After the child’s sixth birthday and until adolescence, developmental assessment is initially done by inquiring about school performance (academic achievement and behavior). Inquiring about concerns raised by teachers or other adults who care for the child (after-school program counselor, coach, religious leader) is prudent. Formal developmental testing of these older children is beyond the scope of the primary care pediatrician. Nonetheless the health care provider should be the coordinator of the testing and evaluation performed by other specialists (e.g., psychologists, psychiatrists, developmental pediatricians, and educational professionals).
Ignorance of the environmental influences on child behavior may result in ineffective or inappropriate management
Congenital hearing loss in first cousin or closer relative Bilirubin level of ≥20 mg/dL Congenital rubella or other nonbacterial intrauterine infection Defects in the ear, nose, or throat Birth weight of ≤1500 g Multiple apneic episodes Exchange transfusion Meningitis Five-minute Apgar score of ≤5 Persistent fetal circulation (primary pulmonary hypertension) Treatment with ototoxic drugs (e.g., aminoglycosides and loop
Health (past and current) Developmental status Temperament (e.g., difficult, slow to warm up) Coping mechanisms
Misinterpretations of stage-related behaviors Mismatch of parental expectations and characteristics of child Mismatch of personality style between parent and child Parental characteristics (e.g., depression, lack of interest, rejection,
Stress (e.g., marital discord, unemployment, personal loss) Support (e.g., emotional, material, informational, child care) Poverty Racism (or both). Table 8-4 lists some contextual factors that should be considered in the etiology of a child’s behavioral or developmental problem.
Building rapport with the parents and the child is a prerequisite for obtaining the often sensitive information thatis essential for understanding a behavioral or developmentalissue. Rapport usually can be established quickly if the parents sense that the clinician respects them and is genuinelyinterested in listening to their concerns. The clinician develops rapport with the child by engaging the child in developmentally appropriate conversation or play, perhaps providingtoys while interviewing the parents, and being sensitive to thefears the child may have. Too often the child is ignored until itis time for the physical examination. Similar to their parents,children feel more comfortable if they are greeted by name and involved in pleasant interactions before they are askedsensitive questions or threatened with examinations. Youngchildren can be engaged in conversation on the parent’s lap,which provides security and places the child at the eye levelof the examiner.
With adolescents emphasis should be placed on building a physician-patient relationship that is distinct fromthe relationship with the parents. The parents should not beexcluded; however the adolescent should have the opportunity to express concerns to and ask questions of the physician in confidence. Two intertwined issues must be taken into consideration—consent and confidentiality. Althoughlaws vary from state to state, in general, adolescents whoare able to give informed consent (i.e., mature minors) mayconsent to visits and care related to high-risk behaviors (i.e.,substance abuse; sexual health, including prevention, detection, and treatment of sexually transmitted infections; and pregnancy). Most states support the physician who wishesthe visit to be confidential. Physicians should become familiar with the governing law in the state where they practice (see www.guttmacher.org/statecenter/updates/index.html ). Providing confidentiality is crucial, allowing for optimal care(especially for obtaining a history of risk behaviors). Whenassessing development and behavior, confidentiality can beachieved by meeting with the adolescent alone for at least part of each visit. However parents must be informed whenthe clinician has significant and immediate concerns aboutthe health and safety of the child. Often the clinician canconvince the adolescent to inform the parents directly abouta problem or can reach an agreement with the adolescentabout how the parents will be informed by the physician (seeChapter 67).