Comprehensive information gathering

Karen G. Duderstadt; and Naomi A. Schapiro

The skill of obtaining a comprehensive, holistic health history remains the most important clinical tool for pediatrics. Despite the technological advances in health care and electronic medical records, expert assessment is most influenced by observing, listening, and thinking critically in a clinical setting. Recognizing patterns of health and illness in infants, children, and adolescents requires obtaining relevant pieces of data from the health history, thinking about their meaning, and explaining them logically. Taking a comprehensive history with families not only develops a profile to guide physical assessment, diagnosis, and treatment, but also contributes to the development of a continuity relationship between the family and health care provider.

Information gathered from the family history is also key to identifying genetic patterns of inheritance in health conditions and is a guide to health education and promoting responsible health behaviors in the child and adolescent.¹ Identifying and counseling children and adolescents at risk for chronic health conditions such as diabetes, hypertension, and cardiovascular disease begins with gathering a comprehensive family history.¹

Identifying and counseling for childhood overweight and obesity remains a top priority in pediatrics. Identifying early childhood factors in the comprehensive history that are significant predictors of obesity in adulthood is an important role for pediatric health care providers in prevention and anticipatory guidance. Probable early markers of obesity include maternal body mass index; childhood growth patterns, particularly early rapid growth and early adiposity rebound; childhood obesity; and parental employment, a marker for socioeconomic status of the family.² When gathering the health history, it is important to talk to children and adolescents about the importance of physical activity and their dietary routines to establish early positive health habits.

The comprehensive health history in children and adolescents also includes psychosocial screening. In child health, the top five chronic health conditions in pediatrics currently are speech and language delays, learning disabilities, attention-deficit/hyperactivity disorders, developmental disabilities, and emotional, behavioral, and mental health problems.³ These findings indicate the importance of psychosocial screening during every well-child and adolescent encounter in a clinical setting.

Another important component of comprehensive information gathering is oral health. Tooth decay continues to be the single most common chronic health condition in pediatrics. Tooth decay affects more than one fourth of U.S. children from 2 to 5 years of age and half of adolescents 12 to 15 years of age.⁴ Globally, 60% to 90% of school children have dental caries.⁵ Assessing children’s oral health and access to dental health services is key to establishing positive dental health behaviors early in life.

The genetic family history

Genetics has transformed the use of family history information and has led to the reemergence of the detailed genetic family history. The increased use of genetic screening is creating a paradigm shift in medical treatment by emphasizing primary prevention and early intervention for families with hereditarily linked health conditions.⁶ Gathering of the comprehensive family history is necessary to make this link and advance the health of children and families. It is important to be aware of the emotional and ethical issues that may arise when taking a genetic family history, such as the hereditary link between breast cancer in female relatives and familial gene testing. Pediatric health care providers are well placed to provide this support to individuals and families.⁷ Also, pediatric providers are particularly well positioned to use this knowledge as they provide primary care for children from birth to young adults, the period during which many genetic disorders emerge.¹

The genetic family history establishes a family pedigree. The family pedigree or genogram is a visual way to enhance recognition of patterns of inheritance. This approach leads to insights in patterns of inheritance across generations, and gives health care providers an opportunity to counsel families on prevention and offer referrals for further genetic testing. Knowledge of the genetic family history can aid in the diagnosis of rare single-gene disorders such as cystic fibrosis, fragile X syndrome, Huntington disease, or familial hypercholesterolemia.

An accurate genetic family history requires the availability of a reliable family source and the knowledge of a three-generation family history. The challenge is to gather a family and genetic history within the brief time available in the clinical setting. Table 4-1 presents the SCREEN mnemonic for an initial genetic family history.⁸ The SCREEN mnemonic represents an initial series of questions used to quickly identify potential genetically influenced health conditions in the family that require further intervention, counseling, referral, or screening by a geneticist. Figure 4-1 is an example of a family pedigree with a multigenerational inheritance of cardiovascular disease.

TABLE 4-1

The SCREEN Mnemonic for Family History Collection

SC	Some concerns	“Do you have any (some) concerns about diseases or conditions that run in the family?”
R	Reproduction	“Have there been any problems with pregnancy, infertility, or birth defects in your family?”
E	Early disease, death, or disability	“Have any members of your family died or become sick at an early age?”
E	Ethnicity	“How would you describe your ethnicity?” or “Where were your parents born?”
N	Nongenetic	“Are there any other risk factors or nonmedical conditions that run in your family?”

From Trotter TL, Martin HM: Family history in pediatric primary care, Pediatrics 120(Suppl 2):S60-65, 2007.

FIGURE 4-1 Family pedigree with a multigenerational inheritance of cardiovascular disease. (From Bennett RL: The practical guide to the genetic family history, New York, 1999, Wiley-Liss, Inc.)

Evidence-Based Practice Tip

The increased use of genetic screening is creating a paradigm shift in medical treatment by emphasizing primary prevention and early intervention for families with hereditarily linked health conditions.⁶

Family-centered history

The following key strategies are involved in developing a successful family-centered relationship with children and families in the pediatric setting:

• Listen actively to the concerns of the family. A caring relationship is established by developing an understanding of the feelings and values within the family context.

• Understand the family expectations for the encounter. To successfully establish a caring relationship, the parent’s agenda must be identified and addressed during the encounter.

• Ask open-ended questions, thereby allowing relevant data to unfold.

• Personalize your care. Ask about the health and well-being of other family members and extended family members to personalize your care and demonstrate your connectedness with the family unit. Taking the time to obtain and integrate this relevant personal data on the child and family will assist in building the family profile and family-centered relationship.

• Learn and understand the role and importance of cultural influences in the family and the primary language spoken in the home. The health interview should be conducted in the family’s primary language if possible to promote family engagement.

• Identify protective factors in the family that create a positive environment for the child. Social supports for the parents, involvement of relatives or extended family, and shared family interest in activities such as sports, cultural events, or religious services often help to form a supportive and protective community for children and adolescents.

• Build a sense of confidence in parents by confirming and complimenting their strengths in caring for their child. This approach also builds a trusting relationship between the family and health care provider.

• Time management is key. With the increased workload in health care settings and the implementation of electronic health records, being present when talking with children and families becomes more challenging. Remember to sit rather than stand, maintain eye contact with the child and family in between screen time, and share screen health information such as growth chart and lab results to engage with families.

Evidence-Based Practice Tip

Families expressed more satisfaction, felt their questions were better addressed, and expressed a better sense of understanding of their child’s condition when health care providers sat rather than stood at the bedside or during health visits.⁹

Pediatric health care providers are uniquely suited to assess children from a family-centered perspective. Box 4-1 approaches the family-centered interview from three levels to assess family strengths, stressors, and threats to the family unit. Families hold trust in the pediatric provider, and their relationship is based on the knowledge, understanding, respect, and care the pediatric provider demonstrates during the encounter with their child.

BOX 4-1 Three Levels of Family-Centered Assessment

Level 1: Micro level

The child, parent or parents, partner, caregiver, other adults or children in household