- Email: [email protected]
Developmental strategies for interviewing children
PH C
CLINICAL REPORT
GROWTH AND DEVELOPMENT
SECTION EDITOR Susan L. Instone, DNSc, CPNP U n ive r s i t y o f S a n D i e g o San Diego, California
Developmental Strategies for Interviewing Children
Susan L. Instone, DNSc, CPNP
E
ngaging children during a clinical interview can be one of the more rewarding and challenging aspects of providing pediatric health care. While it may be easier and more efficient to elicit only the parents’ perspective about the reason for the visit and the relevant history, nurse practitioners and other health care professionals risk the loss of important data unless the children’s perceptions are also elicited. These perceptions can reveal their understanding or misconceptions about health and illness, demonstrate their receptive and expressive language capacities, and provide insight into their social-emotional adjustment. Furthermore, directly involving children in the interview conveys our interest in them as individuals, models a mutual and reciprocal style of interaction for parents and guardians, and establishes a therapeutic alliance for future clinical encounters. Experience and research demonstrate that children as young as 3 years of age can participate in the clinical interview. Child development experts have advocated for decades that children can be effectively involved (Faux, Walsh, & Deatrick, 1988; Rich, 1968; Yarrow, 1960). Even in the current practice milieu of shorter primary care visits, a recent study suggests that primary care providers still actively interview children despite these time constraints. This study of 250 Midwestern pediatricians found that 84% obtained part of
304
the history from preschool children (usually information about toys, activities, playmates, and school), while over 96% of the sample directly interviewed school-age children and adolescents for some or most of the history (Mendelsohn, Quinn, & McNabb, 1999). Given the capacity for children to make important contributions to the clinical interview, the use of developmental strategies can further enhance these interactions.
Interview Climate Creating a therapeutic climate for the pediatric interview should be one of the clinician’s primary goals. Stein (2000) suggests that the clinical interview can be conceptualized as a planned educational encounter where the developmental needs of children and parents are thoughtfully considered. Attention to the physical setting (safe, childfriendly décor and furnishings in the examining room) establishes the pediatric office or clinic as a non-threatening, pleasant environment where children and parents can feel comfortable.
Allowing children to choose where to sit or stand, and giving them access to age-appropriate activities and toys before and during the interview will help to establish rapport, alleviate strangeranxiety, and enlist cooperation. Parents can be encouraged to keep infants and young children, especially when ill, on their lap if they wish. Other children might prefer to draw, an activity that often captures the child’s interest and serves as a means of non-verbal communication about important issues (Welsh & Instone, 2000). Adolescents should be interviewed separately, although some clinicians prefer to begin the encounter with the parent in the room to enlist mutual concerns. Appreciation of cultural values that influence parents’ or children’s willingness to discuss sensitive issues will also enhance the quality of the interview. Even the time of day can affect how the children interact, especially if they do not feel well. Seeing a sleepy adolescent early in the morning or a cranky preschooler during her usual naptime can result in a less-than-optimal encounter.
Susan L. Instone is Assistant Professor of Nursing at the Hahn School of Nursing and Health Science, University of San Diego, Ca. Reprint requests: Susan Instone at 1223 Crest Road, Del Mar, CA 92014; e-mail: [email protected]. J Pediatr Health Care. (2002). 16, 304-305. Copyright © 2002 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2002/$35.00 + 0
25/1/128766
doi:10.1067/mph.2002.128766
November/December 2002
PH GROWTH AND DEVELOPMENT C Content Strategies The purpose of the visit (health supervision, illness, developmental-behavioral concern) determines the content of the interview, or put simply, what information is needed from the parent and child about the reason for the visit. A wide range of detailed interview guidelines is available. For example, the American Academy of Pediatrics (1998) and Bright Futures (2002), a project of the National Center for Education in Maternal Child Health, provide developmentally-appropriate questions to ask children during visits for health supervision. Sattler (1998) offers a comprehensive set of semi-structured interview questions designed for children with a range of chronic physical and psychosocial problems, such as substance abuse, learning disabilities, and diabetes. Eliciting information from children and adolescents should generally proceed from topics that are typically less threatening, such as friends, school, and hobbies, to more sensitive issues, such as concerns, fears, or risk behaviors. The use of simple terminology and concrete language with younger children is important. For example, questions for the preschool and school-age child that focus on what the child “would do” in a given situation rather on how the child “would feel” may more readily encourage a response. With the emergence of adolescents’ abstract thinking, the clinical interview can focus on the insights they are developing into themselves, their families, and the lifestyle choices they are beginning to make. Open-ended questions during adolescent health supervision visits, such as “tell me how things are going at school this year,” create a nonthreatening opportunity for teens to elaborate and reflect on their experiences, both positive and negative. In addition, the construction of the interview question depends upon the sensitivity of the information desired. Direct questions are appropriate for obtaining basic information (such as age, name of school, etc.) but are rarely useful for uncovering thoughts or feelings about topics that are taboo or have threatening undertones (Kanfer, Eyberg & Krahn, 1992). Indirect and projective questions are generally more helpful for children who are reluctant to discuss difficult issues. Indirect ques-
