Jump to the Psychosocial Assessment of the Pediatric Patient
I. The Pediatric Examination Is Performed under the Critical Eye of the Parent
The good historian should be sensitive to the mother's anxieties; the competent examiner should make certain that these anxieties are relieved. The area of concern should be examined with special care and all findings of the entire examination should be explained to the parent as simply and thoroughly as possible.
The behavior of the mother during the examination may tell the examiner much about her, her reactions to stress, and her attitude toward the child. Parental presence during the examination sometimes intensifies patient resistance. Handle each situation individually; skill in this area comes with experience.
II. The Child Is an Unwilling Subject
The pediatrician often deals with an uncooperative patient who can disrupt the examination in a number of ways. The child can scream, kick, fight, urinate or vomit, all or any of which can interfere with the orderly sequence of any examination.
The examiner must plan a course of action which serves to put the child at ease, relieve the child's fears, and give the child a chance to become accustomed to the situation. The examiner may pretend to ignore the child completely at first while talking to the mother, avoid eye contact with the child, allow a wary toddler to play with his stethoscope, or chat for a short time with an older child. Any ploy which makes the examiner less threatening to the child may prepare him better for the subsequent examination.
The prudent examiner may find it necessary to listen to the child's heart and lungs while he is held in his mother's arms, or palpate the child's abdomen while the child is spread across her lap. Never examine the child's ears and throat first.
In short, the best general rule to follow performing a pediatric physical examination is to be flexible. Thoroughness is essential, but the order and method one follows in examining a child is not important.
III. Observation is the First and Most Important Step in the Examination
Considerable information can be gained by observation of the child before proceeding with the actual examination. This information will be of great value in assessing the severity of the illness and will provide valuable clues in arriving at a diagnosis.
Does the child appear to be well, acutely ill or chronically ill? Lethargic, alert? Does he or she appear to be in pain? What is his or her state of nutrition? In the older child, is the patient apprehensive? Facies is important, both from the point of view of severity of illness and a variety of clinical entities. Are the eyes sunken? Is nystagmus present? What is the color of the skin -- pale, cyanotic, icteric? (In black children, pallor and cyanosis can best be determined by inspection of the mucous membrane and nail beds. Icterus can be evaluation by inspection of the sclerae.) Is a rash present and if so, is it macular, papular, petechial or vesicular?
What is the character of the cry? Is it weak (a seriously ill infant or child), strong (often a good sign, but may indicate pain), hoarse (laryngitis, epiglottitis, foreign body in the larynx, hypothyroidism, intrinsic laryngeal pathology, congenital mitral stenosis), high-pitched (intracranial pathology), infrequent (mongolism, hypothyroidism), excessive ("colic," pain, parental anxiety), unusual (cri du chat)?
What is the character of the respirations? Rate (consider age, fever, crying), depth, dyspnea (flaring of nose, grunting, retractions, use of accessory muscles of respiration - thoracic & abdominal), wheezing (with bronchiolitis, asthma, foreign body, vascular ring), stridor (laryngeal pathology, foreign body in larynx), brassy cough (tracheobronchitis in early stages, extrinsic pressure on trachea), loose cough (upper respiratory infection, pneumonia)?
Observe the position of the child. Is the head tilted to one side (torticollis, cerebellar tumor) or held in a retracted position (retropharyngeal abscess, tumor at base of tongue)? Patients with peritoneal inflammation (appendicitis) may lie on the unaffected side and keep the leg flexed at the hip and knee. Patients who have pain due to an inflammatory process of the pleural cavity may lie on the affected side in order to sling this side, avoiding pain with respiration.
Does the child have an odor of any kind? Mousy odor (PKU disease), maple syrup odor of urine (maple syrup urine disease), fetid odor from nose (foreign body), fetid mouth odor (gingivostomatitic of numerous cases, dental caries), acetone breath (diabetic ketoacidosis), noxious mouth odor (ingestion of agents such as kerosene, bleach, glue, alcohol), fetid ear odor (chronic otitis media or externa), foul odor of umbilical area (omphalitis), foul odor of vaginal area (poor hygiene, foreign body).
Are there any unusual muscular movements present? Tremors, twitching of facial muscles, tonic, clonic choreiform or athetoid movements of various muscles, extremity or truncal, absence of movement from one or more extremities.
Before the examiner even touches the patient, he or she has had an opportunity to make several important observations which may, by their presence or absence, help him in his evaluation of the child.
IV. The Child is a Growing Dynamic Subject and Normality Must Be Evaluated in the Context of Age
In evaluating the child from infancy through adolescence, the pediatrician is confronted with an enormous range of physical and developmental patterns that he must interpret as normal or abnormal. The child is constantly changing and a dynamic subject; the younger the child, the greater the rate of change and variability in findings.
Therefore, it is essential for a pediatrician to know normal standards at different ages for a variety of factors - weight, height, body proportions, head circumference, organ size, developmental patterns of psychomotor achievement and the accepted ranges of normal. He or she must be able to assess the rate of change in a particular child in relationship to his state of health, environmental factors, and genetic factors. The pediatrician must decide whether or not a problem exists and if treatment is indicated. It is only with thorough knowledge of the normal values at any given age that the pediatrician will be able to evaluate a patient intelligently and treat him or her judiciously.
