Responses to open-ended questions often provide clues to underlying, unstated problems and identify the appropriate direction for further, more directed questions. Histories about developmental and behavioral problems are often vague and confusing; to reconcile apparent contradictions, the interviewer frequently must request clarification, more detail, or mere repetition. By summarizing an understanding of the information at frequent intervals and by recapitulating at the close of the visit, the interviewer and patient and family can ensure that they understand each other.
If the clinician’s impression of the child differs markedlyfrom the parent’s description, there may be a crucial parental concern or issue that has not yet been expressed, eitherbecause it may be difficult to talk about (e.g., marital problems), because it is unconscious, or because the parent overlooks its relevance to the child’s behavior. Alternatively thephysician’s observations may be atypical, even with multiplevisits. The observations of teachers, relatives, and other regular caregivers may be crucial in sorting out this possibility. The parent also may have a distorted image of the child,rooted in parental psychopathology. A sensitive, supportive,and noncritical approach to the parent is crucial to appropriate intervention. More information about referral and intervention for behavioral and developmental issues is covered inChapter 10.
Health maintenance or supervision visits should consist of a comprehensive assessment of the child’s health and of theparent’s/guardian’s role in providing an environment for optimalgrowth, development, and health. Bright Futures standardizeseach of the health maintenance visits and provides resourcesfor working with the children and families of different ages(see www.brightfutures.aap.org ). Elements of each visit includeevaluation and management of parental concerns; inquiryabout any interval illness since the last physical, growth, development, and nutrition; anticipatory guidance (including safetyinformation and counseling); physical examination; screening tests; and immunizations (Table 9-1). The Bright Futures’“Recommendations for Preventive Pediatric Health Care,” found at http://brightfutures.aap.org/clinical_practice.html , summarizes requirements and indicates the ages that specificprevention measures should be undertaken, including riskscreening and performance items for specific measurements.Bright Futures is now the enforced standard for the Medicaid
Concerns (parent’s or child’s) Past problem follow-up Immunization and screening test update Routine care (e.g., eating, sleeping, elimination, and health habits) Developmental progress Behavioral style and problems
Caregiving schedule for caregiver who lives at home Parent-child and sibling-child interactions Extended family role Family stresses (e.g., work, move, finances, illness, death, marital and other interpersonal relationships) Family supports (relatives, friends, groups)
Caregivers outside of the family Peer interaction School and work Recreational activities and the Children’s Health Insurance Program, along with manyinsurers. Health maintenance and immunizations now are covered without co-pays for insured patients as part of the PatientProtection and Affordable Care Act.
Children usually are quite healthy and only the following screening tests are recommended: newborn metabolic screening with hemoglobin electrophoresis, hearing and vision evaluation, anemia and lead screening, and tuberculosis testing. Children born to families with dyslipidemias or early heart disease should also be screened for lipid disorders. (Items marked by a star in Bright Futures’ recommendations should be performed if a risk factor is found.) Sexually experienced adolescents should be screened for sexually transmissible infections. When an infant or child begins care after the newborn period, the pediatrician should perform any missing screening tests and immunizations.