Unique role of the pediatric provider

Pediatric health care providers have a unique role in the development of a child’s health over a lifetime. Health is an interactive process shaped by genetics, exposures, human experiences, and individual choice.¹ From a life course perspective, early experiences can “program” a child’s health and development. Protective factors, such as a nurturing family and safe neighborhood, improve health and contribute to healthy development; and risk factors, such as limited access to health care and social services, impact a child’s development and ability to reach his or her full developmental potential.¹

Since physical, cognitive, and social-emotional health is established in the early years of life, a health care provider skilled in physical, behavioral, and mental health assessment can significantly promote the health and well-being of children and families. A significant body of literature indicates many chronic conditions in adulthood and disparities in adult health have their origins during childhood and increase over time.² Early investments in health promotion can empower individual health choices, greatly improve child health outcomes, alter the life course, and decrease the cost of health care services.

Establishing a caring relationship

Children have unique needs because of their long period of dependency and development, and this presents a unique challenge to the pediatric health care provider. Children’s health and well-being depend greatly on the care received from their family units and the surrounding environment in which they live. Addressing the needs of the parent while caring for the child and fostering a healthy relationship between the parent and child are the most important and challenging tasks in pediatrics.

Care is best provided in a pediatric health care home or medical home, which promotes holistic care of the child and family by partnering with a primary pediatric health care provider.³ This model of care allows the provider to create a partnership to empower and support the family. Children, adolescents, and families benefit from motivational and anticipatory guidance in health promotion, which is particularly effective in the context of a pediatric health care home.⁴ The caring relationship established by the primary care provider reinforces positive parenting and provides behavioral consultation to the family at critical periods of child development.

A caring relationship includes a patient-provider relationship without bias in regard to racial, ethnic, and socioeconomic difference. Provider bias has been shown to contribute to disparities in health care and health outcomes.⁵ Cultural biases may affect clinical decision making, and the perception of bias in clinical encounters undermines the caring relationship. Health care providers must make conscious efforts to overcome bias in their actions.⁵ Educating providers on racial, cultural, and socioeconomic biases, self-regulating behavior, and developing new mental habits can provide the highest quality care to all children and families.⁵

Parent and child interaction

One of the most important aspects of the health interview is eliciting and observing interactions between the parent and child or adolescent. Analyzing verbal responses and interactions during the encounter gives the health care provider an idea of how the parental relationship fosters child development and child self-esteem. It also gives the health care provider a window into the child’s world. Interactions between the parent or caregiver, the family members, and the health care provider reveal family dynamics, family connectedness, family authority, and the approach to problem solving.

Nonverbal cues provide the most revealing picture of the child’s demeanor and of the parent/child relationship. Stop and observe these cues, and verbalize your concerns to the parent and child: “You look sad today. Can you tell me what that is about?” Ask yourself the following: Is the parent or caregiver disengaged with the child or infant during the encounter? Does the parent appear depressed or angry? Do the data from the health interview fit with the demeanor of the child during the encounter? The child or adolescent’s nonverbal cues give the health care provider additional understanding of the context in which the child lives.

A child who is withdrawn, refusing to make eye contact, or who is consistently stressed when communicating with a parent is exhibiting signs of strain in her/his environment. This should alert the health care provider to communicate her/his concern to the family and provide support, counseling, and referral when indicated. Children often mirror the emotions of the adults around them. Families involved in conflict or who are under stress often cannot see their own interactions clearly or the impact their interactions have on the child. Early intervention by the health care provider in harmful or ineffective family communications is critical to the healthy psychosocial development of the child.

A large part of social and emotional development for children and adolescents is now occurring while the child or adolescent is on the Internet or on a cell phone.⁶ Children’s and adolescents’ online lives constitute a large part of their social interactions, and there are potential risks to their privacy and safety.⁶ It is important for parents and caregivers to monitor children’s social media, Web, and cell phone activities for potential impact on their emotional health. Health care providers are in a unique position to urge parents to communicate with their children and educate them about the social anxiety, bullying, and risk taking that can occur with peer-to-peer communications online.⁶ The American Academy of Pediatrics (AAP) provides resources for parents at http://safetynet.aap.org to assist them with safeguarding children and promoting healthy online behavior.

A child’s perspective

The United Nations Convention on the Rights of the Child (1989) asserts that children have the right to self-determination, dignity, respect, noninterference, and to make informed decisions. Health care providers have a responsibility to ensure children’s rights, and the child is encouraged or enabled to make their perspective known on issues that affect their health and well-being.⁷ This perspective does present inherent conflicts for health care professionals in ensuring children’s right to participate in health care decisions as well as their need for protection. Health professionals are aware of the importance of consulting with children during the health care visit, but they do not always wholly seek or acknowledge the child’s or adolescent’s view.⁷ The view of the parent or caregiver and the view of the child may differ quite remarkably, and this difference can often impact health care decisions and treatment outcomes. Promoting opportunities for children and adolescents to contribute to health care decisions with families and caregivers creates a child-centered approach to care that empowers and enables the child or adolescent.

Shier proposed a model to facilitate children’s participation in the health history.⁸ The model provides a framework for communication that is attentive, sensitive, and supportive of a child’s perspective while capturing the shared responsibility of families, health care professionals, and health care organizations. The model proposes the following:

The last point is not to leave the responsibility to the child but to value the child’s perspective while considering the needs and views of the family.⁸ This framework provides pediatric health care providers with a child-centered approach to health care within the context of the family.

Family, cultural, racial, and ethnic considerations

It is essential that health care professionals are committed to knowing the rationale and conceptual model for delivering family-centered, culturally, and linguistically competent care to provide a pediatric health care home or medical home.⁹ The increasing global immigration of populations will continue to provide challenges to health care professionals working with diverse populations. Providers will be required to assess the extent to which culture plays a role in health care decisions in the family and impacts treatment plans and adherence to these plans.

There are significant disparities in pediatric health care, and children from economically disadvantaged and racially and ethnically diverse backgrounds are most affected. Recent studies have shown children with special health care needs are more racially and ethnically diverse than the general pediatric population, have less access to a pediatric health care home, and require special consideration.⁹

Cultural beliefs also impact care-seeking behavior and affect the delivery of clinical care by health care providers. Effective models of care incorporate sensitivity to cultural differences and enhance the protective factors of cultural practices within families. Studies demonstrate differences within ethnic groups are as great as the cultural differences between groups; therefore, no valid assumptions can be made in health care on the basis of physical appearance or surname. It is important for providers to acknowledge cultural differences, understand their own culture and how that influences the care they deliver, engage in self-assessment, acquire cultural knowledge and skills consistent with the practice setting, and value diversity within the health care team.⁹

Ideally, delivery of health care services should occur in the first language of the client. When this is not possible, a model framework for the encounter between the health care provider, child, and family includes the following: