Talking With Children
Geeta Grover, MD, FAAP
The moment you walk into the examination room, the 2-year-old girl begins to cry and scream uncontrollably. She clings to her mother and turns her face away. The mother appears embarrassed and states that her daughter reacts to all physicians this way. After reassuring the mother that you have received such welcomes before, you sit down at a comfortable distance from the girl and her mother. You smile at the girl and compliment her on her dress, but she does not seem to be interested in interacting with you at this point. You place an age-appropriate book on the examination table, indicating to the child that the book is for her. You begin your interview with the mother and try not to look at the girl. Out of the corner of your eye, you see that her crying is easing and she has begun to examine the book you had placed on the table.
1. How does the age of children influence their understanding of health and illness?
2. Should physicians speak directly with children about their illnesses?
3. At what age can children begin to communicate with physicians about their illnesses?
4. How can older children be involved in the management of their health?
5. How can positioning and placement of children in the examination room affect the overall tone and quality of the visit?
Effective communication is essential in developing a meaningful and trusting relationship with children. In pediatrics, interviewing involves balancing the needs of parents and children. Whereas parents may be more focused on issues pertaining to disease, treatment, or aspects of parenting, children look to physicians with different needs and concerns, depending on their age. Developmental maturity, cognitive level, language ability, and sociocultural factors all play a role in a child’s ability to communicate and affect their concepts of health and illness. As children grow and develop, their understanding of health and illness matures and develops as well. Developmentally sensitive communication helps build a trusting relationship that allows pediatricians to guide children as they grow to make appropriate decisions about their own health as well as assume responsibility for behaviors that may affect their health and well-being. The American Academy of Pediatrics advises that physicians have both a moral and an ethical obligation to discuss health and illness with children, and further, in keeping with their developmental capacities, allow them to be active participants in their own care.
Developmental Approach to Communicating With Children
Childhood is a time not only of considerable physical growth but also of tremendous social, emotional, and cognitive maturation. An appreciation of the cognitive stages of development helps pediatricians develop a healthy relationship with their patients by allowing them to communicate with children in an age-appropriate manner.
Piaget defined 4 stages of cognitive development, which occur in the same sequence but not at the same rate in all children (Table 3.1).
In the sensorimotor stage (birth–2 years of age), children experience the world and act through sensations and motor acts. They are developing the concepts of object permanence, causality, and spatial relationships. In the preoperational stage, (2–6 years of age), children understand the world only from their own viewpoint. As egocentric thinkers, they are unable to separate internal from external reality, and fantasy play is important. School-age children (6–11 years of age) are capable of concrete operational thinking. These children can reason through problems that relate to real objects. Older children (>11 years of age) have the capacity for abstract thought, which defines the formal operations stage.
|Table 3.1. The Four Stages of Cognitive Development According to Piaget|
Experiences the world through sensations and motor acts
Egocentric thinking Imitation and fantasy play
Mental processes only as they relate to real objects
Capacity for abstract thought
a Approximate ages.
An appreciation of how children’s cognitive development affects their understanding of illness and pain aids physicians in developing therapeutic relationships with their patients. When using a developmental approach to children’s understanding of illness, children’s explanations of illness are classified into 6 categories that are consistent with Piaget’s cognitive developmental stages (Table 3.2). Children 2 to 6 years of age view illness as being caused by external factors near the body (ie, phenomenalism, contagion). Young children engage in so-called magical thinking; proximity alone provides the link between cause and illness. Children 7 to 10 years of age should be able to differentiate between self and nonself. At this stage, they begin to understand that although illness may be caused by some factor outside the body, illness itself is located inside the body (ie, contamination, internalization). Children 11 years of age and older understand physiologic and psychophysiologic explanations of illness.
A similar developmental sequence applies to children’s understanding of pain. Younger children may attribute pain to punishment for some transgression or wrongdoing on their part. They may not understand the relationship between pain and illness (eg, “Pain is something in my tummy.”). Children with concrete operational thought can appreciate that pain and illness are related, but they may not have a clear understanding of the causation of pain (eg, “Pain is a feeling you get when you are sick.”). Older children and adolescents begin to understand the complex physical and psychologic components of pain. For example, they realize that although the bone in the arm is broken, pain is ultimately felt in the head (eg, “Pain goes up some nerves from the broken bone in my arm to my head.”).
Guidelines for Doctor-Child Communication
A developmental framework that accounts for children’s language skills and causal reasoning abilities is essential in providing appropriate health care to children. Successful communication with children depends not only on spoken words but also on nonverbal cues and the environment itself. A pleasant, child-friendly environment with bright colors, age-appropriate wall decorations, and toys helps make children feel more comfortable. Health professionals should be sincere, because children are extremely sensitive to nonverbal cues. The pediatrician should take a few minutes to enjoy time with the child; this not only gives the child a chance to evaluate the physician but also allows the clinician to begin assessing areas of development. A general principle of the pediatric examination is to begin with the least invasive portions of the examination (eg, heart, lungs, abdomen) and save the most invasive for last (eg, oropharynx, ears). Pediatricians should maintain their self-control in difficult situations. If they approach their limit, they should step outside for a few minutes or ask someone for assistance. Guidelines for physician-child communication are provided in Box 3.1. Age-specific guidelines exist for children from birth to 6 months of age, 7 months to 3 years of age, 3 to 6 years of age, 7 to 11 years of age, and 12 years and older.
Birth to 6 Months of Age
Newborns and infants through 6 months of age have not yet developed a fear of strangers and can therefore usually be easily examined in a parent’s arms or on the examination table. Although verbal interaction is limited, it is important to play with newborns and infants, hold them, and talk to them. By watching physicians interact with their infants, new parents have an opportunity to learn how to behave with their infants.
Seven Months to 3 Years of Age
Infants and children 7 months through 3 years of age are perhaps the most challenging with whom to develop rapport and on whom to perform examinations. After entering the examination room, pediatricians should take a few moments to converse or play with these infants and children. Such actions help put children at ease and allow them to get to know their doctor. Children 1 to 2 years of age will likely busy themselves exploring the room during the history taking. By acknowledging them periodically, physicians build rapport that will help later during the examination. Children 2 to 3 years of age are usually very apprehensive of the examination. The physician should get down to children’s eye level when speaking to them. If applicable and true, reassurances such as, “You’re not going to get any shots today,” can help alleviate their fears. Making false promises, however, can be detrimental to developing a trusting relationship. Because stranger anxiety has developed, the physician should try to do as much of the examination as possible with the child in the parent’s lap. Distractions such as stethoscope toys, flashing penlights, or keys may be helpful.
Adapted with permission from Bibace R, Walsh ME. Development of children’s concepts of illness. Pediatrics. 1980;66(6):912–917.
Box 3.1. Physician-Child Communication
•Provide a pleasant environment.
•Pay attention to nonverbal cues.
•Be sincere and honest.
•Enjoy interacting with the child.
•Speak to the child in an age-appropriate manner.
•Get down to the child’s eye level.
•Examine from least to most invasive.
•Respect the child’s privacy.
•Have a sense of humor.
•Limit the child’s participation.
•Threaten the child.
•Compare the child to others.
•Engage in power struggles.