Assessing children and adolescents really is an art, maybe more so than it is even a highly sophisticated science. Children themselves don't really seek or desire primary care, so often the reason they present initially is more a concern of mom or dad, but that isn't what later reveals itself within the visit once the littler one begins to share.
Children aren't always the best at articulating their symptoms either, so there can be a bit of discerning required for the practitioner, but to really be good at this, trust must be quickly established and even before trust, the child or teenager must feel quite comfortable in the office and safe with the practitioner. A rapport built over time can be incredibly advantageous then before emergencies occur, or before behavioral or emotional concerns present which create great vulnerability and even isolation.
Imagine then if your child has a concern that is embarrassing, not to you maybe, but to them. They are even less likely to share and maybe they haven't even shared these concerns with you, in spite of your having a really healthy and loving relationship. Many of us also worry about what our children may share as well, and how that information will be handled by the practitioner, so again, we default to remaining within our familiar, and seemingly safe, bubble.
Funny story, I just saw a mother share today that her child was in the emergency room and when her son was asked if he felt safe at home, he said no. She was then asked to step outside the room and a social worker was called to talk to the child. The mother was laughing in her social media post because her son hadn't been given the opportunity to yet share that the reason he felt unsafe was because he hated the family cat. Thankfully, she found the humor in this, but I imagine so many other parents would feel absolute terror, even a bit violated.
Imagine though having an unexpected situation that causes your little one to end up in the emergency room, and child protective services is called just for precaution - maybe your child swallowed a penny and it's their policy that protective services are called to rule out any potential neglect. You have a healthy relationship with your primary care provider though, so you reach out to her and she is available to act as your family's advocate. Even more simply, it can mean the world just to have someone to call when you want a second opinion when you child is facing emergency management or needs follow-up after dismissal. Our role, at least in my eye, is to be your trusting guide, your family's advocate, educator and expert healer.
Intentions of Primary Care for the Child
My goal as a practitioner, is to build a relationship with your child, so not only can I be a safe and encouraging advocate in an emergency, in those unexpected times when medical care is a necessity, but also be a source of education and accountability for optimizing their wellness.
My practice is modeled around supporting clients, young and old, to really honor themselves, to hold space for their needs, to check in and explore how they might better optimize their health so they can live a life full of vitality. While we have the best intentions as parents, our schedules are packed and our resources are few, so to have an alley in that aspect of our roles can be tremendous - someone to help carry the load, to offer another perspective.
Primary care for pediatrics isn't just about ensuring there is no mysterious underlying pathology, but also about acknowledging the individual needs that often go unchecked because life keeps us busy. When you live in the fish bowl it can be challenging to see it has gotten a bit murky and once murky, it can be hard to breathe and simultaneously evaluate your options. This is my role, my expertise.
The goal of the clinical exam is to then formulate a case that guides management decisions. We dig into epigenetics to better understand the potential for your child, good and bad, but more specifically how to best accommodate their environment, their challenges, and understand themselves better so that into the future they can see earlier warnings of dis-ease and course correct.
Wellness is about so much more than our physical wellness though; it's also about our emotional health, our boundaries, our relationships, our ability to identify and communicate feelings, and it's about our understanding of who we are in all of this. Understanding how we best learn, what we need to feel safe and loved, and how we grow as people and heal from bumps along the way is all part of maximizing our vitality. Identifying disease and prescribing medication or even supplements only goes so far when we are also battling interpersonal relationship issues, fear, overwhelm, or feelings of hopelessness. Yes, our little ones feel these things too and they do impact their health. True primary care is self-care which our practice takes to heart; our model is to empower through education. We also have the desire of offering like-minded community and connection.
The clinical assessment or a wellness plan then is so much bigger than listening to heart and lungs, which is important, but it is a culmination of these individual components of each person. It's creating a holistic view of the child's unique needs and helping them create a plan that best meets their needs for growth in any area of their lives. This may be dis-ease focused for some, in some seasons of their lives, but for most, this will be about identifying trauma, learning to communicate feelings, even identifying needs and drawing healthy boundaries. It may be about evaluating our relationships, exploring new thoughts and ideas, even allowing our bodies to move and feel more grounded.
