Techniques for Examining the Fearful Child
Janet H. Friday
Fred M. Henretig
Introduction
In caring for children in the outpatient setting, most of us have been humbled at some time by the difficulty of examining an uncooperative child. Although no single fail-proof technique exists to avoid this problem, a calm and relaxed approach that incorporates knowledge of developmental stages can smooth the interaction (1,2,3,4,5). This method should not significantly increase the time spent on the examination. Instead, it will help to establish a relationship with the family, provide a basis for future interventions, and allow an optimal diagnostic evaluation in a timely manner. A related subject, minimizing fear and anxiety during procedures, is discussed in Chapter 33.
Physiology: Normal Developmental Stages
Recognition of childhood developmental stages and their accompanying issues will help the examining physician to interact with the child in a way that optimizes patient comfort and acceptance of the examination (Table 2.1).
Infants (Birth to 1 Year)
Until the appearance of stranger anxiety around 8 to 9 months of age, the infant examination is not constrained by fear; however, infants are quite sensitive to their immediate environment. After stranger anxiety appears, the infant may be threatened by the physician’s presence and will remain most cooperative in a parent’s arms.
Toddlers (1 to 3 Years)
Although the young toddler may appear relatively nonverbal, the child’s receptive language skills develop sooner than the expressive ones. Therefore, the physician must be careful of what is said in the child’s presence. The toddler is most cognizant of his or her developing individuality and independence. The negativism of the “terrible twos” is prevalent. The child fears separation from the parents and will be best examined in a parent’s lap.
Preschool-Age Children (3 to 5 Years)
The preschooler has developed expressive skills and a strong concept of self. Magical thinking and fantasy play become important during preschool years and can be incorporated into the examination.
School-Age Children (5 to 10 Years)
Development of logic and reason and a good grasp of language allow the older child to cooperate with the examination. An understanding of body function and structure can be incorporated during these years. Even before the development of sexual maturation, modesty will emerge and should be anticipated.
Adolescents (10 to 19 Years)
In general, cooperation with the physical examination is not an issue with the adolescent. However, appreciation for the importance of the adolescent’s particular issues with autonomy, peer group importance, self-determination, and control will certainly ease the interaction.
TABLE 2.1 Developmental Approach to Pediatric Emergency Care Patients | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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