JOURNAL OF PEDIATRIC HEALTH CARE
Instone
tions involve asking children what they would do or how they might feel in a hypothetical situation. Projective questions extend this idea so that the person involved in the hypothetical situation is not the child in your office, but a hypothetical child. For example, you might ask a child whose parent recently died in a car accident to respond to the following: “Once there was a little girl who lost her mommy in a plane crash. I wonder what that little girl did when her mommy died?” Sometimes children and parents repeatedly use evasions, such as “I don’t know” or “no,” in response to a line of questioning that may be too threatening during a clinical interview. It may be useful in this situation to defer the topic until later in the encounter or even to a subsequent visit. To evaluate inconsistencies in a child’s response, counter suggestions can be made by the clinician. This strategy involves the repetition of a question or statement in an alternate or opposite way (Inhelder & Piaget, 1964). For example, one might say, “Well, some kids tell me that they throw their toys when they get mad,” in response to children who deny ever doing anything destructive when they are angry.
Process Strategies The process of the clinical interview, or how the child, parent, and clinician interact, is even more vital to the success of the encounter than are the content and structure of the interview questions and verbal responses. In general, non-verbal cues are more powerful than the spoken word; how actively we listen, use attentive body language, and physically calm or reassure a distressed child or parent signifies our concern better than anything we say. It is helpful to position ourselves at eye level with our patients and their parents, although children under 2 years of age are more anxious when a stranger makes direct eye contact too soon. It is often better to initially direct our attention to the parent so that the child has time to adjust to our presence in the room. Another process strategy that enhances the clinical interview is the ability to carefully observe the child’s behavior and the quality of parent-child interaction for non-verbal cues to significant clinical issues. For example, a child’s depressed tone of voice, sad facial expression, and withdrawn body
posture are incongruent with a parent who says that “everything’s fine.” The astute clinician attends to these nonverbal cues and interprets them in the context of the child’s age, temperament, developmental stage, health history, and family situation. Foundational knowledge of normal variations in children’s behavior also helps to understand the situation. Taken together, these strategies can facilitate a developmentally sound approach to the clinical interview and foster the active participation of children in their health care. For parents, these health care encounters are opportunities to learn more about their child’s growing capacity to understand and communicate issues of concern about health or illness. As pediatric clinicians, the ability to model effective interaction with children of all ages should be a major component of professional expertise.
REFERENCES Bright futures: Guidelines for health supervision of infants, children, and adolescents (2nd ed., rev.). (2002). Arlington: National Center for Education in Maternal Child Health. Faux, S., Walsh, M., & Deatrick, J. (1988). Intensive interviewing with children and adolescents. Western Journal of Nursing Research, 10(2), 180194. Guidelines for health supervision. (1998) Elk Grove: American Academy of Pediatrics. Inhelder, B. & Piaget, J. (1964). The early growth of logic in the child. New York: W.W. Norton. Kanfer, R., Eyeberg, S., & Krahn, G. (1992). Interviewing strategies in child assessment. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology, 4th ed., pp. 49-62. New York: John Wiley & Sons. Medelsohn, J.S., Quinn, M.T., & McNabb, W.L. (1999). Interview strategies commonly used by pediatricians. Archives of pediatrics and adolescent medicine, 153(2), 154-157. Rich, J. (1968). Interviewing children and adolescents. New York: Macmillan & Co. Sattler, J. M. (1998). Clinical and forensic interviewing of children and families: Guidelines for the mental health, education, pediatric, and child maltreatment fields. San Diego: Jerome M. Sattler, Publisher, Inc. Stein, M.T. (2000). The development-based office visit: Doing more with each visit. In S. D. Dixon & M. T. Stein (Eds.), Encounters with children: Pediatric behavior and development, 3rd ed., pp. 47-65. St. Louis: Mosby. Welsh, J.B. & Instone, S.L. (2000). Use of drawings by children in the pediatric office. In S.D. Dixon & M.T. Stein (Eds.), Encounters with children: Pediatric behavior and development, 3rd ed., pp. 571-589. St. Louis: Mosby. Yarrow, L. (1960). Interviewing children. In P. Mussen (Ed.), Handbook of research methods in child development, pp. 561-602. New York: John Wiley & Sons.
