out concerns, parents often sense that they do not address their child’s unique concerns and dismiss them. Or they may provide more insecurity to a first time parent who is already experiencing self-doubt. Either way, anecdotes are not useful. It is more important to think about the particular child in question.

3. Don’t use labels, technical jargon, or loaded terminology.

“When the teacher at my son’s preschool said that he ‘needed Special Education,’ I thought she meant that she thought he was mentally retarded; I just shut down. Similarly, when my doctor told me she’d ‘Seen kids like him before’, I stopped listening.”

It’s probably too scary to mention a specific disorder to a parent right out of the gate. Many disorders are misunderstood and just the mention of them can bring up great fear in parents who may shut down. Sometimes giving a parent an article or book to read is enough to make the connection.

4. Don’t scare a parent: keep it positive.

“I told my doctor that my daughter’s daycare provider had some concerns about her, but I disagreed. ‘Wasn’t it OK for a child to be a little bit different? Why label?’ I’ll never forget my doctor’s simple, steady words: ‘Just get it checked out, just rule it out. You have nothing to lose.’ She was right. If it hadn’t been for the extra help my son got by being identified at such a young age, he—actually, WE—would never be doing as well today.”

If a parent is encouraged to see their pediatrician with developmental concerns about their child, there will be one of two outcomes, but each will have its positive aspects. If concerns are ruled out, parents can rest easy. If there are indeed confirmed concerns, seeking help through evaluation and referral will eventually get the family back on a healthy developmental path.

No harm can be done by checking out concerns. Things can only get better.

This is a positive message that family and friends can share with parents to encourage them to seek help.