CHAPTER 5

There is much wisdom from the French novelist, essayist, playwright, and Nobel Prize Laureate Albert Camus about what is needed to successfully interview and counsel families in the context of a pediatric visit. The primary pediatric health care professional need not dictate the agenda of the visit and “lead” the family according to a predetermined agenda. Nor should the health care professional limit the interview to the initial concerns that are expressed, without inquiring about and exploring other potential areas salient to child health and development that the family may not explicitly mention. Successful interviewing and counseling of families requires that the health care professional “walk with” a family and develop a therapeutic alliance with the child and caregivers based on mutual respect and the shared goal of optimizing the child’s health and developmental-behavioral outcomes. This holistic, family-centered approach to patient care is most likely to be adopted into practice when this perspective is introduced early in medical training. Arguably, one of the most necessary skills to develop in residency training is the art of building a therapeutic alliance in the context of the patient encounter.1 A healthy therapeutic alliance between a health care professional and a patient is thought to incorporate 3 main components: (1) agreement on goals that are the desired outcomes of the therapeutic process; (2) agreement on tasks that are the steps undertaken to achieve the goals; and (3) a bond between the health care professional and the patient built on shared values, such as trust, respect, genuineness, positive regard, and empathy.²

While many would agree that sensitive, empathic listening and building trust and respect are the foundation for building a therapeutic alliance, the reality is that a collaborative relationship between the primary pediatric health care professional and the patient evolves over time. If the ultimate goal is to build a therapeutic alliance in which the foundation is trust and respect, what is the first brick that should be laid? One possibility considers that perhaps the most important factor for building a therapeutic alliance between a health care professional and a family is the ability to collaboratively identify mutually agreed-upon goals for the health care professional’s encounters with the family. This begins by uncovering the patient’s goals for the encounter and by seeking the patient’s and family’s input on what may be done to achieve these goals. Rather than a problem-focused approach (eg, “What problem brings you in today?”), a goal-based approach begins the dialogue by asking the patient what his or her goals for the visit are, to which the health care professional can add and expand, and a goal-directed partnership can develop.

A mutual, goal-directed partnership between the pediatric health care professional and family is best achieved when pediatric care is continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. This model is most successful when the health care professional is known to the child and family and when there is a partnership of mutual responsibility and trust between them.3

The characteristics of the ideal health care professional–family alliance are best captured in the model of the medical home. The medical home is a vision for how all individuals who are involved in the delivery of health care services can partner with their patients and their families to help them achieve their maximum potential. This vision of a comprehensive medical home is considered to be the standard of quality care for all children.⁴ This vision posits that optimal care is provided in a system that fosters collaboration and cooperation among all members of the community in which the child and family live. In this model of the medical home, health care professionals can promote factors that foster resilience and inquire about factors that can confer developmental risk.^5,6

The goal of the pediatric health supervision visit, according to the American Academy of Pediatrics, is to promote children’s optimal growth and development.⁷

Because of the health care professional’s regular and ongoing contact over time with infants, toddlers, and their families, the primary pediatric health care professional is well positioned to monitor and support early child development and behavior and optimize child health outcomes.⁸ However, evidence suggests that the pediatric visit is an often underutilized opportunity to identify developmental and behavioral concerns and to provide anticipatory guidance to families. To better address developmental and behavioral concerns in the context of the primary care visit, the pediatric health supervision visit must be adapted to address this unmet need. The pediatric visit must provide an opportunity for the parent and health care professional to communicate about the issues that are most salient to childhood health, behavior, and development. To understand how to use this opportunity during the clinical visit, it is helpful to explore the content and meaning of dialogues between a family and pediatric health care professional that emerge in the context of the clinical interview.

