Pediatric Patients

(See Also doc.com Modules 21

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and 22
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)
Integrating patient-centered and clinician-centered interviewing skills applies with
children and adolescents as well as adults.
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You still want to establish a trusting,
therapeutic relationship and obtain adequate personal and symptom data, but
with an emphasis on growth, development, and family interactions.
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The younger
the child, the more age-related communication issues are involved: decreased
ability to communicate, shorter attention span, less cognitive development, and
increased dependency on parents.
For pediatric and some adolescent patients, Steps 15 have to be modified.
Children often lack the psychological maturity to participate fully in the beginning of
the interview, and you may need to rely more on clinician-centered interviewing
skills. Nevertheless, always elicit their concerns and involve them in treatment
discussions and decisions.
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Children become increasingly autonomous as they
grow older and patient-centered interviewing skills will become more effective.
Patient-centered interviewing skills should be used in interacting with the parent,
with a focus on the child's problems, but also empathizing with the impact of the
child's illness on the parent.
Attend to the various steps of the interview, modifying your approach for the age
and initiative of the pediatric patient. In Step 1, age appropriate opportunities and
facilities can be made available; toys, games, and small chairs can improve
interactions with younger children while teens frequently do not want to sit with
children or in childlike circumstances.
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Older children and adolescents can often
provide their own agenda in Step 2 but parents usually formulate the issues for
younger children.
The age of the child determines how Steps 3 and 4 are best carried out. Involve the
parent more when the patient is a younger child. Even then, address the child first in
an open-ended style and keep the child the focus of the inquiry.
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Directly
interview children who can speak, irrespective of age, but keep in mind their
unfamiliarity with many medical and other words.
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The younger the patient, the
more concrete, simple, and brief your questions should be. Always try an open-
ended approach; it can be productive even in the very young. In fact, clinicians
often underestimate how much information they can get from little children
Mommy says Daddy needs to get a better job. Nevertheless, it frequently helps to
initiate conversation by giving age-appropriate menus of topics to choose
from
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such as inquiring about recent birthdays, school, siblings, friends, athletic
events, social events, and the like in an open-ended manner. Get the child to talk
about whatever interests her or him. In addition, you will want to see how the child
interacts with the parent and others, perhaps observing the child in the waiting
room.
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Try to interact with the child, even if briefly, without the parent present.
Observe the child's behavior as well as her or his communication.
In Step 6 (HPI) obtain information from child, parent, or both as already described
inChapter 5. Step 7 (PMH) and Step 8 (SH) are specialized in pediatric interviews.
Because growth and development are critical, the younger the child the more
detail is required about the mother's pregnancy and delivery, and the child's birth
and infancy, and subsequent developmental landmarks (eg, feeding, growth,
walking, talking, toilet training, progress in school, social development).
Immunization status, usual childhood illnesses, hospitalizations, poisonings, accidents,
and injuries merit special attention. The SH contains information about the pertinent
social aspects of the family (eg, father's job) as well as the patient (eg, less fighting
at school and improved reading). Inquire about salient family interactions as well
(eg, ignoring a new brother, parents getting along better since mother got a new
job). It might also be helpful to speak with a child's teacher to best understand the
SH, especially if the child is having problems. Ensure that parents store toxic
substances and medications out of reach, check that hot water temperature is no
more than 125F to prevent scalding, and use protective devices like car seats, seat
belts and bicycle helmets.
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As the child ages, the interview more closely resembles
that of the adult PMH and SH.
Step 9 (FH) also has a unique emphasis in the pediatric interview. The FH and
genogram includes the health histories of grandparents, parents, and siblings.
Because genetic disorders and precursors of adult diseases frequently begin in
childhood, it is important to obtain a careful genetic pedigree. The mother's health
is especially important. Inquire about menses, contraception, marriages,
pregnancies and outcomes, subsequent progress of children, and plans for more
pregnancies. Ascertain her feelings about her pregnancy with the patient, and
learn about her physical and psychological health. Her own rearing (punishment
practices, abuse) and expectations of what being and raising a child are like are
germane. Assess what kind of mother she will be and look for areas where an
intervention may be helpful; eg, she may need support of her own competence. As
mothers increasingly support families, their work situation is important as well. As
fathers become more central to rearing children, many of the preceding
considerations apply to them also. Indeed, fathers frequently are ignored and often
feel left out at all levels of their child's care. They should be actively included and
involved.
Step 10 (review of systems [ROS]) is more important with children than
adults.
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Because children have much shorter histories and because it can be more
difficult to obtain pertinent symptoms during the HPI, make detailed inquiry in all
systems prior to the physical examination and pay more attention to transient or
minor complaints; eg, increased urinary frequency off and on can signify severe
disease, such a congenital genitourinary malformation.
Adolescence is a physically and psychologically tumultuous period. Some
adolescents will be perfectly comfortable with the patient-centered approach you
would use with an adult, while others can be made uncomfortable and anxious by it
and prefer a more structured approach, that is, transitioning to the middle of the
interview sooner than you would with an adult. Prominent issues and themes that
can emerge include dependency on parents, being forced to come to the
clinician, conflict with parents and others, confidentiality, desire to see an adult
clinician, obliviousness of health risks, hypochondriasis, mood changes, confusion
about sexual orientation, and rebelliousness.
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It may be more important to provide
support and comfort rather than obtaining open-ended information, particularly at
the beginning of the relationship. Seeing the adolescent alone for at least part of
the visit is often more effective and can lead to a better relationship.