Communication with children is family centered. It is a process involving the nurse, parent(s) or caregiver, and child.¹ In today’s society of expanded and nontraditional families, there may be many other participants in the communication process, and nurses should note that the principles of communication with families are the same regardless of family make-up.

Although nurses must communicate with both child and family members to be effective as health care providers, the age and cognitive development of the child dictate how much communication will take place with all members of the family present and when separate discussions might be more appropriate. Nurses working with children must have knowledge of family dynamics, relationships, cultural differences, and established communication patterns within the family structure. It is knowledge of how the family communicates that will best assist the nurse in determining the ideal strategy for communicating with the child separately and as an active, participating member of the family.

For children, communication is a process that evolves as cognition, physical and psychosocial development, and experience increase. Communication takes practice and repetition, interaction with role models, confidence, as well as verbal and nonverbal skills. As early as gestation, humans participate in varying forms of communication. Prospective parents listen to classical music, talk to their baby, and
read books to “mommy’s tummy” in hopes that these forms of language are heard, even at a very basic level.

From infancy through adolescence, communication is a dynamic, ongoing, ever-changing, and constantly developing process. Communication continues as the infant begins to interact with the environment and the people in it. Somatic language² is primarily the language of infants’ communication, although components of this means of communication can continue throughout one’s lifespan. Somatic language is focused on communicating through nonverbal vocalization, such as crying to make an infant’s needs heard; facial expressions, as when an infant grimaces and spits out a new food that tastes bad; jerking movements; and the reddening of skin, as in frustration in an infant, which in later life is often identified as blushing with embarrassment. Action language² begins later in infancy as the child learns to communicate wants and needs by reaching, pointing, crawling toward or away, turning his or her head, and/or closing his or her lips. The infant’s ability to communicate is guided by what these actions mean to him- or herself and how these actions are interpreted by the caregiver. Verbal language,² while beginning with the first spoken word at 6 to 7 months of age, does not really become an effective means of communication until toddlerhood. The toddler’s language development progresses from repetitive noises and sounds to word usage, to phrase usage, and finally to sentence usage. This process grows and becomes more refined with experience and cognitive development throughout one’s lifetime.

The younger infant, age 1 to 6 months, uses primarily nonverbal communication. The infant responds to adults through tactile stimulation and by the sound and tone of the adult’s voice. At this age, the infant uses vocalization on a limited basis through crying and cooing. Nursing strategies appropriate for children at this stage include the use of touch; speaking in a high pitched, gentle voice; maintaining eye contact with the infant; and using play appropriately (e.g., “peekaboo”). The older infant, age 6 to 12 months, builds on what has been learned previously. At this age, the infant is starting to become egocentric (the child sees him- or herself as the center of the universe). The infant begins to build a vocabulary with the first words spoken at 6 to 7 months of age. At this stage, the infant begins to experience “stranger anxiety” (a new behavior that involves withdrawing from or rejecting unfamiliar people) and has no sense of object permanence (when an object is out of sight, it does not exist). Nursing strategies on which to focus include all that were used with the younger infant; in addition, the nurse should look for clues that the infant wants to play or interact, as through eye contact or reaching out with his or her arms.¹

The toddler/preschool years span a large range, from 1 to 6 years of age. These children remain egocentric and focus on communication for and about themselves, how they feel, and what they can do. Toddlers continue to communicate with their hands when the words are not there. Toddlers and preschoolers rapidly acquire language skills, including rapid growth in vocabulary and in the ability to use it in sentences as they reach the preschool years. At this age, the child easily misinterprets phrases and interprets words literally. For example, “coughing your head off” means that your head will fall off of your body; “a little stick in the arm” means a tree stick will be put in the child’s arm; and “bleeding out” means blood will come out of the body without stopping. The child is a concrete thinker at this age.

Communication strategies for toddlers include using patience in listening because it sometimes takes the child extra time to express his or her thoughts in words. Do not interrupt the child. Do not discuss frightening or serious subjects with the parents in the presence of the child. Choose your words carefully, keeping in mind the possibility of misinterpretations. Set limits for the child to provide a sense of security. Offer structured choices and redirect and/or reframe behavior when warranted. For example, the child can be given a choice between two different foods for lunch rather than asking an open-ended question such as, “What would you like to eat for lunch?” Using play as a form of communication can enhance the child’s ability to tell you what is needed or desired. Age-appropriate play is discussed in greater detail later in this chapter.

The school-age period includes children ages 6 to 12. The child in this age group wants explanations and reasons for everything, such as what procedures are being done to him or her step-by-step and why. The school-age child is an enthusiastic participant in communication who needs relatively simple explanations at the beginning of the stage of development. As the child progresses from thinking concretely early in this age period to more abstract thinking as the end of this period approaches, more complete explanations can be given. A child at this age wants to use logic and often misinterprets
adult conversations. Nursing strategies to focus on include using simple, straightforward questions and answers. The school-age child is often reluctant to communicate his or her own needs, so speaking and responding in the third person is useful in communication. For example, the nurse remarks, “Some children like to hold my hand when their IV is started.” It is also important for the nurse to obtain the child’s perceptions before any explanations are given to avoid confusion.

The adolescent period ranges from 12 to 18 years in age. This child fluctuates between childlike and adult thinking and behavior. The adolescent has a genuine interest in the care that is being provided and wants to participate in the decision-making process. As the later teen years approach, the adolescent is caught between wanting to be “grown up” and the security that comes from remaining a child. The adolescent has attitudes and feelings that need to be communicated about a wide range of topics from peer groups to identity, sex, substance abuse, and his or her parents. The nurse must recognize where and when to discuss these issues with the adolescent and how much communication can take place with and without the parents. Communicating with the adolescent begins with the development of trust. It is essential for the nurse to build a rapport with the adolescent, to listen vs talk, and to be nonjudgmental and straightforward. Although you may not approve of some of the adolescent’s behavior, it is important to communicate acceptance of the person. The nurse must let the adolescent control the communication within the limitations of confidentiality without minimizing thoughts and feelings.¹,³

There are many traditional as well as nontraditional communication techniques that can be very successful with children of all ages. These communication techniques can be delineated as being either verbal, nonverbal, or a combination of both. Verbal techniques include word games and storytelling. Nonverbal techniques include drawing and story writing. For example, to learn more about the child’s family relationships, you could ask the child to draw a picture of him- or herself and family members doing an activity together. Then ask the child to tell you about the drawing. This strategy engages the child in talking about how he or she views his or her family. Combination communication techniques center on various forms of play therapy. Young children will often spontaneously act out their experiences with dolls or plush animals and reveal their feelings and concerns. Communicating with children takes time and patience, thought and skill, creativity and practice, and, of course, a desire to communicate with children in whatever way possible to reach each unique individual.