Although the pediatrician is not a social worker, certain minimal information about the psychosocial aspects of a child/adolescent's life will clearly enhance the care you are attempting to provide in the pediatric clinic. When a chart is reviewed without information about the psychosocial aspects of a child's life, the reviewer will assume that you did not ask about this area. As there is often confusion as to what constitutes a psychosocial history, the following information may help you to better direct your inquiries. Once you have obtained this information, record it in the visit note!
According to Nelson, a psychosocial assessment considers the child's emotional and social development and its deviations and disturbances in interactional terms between the fetus, infant, or child and his environment. The issues addressed in the assessment will vary dependent upon the age of the child. It is heavily dependent upon biological endowment and parental/guardian factors, the environment and the culture in which the child is raised. The assessment should cover such aspects as:
The family should be questioned about adoptive/foster care status, number and frequency of moves, separation and death (especially of a previously important person in the child's life), television watching, school attendance and performance, etc.
For all aged children, inquiries should be made as to who is caring for the child during the day (the primary caretaker). Does the parent work? Who helps the parent during the day? Has there been a change in the household composition, is there someone who frequently visits the home? What is the parental concept of age-appropriate behavior for this child and is that concept developmentally appropriate? Issues of safety and discipline should always be discussed, for these may not match current developmental status. Always ask about parental concerns. This gives a sense of parental involvement and indicates areas where additional anticipatory guidance may be needed.
For the younger age child, much of this assessment will be based on the parental/guardian history of certain development/behavioral issues (speech, cognitive skills, social adjustment, etc.) If the child is living with the parent and this is an infant, you might inquire as to maternal acceptance of this child. Was this a wanted pregnancy? How is the child fitting into the family? Does the mother have any help with the child? Is there a father figure in the picture? You can observe the parent in your office -- how does she hold the child? making eye contact? or holding the child like a "sack of potatoes." Ask about feeding behaviors and routines. Inquire about maternal responses to crying and other infantile behavior patterns. Does the parent play with the child, take delight in the child and his/her activities? Or does the parent ignore the child?
For the toddler and early preschool-age child, one needs to inquire about activities that begin to indicate striving for autonomy on the part of the infant. (Please note that strivings for autonomy occur at an earlier age, but may not be perceived as that.) Often parents interpret these initial efforts as being issues of discipline and punish the child rather than view the efforts for what they are. Many parents are unable to separate discipline from punishment. Discipline involves setting limits and teaching rules. Punishment is meted out in response to violation of rules. Until the child is able to understand what the rules are, punishment is inappropriate. One must also remember that for many parents, punishment = spanking, something that may be inappropriate for the age of the child. Positive and negative behaviors need to be explored as well as parental responses to both. Can the child separate from the parent? Is there age-appropriate stranger anxiety?
For the school-aged child, school is the "work" of a child and responses to school experiences are very important. Are the learning problems, behavior problems? Does the child have friends? When the child is not in school is he/she supervised or is he/she in self-care? Are there opportunities for large muscle activities or is free time spent in front of the television? Does the child enjoy the school experience? Is the child developing self-confidence? Although this period is called the latency period, it is in fact a very active period of growth. The child develops interpersonal skills as well as other cognitive skills which form the background for the next developmental stage. As is true for the other ages, unless the child masters the tasks of the age level, there will be significant unresolved issues brought into the next period, i.e. adolescence.
During the preadolescent period, in addition to the usual aforementioned information gathered about the child, one must begin to explore sexual development and other social issues that are charged with emotion (sexual activity, smoking, drugs, alcohol use/abuse). The issues need to be discussed before they become problem issues for both parent and child. The changes in the body that occur during this time period are of significant concern to the preadolescent/adolescent. How is he/she adjusting to these normal changes? School performance and life goals remain concerns of both the preadolescent/adolescent and the parent. The increasing independence of the child makes it important to ask the child and the parent separately about these issues. If you have seen this child over a period of time, you can very easily begin to lay the ground work for the child-physician interaction. Without a positive relationship at this time, information gathered will be limited and help with problems will not easily be accepted.
Although parents may feel that they have limited influence with children at this time, they need to be reminded to remain in touch with their preadolescents and adolescents. While there may be many stormy encounters and wide swings in the behavior of the preadolescent/adolescent during this period, if the parent is able to remain objective and open to communication, as this period draws to a close, the adolescent may be more receptive to their advice. As adolescence progresses, risk-taking behaviors become more common and often become a source of conflict between parent and child. The physician has to be very careful to retain the trust of the adolescent without alienating the parent. Where possible, continue to encourage the adolescent-parent relationship.
Psychosocial problems are manifest by disturbances in:
The above list is not inclusive and other issues may be identified in the course of the psychosocial assessment. When the above or other problems are identified, there may be a need for further evaluation by either a social worker, psychologist, or psychiatrist.
Further information and suggested formats for eliciting information concerning psychosocial issues at the various stages of life can be found in Guidelines for Health Supervision II, Committee on Psychosocial Aspects of Child and Family, 1985 - 1988 published by the American Academy of Pediatrics in 1988.