Capturing Missed Opportunities: Optimizing the Pediatric Encounter

The primary pediatric health care professional is well positioned to observe the nuances of the caregiving relationship, monitor early child development, identify difficulties, and offer support, guidance, and intervention when families struggle.9 This “holistic health surveillance” occurring in the context of the pediatric health supervision visit is most successful when the parent feels heard, supported, and “beheld” in the context of the health care professional-patient encounter. Employing some general principles regarding interviewing and assessment is helpful to create an environment where the family can feel that their concerns are heard and respected. This involves building a therapeutic alliance with both the caregiver and the pediatric patient and viewing developmental and behavioral concerns though a culturally sensitive lens. This process is best achieved when the pediatric health care professional can provide a psychological “holding environment,” in which parents feel safe articulating their fears, vulnerabilities, challenges, or concerns as parents.¹⁰ The concept of the “holding environment” was first described by Donald Winnicott, a British pediatrician, psychiatrist, and psychoanalyst, as a means of articulating what infants need from their caregivers to feel safe and secure.¹¹ In Winnicott’s “holding environment,” the primary caregiver provides an environment of physical and psychological support, in which the infant can feel safe and develop a sense of self. In much the same way, the primary pediatric health care professional can create a supportive “holding environment” for parents, in which they feel a sense of safety, nurturance, support, and trust, and in which the health care professional can explore issues with the family that are most relevant to the child’s and family’s well-being.

Based on trust built of an ongoing caring relationship, the primary pediatric health care professional can comfortably ask important personal questions that shed light on the key resources for achieving each child’s developmental potential. Because the health and well-being of children are intimately related to the parent’s physical, emotional, and social health and social circumstances,¹² relevant areas of inquiry with parents may include their mood, family ties, work issues, perceived social support, social affiliations, child-care needs, health status, financial security, as well as conditions that can be toxic and maladaptive to the child’s well-being.¹³ Environmental toxins, such as air and water quality, as well as housing and food security are important areas to address as well. These conditions influence family dynamics, contribute to a child’s health and growth, and as such, are essential domains for the primary pediatric health care professional to explore.¹⁴

The opportunity to identify problems begins when the clinician first inquires about positive developments within and between the child and family. Potential problems are further elucidated by discussing any concerns about their child’s development and behavior. The clinical interview provides an ideal opportunity for the primary pediatric health care professional to enhance the relationships with patients and families, assess the emotional states of patients, and uncover clues that might point to psychosocial distress or disturbance within the family context. The clinical interview can serve as a tool for gathering information, providing an opportunity to form a therapeutic alliance with the family and serving as a means to influence behavior. Successful interviewing is maximized by using a developmental approach and some principles of family engagement and assessment.15

A potentially helpful framework to address parents’ concerns and provide anticipatory guidance in the context of the pediatric encounter can be conceptualized by the mnemonic: SHARE.¹⁶

   Set the tone: Create a “holding environment” in the context of the pediatric visit. Support parent and child: Build a therapeutic alliance.

   Hear the parent’s concerns about the child’s behavior and development and the effects on family functioning through the use of some guided questions.

   Address specific risk factors for child development and family functioning. Allow parents to reflect how cultural traditions contribute to their expectations of child behavior and development.

   Reflect with parents on their experience of the child.

   Reframe the child’s behavior and development in terms of the child’s developmental level. Revisit the therapeutic goals set.

   Empower the parent and child by formulating an action plan to address the concerns voiced in the visit.

The Art of Interviewing

Setting the Tone/Supporting the Parents and Child in the Pediatric Visit: Developing a Therapeutic Alliance

Creating a safe space and open environment to share the details that are most salient to child development and family functioning requires special attention to the nuances of the initial family encounter. Nurturing emotional development in children must begin with supporting and nurturing the parents in their roles as caregivers. As the family is the primary vehicle for children’s early development, the family is the pediatric patient.¹⁴ This alliance can begin by creating the time and space for parents and children to feel that they can voice their concerns. Some general principles regarding interviewing and counseling should be considered. Efficient communication requires unbroken attention. Privacy will increase the information shared during an interview and is especially important when sensitive psychosocial issues are being discussed. Equally important is explicitly addressing issues of confidentiality with patients and parents prior to clinical assessment and having adequate time to address the family’s concerns. The primary pediatric health care professional has the added challenge of developing a therapeutic alliance with both the parent and the pediatric patient. This can be facilitated if an alliance can be forged with the child in a developmentally sensitive manner.

