Doctor–parent–child relationships: a ‘pas de trois

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Abstract

Adult participants play a pivotal role in doctor–parent–child interactions at the general practitioner’s (GP’s) surgery. The child’s opportunities to participate are rather limited and parental speaking for the child is, in a way, institutionally co-constructed. This study aimed at further characterizing the relationships within this triad by developing a typology of doctor–parent–child interactions, which classified adult behavior in terms of supporting versus non-supporting child participation. The child’s participation was described in terms of display of involvement and turning for support. Analyses of 105 videos show that in most consultations, both GP and parent displayed non-supportive behavior. Despite the GPs’ initial efforts to involve the child in the interaction, 90% of the consultations ended up in a non-participatory way. During this last segment of diagnosis and treatment information, the child’s voice was hardly heard, as reflected in the minimal involvement displayed and the absence of turning to the parent for support. It is concluded that the bi-directional perspective chosen in this analysis allowed for a better understanding of the underlying mechanisms leading to the stereotypical picture in both literature and actual practice of triadic medical interactions being dominated by both adult participants. The low degree of child participation should not solely be seen as a consequence of adult behavior, but rather as a co-construction of all three participants. The results are discussed from a pedagogical perspective, and implications for medical practice are formulated.

Introduction

Previous studies on doctor–parent–child communication emphasized the pivotal role of both adult participants in doctor–parent–child interactions. The child’s opportunities to participate in the medical interview appear to be strongly related to characteristics of adult behavior [1], [2]. Whereas parents, regardless of the child’s age, tended to control the interaction by interfering in doctor–child interactions, physicians were more inclined to involve older children more directly in the medical interaction [1]. By focusing on the discursive construction of participant roles, we were able to show that these differences in adult accommodation were due to dissimilarities in the adults’ orientations regarding the underlying participation framework [3].

In the past, there was a tendency to rely on parents as sources of information about their child’s health status. However, it is increasingly being acknowledged that children can provide information themselves and should be involved in decisions about their own health care [4], [5]. In addition, empirical studies have shown the health-promoting value of active child participation [6], [7].

The present study aims at further exploring the relationships between general practitioner (GP), parent and child. Relationships between people both shape and reflect the expectations each participant has about the conduct of the other [8]. As relationships may have substantial implications for how the curing and caring process is to be accomplished and the extent to which needs and expectations will be met [9], more insight into the possible relationships between doctor, parent and child is imperative for the development of optimal medical care in this triad. The purpose of this paper is two-fold: (1) to develop a typology of doctor–parent–child relationships; (2) to provide empirical validation for the typology proposed with our data at the GP’s surgery.

Doctor–parent–child interactions are to be understood both in terms of a pedagogic relationship, and in terms of a provider–patient relationship. Children must learn to manage their own disease, so part of the goal of medical interaction is to create a developmental environment which offers the child the opportunity to learn how to participate in medical encounters [7], [10]. The idea of guiding the child on his or her way to active participation matches the concept of ‘guided participation’ or learning through participation [11], and implies a focus on the active role of children in medical interaction and on the enabling or constraining characteristics of adult behavior. A first step for understanding this concept of guided participation was to develop a typology of doctor–parent–child relationships, which sets out the adults’ interaction style along an interaction dimension, in terms of supporting versus non-supporting the child to participate in the medical interaction. This distinction refers to supportive, child-centered behavior versus non-supportive behavior and non-involvement of the child [12], [13], [14]. Models on doctor–patient communication denote this distinction in terms of a participatory relationship (in which patients are facilitated to assume a responsible role in the medical dialogue and in decision-making) as opposed to a non-participatory doctor–patient relationship [9], [15]. The behavior of GP and parent can be characterized separately along this dimension.

The prototypical supportive triadic medical interaction is a situation in which both GP and parent encourage the child to take an active role in the medical encounter. The GP who assumes a supportive role displays child-oriented behavior, e.g. by inviting the child to formulate the problem definition, by directing medical questions at the child, and by involving the child in the discussion of the diagnosis and treatment. Parental behavior is characterized as supportive where the parent both verbally and non-verbally encourages the child to take an active role in the medical interaction. In addition, a supportive parent strives for effective doctor–child communication by remaining in the background and leaving the child enough room to respond to the questions asked by the GP, and by acting as an information provider or translator should the child misinterpret a question or lack background information.

