Pediatric Patient Interview

8/11/2019 Pediatric Patient Interview

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Pediatric Patients

(See Also doc.com Modules 21 30 and 22 31)

Integrating patient-centered and clinician-centered interviewing skills applies withchildren and adolescents as well as adults .32 ,33 You still want to establish a trusting,therapeutic relationship and obtain adequate personal and symptom data, butwith an emphasis on growth, development, and family interactions .34 ,35 The youngerthe child, the more age-related communication issues are involved: decreasedability to communicate, shorter attention span, less cognitive development, andincreased dependency on parents.

For pediatric and some adolescent patients, Steps 1 5 have to be modified.Children often lack the psychological maturity to participate fully in the beginning ofthe interview, and you may need to rely more on clinician-centered interviewingskills. Nevertheless, always elicit their concerns and involve them in treatmentdiscussions and decisions .32 ,33 Children become increasingly autonomous as theygrow 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 thechild's illness on the parent.

Attend to the various steps of the interview, modifying your approach for the ageand initiative of the pediatric patient. In Step 1, age appropriate opportunities andfacilities can be made available; toys, games, and small chairs can improveinteractions with younger children while teens frequently do not want to sit with

children or in childlike circumstances .34 ,35 Older children and adolescents can oftenprovide their own agenda in Step 2 but parents usually formulate the issues foryounger children.

The age of the child determines how Steps 3 and 4 are best carried out. Involve theparent more when the patient is a younger child. Even then, address the child first inan open-ended style and keep the child the focus of the inquiry .32 ,33 ,35 Directlyinterview children who can speak, irrespective of age, but keep in mind theirunfamiliarity with many medical and other words .32 The younger the patient, themore 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, cliniciansoften underestimate how much information they can get from little children Mommy says Daddy needs to get a better job. Nevertheless, it frequently helps toinitiate conversation by giving age- appropriate menus of topics to choosefrom 34such as inquiring about recent birthdays, school, siblings, friends, athleticevents, social events, and the like in an open-ended manner. Get the child to talkabout whatever interests her or him. In addition, you will want to see how the child
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interacts with the parent and others, perhaps observing the child in the waitingroom .35 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 moredetail is required about the mother's pregnancy and delivery, and the child's birthand 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 pertinentsocial aspects of the family (eg, father's job) as well as the patient (eg, less fightingat 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 theSH, especially if the child is having problems. Ensure that parents store toxicsubstances and medications out of reach, check that hot water temperature is nomore than 125F to prevent scalding, and use protective devices like car seats, seatbelts and bicycle helmets .36 As the child ages, the interview more closely resemblesthat of the adult PMH and SH.

Step 9 (FH) also has a unique emphasis in the pediatric interview. The FH andgenogram 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 healthis especially important. Inquire about menses, contraception, marriages,pregnancies and outcomes, subsequent progress of children, and plans for morepregnancies. Ascertain her feelings about her pregnancy with the patient, andlearn about her physical and psychological health. Her own rearing (punishmentpractices, abuse) and expectations of what being and raising a child are like aregermane. Assess what kind of mother she will be and look for areas where anintervention may be helpful; eg, she may need support of her own competence. Asmothers increasingly support families, their work situation is important as well. Asfathers become more central to rearing children, many of the preceding

considerations apply to them also. Indeed, fathers frequently are ignored and oftenfeel left out at all levels of their child's care. They should be actively included andinvolved.

Step 10 (review of systems [ROS]) is more important with children thanadults .34 Because children have much shorter histories and because it can be moredifficult to obtain pertinent symptoms during the HPI, make detailed inquiry in all
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systems prior to the physical examination and pay more attention to transient orminor complaints; eg, increased urinary frequency off and on can signify severedisease, such a congenital genitourinary malformation.

Adolescence is a physically and psychologically tumultuous period. Some

adolescents will be perfectly comfortable with the patient-centered approach youwould use with an adult, while others can be made uncomfortable and anxious by itand prefer a more structured approach, that is, transitioning to the middle of theinterview sooner than you would with an adult. Prominent issues and themes thatcan emerge include dependency on parents, being forced to come to theclinician, co nflict with parents and others, confidentiality, desire to see an adultclinician, obliviousness of health risks, hypochondriasis, mood changes, confusionabout sexual orientation, and rebelliousness .34 It may be more important to providesupport and comfort rather than obtaining open-ended information, particularly atthe 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.
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Documents

Pediatric Patient Interview