Children's psychosocial problems presenting in a family medicine practice

Increased family psychosocial focus during children's developmental assessments: a study of parents' views

BACKGROUND

Family psychosocial challenges during the early years of a child's life are associated with later mental and physical health problems for the child. An increased psychosocial focus on parents in routine child developmental assessments may therefore be justified.

METHODS

Participants in this qualitative study included 11 mothers and one parental couple (mother and father) with children aged 9-23 months. Participants were recruited to Project Family Wellbeing through their general practice in Denmark. Twelve interviews were conducted, transcribed and analysed with a deductive approach. The topic guide drew on the core components of the Health Belief Model, which also served as a framework for the coding that was conducted using thematic analysis.

RESULTS

Results are presented in four themes and 11 subthemes in total. Parents welcome discussion of their psychosocial circumstances during their child's developmental assessments. Clinicians' initiatives to address psychosocial challenges and alignment of parents' and clinicians' expectations may be required to allow this discussion. A flowing conversation, an open communication style and a trustful relationship facilitate psychosocial discussion. Barriers included short consultation time, concerns about how information was used and when parents found specific psychosocial aspects stigmatising or irrelevant to discuss.

CONCLUSION

Enquiry about the family's psychosocial circumstances in routine developmental assessments is acceptable among parents. Alignment of clinical and parental expectations of developmental assessments could facilitate the process. Future research should examine the predictive validity of the various components of developmental assessments.

TRIAL REGISTRATION

This is a qualitative study. The study participants are part of the cohort from Project Family Wellbeing (FamilieTrivsel). The project's trial registry number: NCT04129359. Registered October 16th 2019.

Increasing the psychosocial focus in child developmental assessments: a qualitative study

BACKGROUND

Previous studies have indicated a need for increased psychosocial focus on children and their families to improve children's wellbeing and mental health. Child developmental assessments could be a place to implement changes to achieve this. A standardised record might be helpful to clinicians trying to increase psychosocial focus. The aim of this study is to investigate clinical barriers and facilitators when introducing standardised child records with increased focus on psychosocial wellbeing and mental health into child developmental assessments.

METHODS

This is a qualitative study based on 12 semi-structured interviews with four midwives and nine doctors who carry out child developmental assessments in general practice. Data is analysed in the framework of Normalisation Process Theory.

RESULTS

General practice-based clinicians were positive towards increasing the psychosocial focus in child developmental assessments. The main barriers when clinicians used the standardised child records were: feeling forced to ask certain questions, in turn making the conversation rigid; leaving less room for parents to bring up other issues; making clinicians feel awkward when addressing problems that they cannot solve; the need for extended consultation time; and medico-legal concerns when registering findings. The experience of positive aspects when using the standardised child records facilitated continuous use of the records. Positive aspects included having a standardised approach to recording important findings, thereby uncovering psychosocial problems that could potentially be overlooked. Additionally, structured observation of parent-child interaction and gaining a new vocabulary to describe the findings were valued by clinicians. Balancing a standardised approach with clinicians' ability to steer the consultation and explore topics in depth while preserving the potential for patients to bring up other issues became an important theme.

CONCLUSION

Clinicians need to be well-equipped to handle psychosocial problems through coping strategies, referral options and communication techniques in the psychosocial domain. The parent-child-interaction assessment might expose potentially dysfunctional parenting behaviours and could improve communication between health professionals. Implementing standardised child development records with an increased psychosocial focus is feasible but improvements could optimise the use of the records. Parental views on an increased psychosocial focus during child developmental assessments should be investigated prior to further implementation.

TRIAL REGISTRATION

Trial registry number for the FamilieTrivsel (Family Wellbeing) trial: NCT04129359.

Dealing with parental concerns: A study of GPs' practice

OBJECTIVE

To investigate patterns of GPs' exploration and termination of dialogues about parental concerns in preventive child health assessments.

METHODS

Interactional microanalysis of video recordings of 32 preventive child health assessments using conversation analysis.

RESULTS

The GPs asked parents about concerns, but most concerns disclosed by parents were still left unexplored at the end of the consultation. Termination of dialogues about concerns could be achieved effectively by GPs through letting the biomedical agenda dominate or addressing the child directly. The parents generally cooperated with the various approaches to handling concerns.

CONCLUSION

GPs displayed initial attentiveness towards emotional concerns but did not always follow through with subsequent exploration; many concerns raised were left unexplored. However, the same GP could employ both non-exploratory and exploratory practice within individual consultations.

PRACTICE IMPLICATIONS

Preventive child heath assessments offer an opportunity for parents to raise concerns about their children's development. Improved understanding of the conversational mechanisms through which concerns are examined or sidelined could allow clinicians to maximise the effectiveness of their preventive consultations.

Curriculum development: Preparing trainees to care for children and adolescents with psychiatric disorders

Family physicians provide care for about one-third of the children and adolescents in the United States, many of whom present with psychological concerns. Family physicians often do not recognize these psychological disorders and therefore do not diagnose or treat them. This report describes the implementation of a curriculum designed to increase family medicine trainees' level of awareness that children/adolescents experience psychiatric conditions. This goal is achieved through the addition of a clinical child/adolescent psychologist faculty member, resident self-assessment of training needs and subsequent development of didactic presentations to address these needs. The curriculum relies on the acquisition of child/adolescent psychiatric screeners, development of child/adolescent-focused bibliotherapy materials, and the development of a longitudinal behavioral sciences curriculum. To facilitate the screening of child/adolescent psychiatric disorders, a comprehensive collection of age-appropriate psychiatric screeners were compiled and made readily available in all precepting areas. To assist with the identification of specific child/adolescent psychiatric deficit areas, family medicine resident physicians were presented with an inventory of child/adolescent psychiatric, psychosocial, and behavioral topics, based upon American Academy of Family Practice guidelines and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition psychiatric disorders, and self-selected training deficiencies.

Teaching child psychiatric assessment skills: Using pediatric mental health screening tools

This article describes the workshop "Teaching Child Psychiatric Assessment Skills: Using Mental Health Screening Instruments," presented at the 35th Forum for Behavioral Sciences in Family Medicine on 20 September 2014. The goals of the presentation were (1) to teach family medicine behavioral health educators to use both general and problem-specific mental health screening tools (MHSTs) in their work with trainees to help satisfy the Accreditation Council for Graduate Medical Education (ACGME) mandate for behavioral and mental health experience during family medicine residency, (2) to reflect on how MHSTs might be integrated into the flow of family medicine teaching practices, and (3) to exemplify how evidence-based methods of adult education might be used in teaching such content. One general MHST, the Pediatric Symptom Checklist-17 and one problem-specific MHST for each of the four commonest pediatric mental health issues: for attention-deficit hyperactivity disorder, the Vanderbilt; for Anxiety, the Screen for Childhood Anxiety-Related Emotional Disorders; for Depression, the Patient Health Questionnaire-9 for teens; and for Aggression, the Retrospective-Modified Overt Aggression Scale, were practiced at least twice in the context of a clinical vignette. All of the selected MHSTs are free in the public domain and available for download from the website: www.CAPPCNY.org. Participants were asked to reflect on their own office practice characteristics and consider how MHSTs might be integrated into their systems of care. This workshop could be replicated by others wishing to teach the use of MHSTs in primary care settings or teaching programs.