November/December 2002
305
CLINICAL REPORT
GROWTH AND DEVELOPMENT
SECTION EDITOR Susan L. Instone, DNSc, CPNP U n ive r s i t y o f S a n D i e g o San Diego, California
Developmental Strategies for Interviewing Children
Susan L. Instone, DNSc, CPNP
E
ngaging children during a clinical interview can be one of the more rewarding and challenging aspects of providing pediatric health care. While it may be easier and more efficient to elicit only the parents’ perspective about the reason for the visit and the relevant history, nurse practitioners and other health care professionals risk the loss of important data unless the children’s perceptions are also elicited. These perceptions can reveal their understanding or misconceptions about health and illness, demonstrate their receptive and expressive language capacities, and provide insight into their social-emotional adjustment. Furthermore, directly involving children in the interview conveys our interest in them as individuals, models a mutual and reciprocal style of interaction for parents and guardians, and establishes a therapeutic alliance for future clinical encounters. Experience and research demonstrate that children as young as 3 years of age can participate in the clinical interview. Child development experts have advocated for decades that children can be effectively involved (Faux, Walsh, & Deatrick, 1988; Rich, 1968; Yarrow, 1960). Even in the current practice milieu of shorter primary care visits, a recent study suggests that primary care providers still actively interview children despite these time constraints. This study of 250 Midwestern pediatricians found that 84% obtained part of
304
the history from preschool children (usually information about toys, activities, playmates, and school), while over 96% of the sample directly interviewed school-age children and adolescents for some or most of the history (Mendelsohn, Quinn, & McNabb, 1999). Given the capacity for children to make important contributions to the clinical interview, the use of developmental strategies can further enhance these interactions.
Interview Climate Creating a therapeutic climate for the pediatric interview should be one of the clinician’s primary goals. Stein (2000) suggests that the clinical interview can be conceptualized as a planned educational encounter where the developmental needs of children and parents are thoughtfully considered. Attention to the physical setting (safe, childfriendly décor and furnishings in the examining room) establishes the pediatric office or clinic as a non-threatening, pleasant environment where children and parents can feel comfortable.
Allowing children to choose where to sit or stand, and giving them access to age-appropriate activities and toys before and during the interview will help to establish rapport, alleviate strangeranxiety, and enlist cooperation. Parents can be encouraged to keep infants and young children, especially when ill, on their lap if they wish. Other children might prefer to draw, an activity that often captures the child’s interest and serves as a means of non-verbal communication about important issues (Welsh & Instone, 2000). Adolescents should be interviewed separately, although some clinicians prefer to begin the encounter with the parent in the room to enlist mutual concerns. Appreciation of cultural values that influence parents’ or children’s willingness to discuss sensitive issues will also enhance the quality of the interview. Even the time of day can affect how the children interact, especially if they do not feel well. Seeing a sleepy adolescent early in the morning or a cranky preschooler during her usual naptime can result in a less-than-optimal encounter.
Susan L. Instone is Assistant Professor of Nursing at the Hahn School of Nursing and Health Science, University of San Diego, Ca. Reprint requests: Susan Instone at 1223 Crest Road, Del Mar, CA 92014; e-mail: [email protected]. J Pediatr Health Care. (2002). 16, 304-305. Copyright © 2002 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2002/$35.00 + 0
25/1/128766
doi:10.1067/mph.2002.128766
November/December 2002
PH GROWTH AND DEVELOPMENT C Content Strategies The purpose of the visit (health supervision, illness, developmental-behavioral concern) determines the content of the interview, or put simply, what information is needed from the parent and child about the reason for the visit. A wide range of detailed interview guidelines is available. For example, the American Academy of Pediatrics (1998) and Bright Futures (2002), a project of the National Center for Education in Maternal Child Health, provide developmentally-appropriate questions to ask children during visits for health supervision. Sattler (1998) offers a comprehensive set of semi-structured interview questions designed for children with a range of chronic physical and psychosocial problems, such as substance abuse, learning disabilities, and diabetes. Eliciting information from children and adolescents should generally proceed from topics that are typically less threatening, such as friends, school, and hobbies, to more sensitive issues, such as concerns, fears, or risk behaviors. The use of simple terminology and concrete language with younger children is important. For example, questions for the preschool and school-age child that focus on what the child “would do” in a given situation rather on how the child “would feel” may more readily encourage a response. With the emergence of adolescents’ abstract thinking, the clinical interview can focus on the insights they are developing into themselves, their families, and the lifestyle choices they are beginning to make. Open-ended questions during adolescent health supervision visits, such as “tell me how things are going at school this year,” create a nonthreatening opportunity for teens to elaborate and reflect on their experiences, both positive and negative. In addition, the construction of the interview question depends upon the sensitivity of the information desired. Direct questions are appropriate for obtaining basic information (such as age, name of school, etc.) but are rarely useful for uncovering thoughts or feelings about topics that are taboo or have threatening undertones (Kanfer, Eyberg & Krahn, 1992). Indirect and projective questions are generally more helpful for children who are reluctant to discuss difficult issues. Indirect ques-