The opposite of this supportive pattern is the situation in which no efforts are undertaken either by the GP or the parent to enable the child to join in the medical interaction. Both adult participants control the interaction and treat the child as a passive bystander in his or her own medical consultation. GPs who assume a non-supportive role display parent-oriented behavior, e.g. by explicitly inviting the parent to formulate the problem definition, by directing most questions concerning the medical condition at the parent, and by discussing all diagnosis and treatment information only with the parent. Parents who assume a non-responsive role are mainly doctor-centered and tend to speak for the child, e.g. by ignoring the child’s contributions or by interrupting doctor–child interaction. As a consequence, the child’s voice is largely absent in non-supportive doctor–parent–child interactions; the child is not considered capable of discussing his or her health problems and is excluded from the interaction.

It is important to realize that the GP and parent may display either similar or conflicting behavior in terms of supporting the child to participate in the medical interaction.

It should be emphasized that the behavior of GP and parent as described earlier refers to the adults’ perspective on child participation as displayed in their verbal and non-verbal behavior. Concurrently, children may display different degrees of involvement in the medical interaction, and may differ in the extent to which they will turn to their parents for support. Advocating a bi-directional perspective, we want to emphasize the mutually influential nature of the interaction between doctor, parent and child.

Opportunities for child participation depend on the segment of the medical interview; physicians tend to elicit medical information from children, but exclude them from diagnostic and treatment information [16], [17]. Redefinition of participant roles can take place in particular within the transition of the consultation segments [3]. Therefore, in our analysis we follow the standard sequencing of the medical consultation (medical history-taking, physical examination, diagnosis and advice). As relationships are expected not to be static across the encounter, the adult participants’ behavior needs to be characterized during the segment of medical history-taking as well as in the segment of diagnosis and information on treatment. On basis of previous research a decrease in the adults’ supportive behavior in the course of the encounter is expected.

A developmental perspective is chosen; children progressively develop communicative skills, including meta-communication and domain-specific knowledge, as their cognitive and linguistic development progresses [18], [19]. As we expect GP and parent to align their behavior to the child’s age, it is hypothesized that the GP and parent will display supportive, child-centered behavior in interaction with older children in particular.

Over the past three decades, a number of important changes have taken place in doctor–patient communication and in adult–child interactions which might have influenced the doctor–parent–child relationship. First, the development of the patient-centered approach with an increasing emphasis on the patient’s own responsibility, evoked a shift in the participant roles in medical consultations. As a result, patients have become more emancipated and autonomous over the years [9], [15], [20]. In addition, parenting has become less restrictive and authoritarian, and adult–child interactions are increasingly characterized by a greater openness towards the child [21], [22]. In view of these developments, it is hypothesized that in the course of time the adults’ supportiveness will increase, as well as the child’s display of involvement.

Section snippets

Sample

The study is based on 105 video recordings of doctor–parent–child encounters at general practitioner’s surgeries in The Netherlands. In all selected interviews, the child was seeing the GP for temporary illness and minor complaints. In the Dutch health care system, the GP, comparable to a family physician, has a gate-keeping role; patients do not have access to specialist or hospital care without referral, and 90% of all complaints are treated by GPs [23]. One in six consultations with a GP

Interaction patterns in the medical history segment

In most consultations, both GP and parent assumed a non-supportive role towards the child in the medical history-taking segment as Table 2 shows (72%).

GPs, however, more frequently encouraged the child to take part in the medical interaction compared to parents (28% versus 13%). As expected, both adults were more supportive towards older children (GPs: age 4–6 years, n=5; age 7–9 years, n=6; age 10–12 years, n=19; r=0.35, P<0.01. Parents: age 4–6 years, n=2; age 7–9 years, n=1; age 10–12 years,

Conclusion

The theoretical approach of classifying adult behavior in terms of supporting or non-supporting the child to participate in the medical interaction, and the choice for an interactional perspective enabled us to provide a more finely tuned characterization of the interaction in this triad. Although both GP and parent predominantly assume a non-supportive role in interaction with the child, GPs more frequently display supportive behavior, especially in the medical history-taking segment. This

Discussion

By emphasizing the interactional perspective in this study, we opt for a bidirectional view on adult–child relations and challenge the traditional, unidirectional approach. Bidirectional theories of adult–child relations have shifted attention from unidirectional, impositional models to frameworks that highlight the two-way, mutual, and reciprocal influence in adult–child interactions [12], [13], [28]. The perspective of the child as an active agent makes it possible to consider how children

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