30 and 22 31 ) Integrating patient-centered and clinician-centered interviewing skills applies with children and adolescents as well as adults. 32,33 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. 34,35 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. 32,33 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. 34,35 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. 32,33,35 Directly interview children who can speak, irrespective of age, but keep in mind their unfamiliarity with many medical and other words. 32 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 34 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. 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 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. 36 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. 34 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. 34 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.
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