Infancy (0–1 year of age): In the period of infancy, the most primary developmental process is the development of a sense of trust in the child’s caregiver and the world around him or her. The young infant is dependent on the caregiver for a sense of safety, security, and to help control and regulate emotions.17

In the first year of life, the “interview” of the child, or more accurately put, the assessment of the child, should take place in the presence of the caregiver, preferably, in the caregiver’s arms if possible. A soft tone of voice and gentle handling of the infant are important means of helping the baby develop a sense of trust and comfort with the primary pediatric health care professional. Narrating to the infant what will happen in the context of the visit can help the infant and the caregiver feel more comfortable, as well as implicitly encouraging a more reticent parent to talk with the baby about the world and his or her experiences. A therapeutic alliance can be forged with both the infant and the caregiver when the caregiver’s concerns are articulated and directed toward the infant during the assessment, “Your mommy wonders why you are so fussy at night. Is there something in your ears, in your tummy?”

Toddler Years (1–3 years of age): The hallmark of the toddler years is the desire for autonomy, stranger wariness, separation, and individuation. In the context of the health supervision visit, the toddler may seek to have more control and active participation in the health supervision visit. At the end of the first year of life, the infant has developed a framework of attachment to the primary caregiver based on his or her history of early experiences.¹⁸ In this attachment relationship, the caregiver serves as both a “secure base” from whom the toddler can explore an unfamiliar environment and a “safe haven” to whom he or she can return when distressed.¹⁹ Rapport can be built with the toddler by allowing and encouraging exploration, being sensitive to the toddler’s needs for “emotional refueling” from the caregiver, and indulging the toddler’s desire for autonomy and control, “First I will listen to your heart, then you can listen.”

Preschool Years (3–6 years of age): Preschoolers are developmentally in Piaget’s preoperational thinking stage. This developmental stage is characterized by egocentric and magical thinking. The preschool child has greater verbal and cognitive capacities than the infant and toddler but often views the world in a very concrete and self-oriented way. The preschooler may view illness as a punishment for certain behavior (eg, “My stomach hurts because I did not eat my vegetables last night”) or may view illness as something that was caused by “magic.” To engage the preschool child, it is often helpful to reassure the child that illness is not his or her fault or a result of “bad behavior.” It can be helpful for the primary pediatric health care professional to probe with the child his or her understanding of why he or she does not feel well. The primary pediatric health care professional can further build rapport by engaging with the preoperational child in finding a solution: “What do you think we should do to help you feel better? Maybe we can give you some ‘special medicine’ to take away your earache.”

Adolescence: (13–21 years of age): Adolescence is a critical stage in development in which health behaviors, including those that will last a lifetime, are adopted.20 Developmentally, the adolescent patient is in the process of gaining autonomy from the parents. This emerging autonomy can be respected by structuring the pediatric visit to include both time with the parent and adolescent together and time with the adolescent alone. Confidentiality and its limitations should be addressed and acknowledged before the parent leaves the room.¹⁵ Building an alliance with the adolescent and caregiver can be facilitated if mutually agreed-upon therapeutic goals can be identified in the context of the visit and if both the adolescent and the caregiver are committed to achieving the desired change by working together toward the therapeutic goal.²¹

A successful therapeutic alliance between the primary pediatric health care professional, caregiver, and pediatric patient is best achieved when a partnership can be forged between the parents and the health care professionals caring for their children. This family-oriented approach incorporates the view that parents play an important role in the health and wellbeing of their children and is based on the following assumptions: (1) the parents know the children best and want the best for them, (2) each family is different and unique, and (3) a child’s well-being is affected by the stress and coping of other family members.²²

The pediatric encounter should be structured such that the parents’ desires for the well-being of their child are acknowledged and addressed and that the parents can feel free to share with the primary pediatric health care professional those issues that are serving as a stress to the relationship. This can be facilitated through the careful use of guided, open-ended questions.

Facilitating a Dialogue

Parents often present to the pediatric visit with concerns about their child’s health, development, or behavior. It has been suggested that nearly half of parents have concerns about their young child’s behavior, speech, or social development,23,24 but some parents are reluctant to share their concerns about developmental and behavioral issues with their pediatrician.^25–27 For some parents, societal and cultural beliefs influence what child behavior concerns they feel comfortable divulging to their primary pediatric health care professional and what concerns remain unshared.^25,28 To ensure that the parents’ deepest concerns and needs are expressed and addressed, the pediatric health supervision visit must be adapted to address this aspect of the child’s health. The pediatric health supervision visit must provide the opportunity for parents to tell their story and to express their perceptions about the strengths and vulnerabilities of their children and families.²⁹

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