When I was in my family practice internship, my school sent someone to observe and essentially audit my progression in the clinical setting. While she was kind and offered much praise, her one area of critique was that I asked for consent from a ten-year-old boy to raise his shirt and listen to his belly. I was taken a bit back and shared that this was exactly my intent, that consent was an important part of what I wanted to teach children. Her response was that no, this wasn't appropriate, because what if he refused? Then I wouldn't be able to complete my exam.
I expressed my position that I felt as a primary healthcare care provider, creating a safe and trusting relationship, particularly with regards to bodily autonomy was a far greater priority than this child's bowel sounds, particularly since he was presenting for issues unrelated. My option if he would to refuse would be to respect that and to bring him back sooner to gain another opportunity as his comfort grew as I continued to earn his trust. This is true too of the quiet child. Anxiety may make them slow to warm up, so bring them back so they can ease into the consultation at their own pace. We need not practice purely from a paternalistic perspective; we aren't emergency medicine and if this is the limited exposure you offer your child, understandably they may develop great anxiety as they will likely feel violated.
This is true too of the care plan in itself. Immediate compliance isn't our objective; rather, good rapport is the goal. When we offer them a safe, confidential, nonjudgmental place to "unburden" and discuss possible solutions to their difficulties, here is where we maybe offer them our greatest healing gifts. Compliance, therefore, becomes a byproduct of the therapeutic alliance with the child. When we have to treat clients within an insurance model, it can be hard to break free and do what is needed for this individual client at this time, but our model truly does allow us to prioritize what is truly important.
Direct communication with the child, acknowledging their understanding of the situation, and building a shared understanding, even if simplistic, is fruitful in the long-run. When information is presented to the child and not to the parent, outcomes are improved. We can't assume that all interventions trickle down through the parent, as once home, the child may not be as willing to embrace these recommendations when they were part of the initial discussion. It warms my heart to have little ones come through the front door excited to see "Dr. Layne," to bring me pictures they've colored, or to send me pictures of them doing yoga in their front yard.
When children visit the clinic and they have some level of developmental delays or specific deficits in speech or even social issues, they may find expressing themselves especially challenging which may leave them feeling very isolated. I can't express enough how important it is that these younger ones be given a safe space and the time to truly find comfort to open up and share. When disruptive behavior and substance abuse or even self-harm is part of the picture, kids will certainly be apprehensive about opening up.
I think too of my own boys, now 13 years and 16 years, when they are working to establish self and their group identities. Kids this age are extremely sensitive to the disapproval of peers, interests or behaviors. In an effort to "protect" these, they refuse to talk about these issues. Easing in here is vital if we want to get to the heart of any real concerns, but so is building rapport with parents. Understanding a child or teens temperament is an important part of their health and wellness evaluation. This reflects on their reactivity to environmental situations and their capacity for self-regulation. It is essentially a reflection of social and emotional development in a child.
Developing the Relationship over Time
History and examination are not watertight compartments, in that this won't allow me to catch everything even if I am incredibly thorough, nor will it allow me to develop a truly therapeutic relationship. Consistency is key and this is necessary as well for advocacy. Mental states in children and adolescents have a higher intensity often times, and frequency in variations than they do in adults, so serial examinations are more useful in getting a true picture about their mental health.
Children and adolescents aren't always ready to immediately open up and share their experiences, feelings, and thoughts either. Adolescents especially are very concerned about not being believed, or being considered weak or different. They often put a lot of time and energy into "normalizing" their experiences or denying them. Confidentiality boundaries are important to clarify here, but so is effort in validating their experiences and feelings.
Truly, building a trusting relationship with a primary care provider can be an incredible investment for your child.