JOURNAL OF PEDIATRIC HEALTH CARE
Instone
tions involve asking children what they would do or how they might feel in a hypothetical situation. Projective questions extend this idea so that the person involved in the hypothetical situation is not the child in your office, but a hypothetical child. For example, you might ask a child whose parent recently died in a car accident to respond to the following: “Once there was a little girl who lost her mommy in a plane crash. I wonder what that little girl did when her mommy died?” Sometimes children and parents repeatedly use evasions, such as “I don’t know” or “no,” in response to a line of questioning that may be too threatening during a clinical interview. It may be useful in this situation to defer the topic until later in the encounter or even to a subsequent visit. To evaluate inconsistencies in a child’s response, counter suggestions can be made by the clinician. This strategy involves the repetition of a question or statement in an alternate or opposite way (Inhelder & Piaget, 1964). For example, one might say, “Well, some kids tell me that they throw their toys when they get mad,” in response to children who deny ever doing anything destructive when they are angry.
Process Strategies The process of the clinical interview, or how the child, parent, and clinician interact, is even more vital to the success of the encounter than are the content and structure of the interview questions and verbal responses. In general, non-verbal cues are more powerful than the spoken word; how actively we listen, use attentive body language, and physically calm or reassure a distressed child or parent signifies our concern better than anything we say. It is helpful to position ourselves at eye level with our patients and their parents, although children under 2 years of age are more anxious when a stranger makes direct eye contact too soon. It is often better to initially direct our attention to the parent so that the child has time to adjust to our presence in the room. Another process strategy that enhances the clinical interview is the ability to carefully observe the child’s behavior and the quality of parent-child interaction for non-verbal cues to significant clinical issues. For example, a child’s depressed tone of voice, sad facial expression, and withdrawn body
posture are incongruent with a parent who says that “everything’s fine.” The astute clinician attends to these nonverbal cues and interprets them in the context of the child’s age, temperament, developmental stage, health history, and family situation. Foundational knowledge of normal variations in children’s behavior also helps to understand the situation. Taken together, these strategies can facilitate a developmentally sound approach to the clinical interview and foster the active participation of children in their health care. For parents, these health care encounters are opportunities to learn more about their child’s growing capacity to understand and communicate issues of concern about health or illness. As pediatric clinicians, the ability to model effective interaction with children of all ages should be a major component of professional expertise.
REFERENCES Bright futures: Guidelines for health supervision of infants, children, and adolescents (2nd ed., rev.). (2002). Arlington: National Center for Education in Maternal Child Health. Faux, S., Walsh, M., & Deatrick, J. (1988). Intensive interviewing with children and adolescents. Western Journal of Nursing Research, 10(2), 180194. Guidelines for health supervision. (1998) Elk Grove: American Academy of Pediatrics. Inhelder, B. & Piaget, J. (1964). The early growth of logic in the child. New York: W.W. Norton. Kanfer, R., Eyeberg, S., & Krahn, G. (1992). Interviewing strategies in child assessment. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology, 4th ed., pp. 49-62. New York: John Wiley & Sons. Medelsohn, J.S., Quinn, M.T., & McNabb, W.L. (1999). Interview strategies commonly used by pediatricians. Archives of pediatrics and adolescent medicine, 153(2), 154-157. Rich, J. (1968). Interviewing children and adolescents. New York: Macmillan & Co. Sattler, J. M. (1998). Clinical and forensic interviewing of children and families: Guidelines for the mental health, education, pediatric, and child maltreatment fields. San Diego: Jerome M. Sattler, Publisher, Inc. Stein, M.T. (2000). The development-based office visit: Doing more with each visit. In S. D. Dixon & M. T. Stein (Eds.), Encounters with children: Pediatric behavior and development, 3rd ed., pp. 47-65. St. Louis: Mosby. Welsh, J.B. & Instone, S.L. (2000). Use of drawings by children in the pediatric office. In S.D. Dixon & M.T. Stein (Eds.), Encounters with children: Pediatric behavior and development, 3rd ed., pp. 571-589. St. Louis: Mosby. Yarrow, L. (1960). Interviewing children. In P. Mussen (Ed.), Handbook of research methods in child development, pp. 561-602. New York: John Wiley & Sons.
November/December 2002
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