■ "How about missing school a lot?"

The presence of family members also provides a rich opportunity to observe how they interact with the child. As you talk with the parent, see how a young child relates to a new environment. It is normal for a toddler to open drawers, pull at paper, and wander around the room. An older child may be able to sit still or may get restless and start fidgeting. Watch how the parents set limits on the child or fail to set limits when appropriate.

MULTIPLE AGENDAS. Each individual in the room, including the clinician, may have a different idea about the nature of the problem and what needs to be done about it. It is your job to discover as many of these perspectives and agendas as possible. Family members who are not present (the absent parent or grandparent) may also have concerns. It is a good idea to ask about those concerns too. "If Suzie's father were here today, what questions or concerns would he have?" "Have you, Mrs. Jones, discussed this with your mother or anyone else?" "What does she think?" Mrs. Jones brings Suzie in for abdominal pain because she is worried that Suzie may have an ulcer. She is also worried about Suzie's eating habits. Suzie is not worried about the belly pain—it rarely interferes with what she wants to do. She is uneasy about the changes in her body, especially her belief that she is getting fat. Mr. Jones thinks that Suzie's schoolwork is not getting enough attention. You, as the clinician, need to balance these concerns with what you see as a healthy 12-year-old girl in early puberty with some mild functional abdominal pain. Your goals need to include helping the family to be realistic about the range of "normal" and uncovering the concerns of Mr. and Mrs. Jones and Suzie.

THE FAMILY AS A RESOURCE. Much of the information you obtain about a child comes from the family. In general, family members provide most of the care and are your natural allies in promoting the child's health. Being open to a wide range of parenting behaviors helps to make this alliance. Raising a child reflects cultural, socioeconomic, and family practices. It is important to respect the tremendous variation in these practices. A good strategy is to view the parents as experts in the care of their child and you as their consultant. This demonstrates respect for the parents' care and minimizes their likelihood of discounting or ignoring your advice. Most parents face many challenges raising children, so practitioners need to be supportive, not judgmental. Comments like "Why didn't you bring him in sooner?" or "What did you do that for!" do not improve your rapport with the parent. Statements ac-jknowledging the hard work of parenting and praising successes are always appreciated.

HIDDEN AGENDAS. Finally, as with adults, the chief complaint may not rete to the real reason the parent has brought the child to see you. The com-aint may be a "ticket to care" or bridge to concerns that may not seem itimate. Try to create a trusting atmosphere that allows parents to be open out all their concerns. Ask facilitating questions like the following:

■ "Do you have any other concerns about Randy that you would like to tell me about?"

■ "What did you hope I would be able to do for you today?"

■ "Was there anything else that you wanted to tell or ask me today?"

Talking With Adolescents. Adolescents, like most other people, usually respond positively to anyone who demonstrates a genuine interest in them. It is important to show interest early and then sustain the connection if communication is to be effective. Adolescents are more likely to open up when the interview is focused on them rather than on their problems. In contrast to most other interviews, start with specific directed questions to build trust and rapport and start the conversation. You may have to do more talking than usual. A good way to begin is to chat informally about friends, school, hobbies, and family. Using silence in an attempt to get adolescents to talk or asking about feelings directly is usually not a good idea. It is particularly important to use summarization (see p._) and transitional statements (see p._) and to explain what you are going to do during the physical examination. The physical examination can also be an opportunity to get the young person talking. Once you have established rapport, return to more open-ended questions. At that point, make sure to ask what concerns or questions the adolescent may have.

Remember also that adolescents' behavior is related to their developmental stage and not necessarily to chronologic age or physical maturation. Their age and appearance may fool you into assuming that they are functioning on a more future-oriented and realistic level. The reverse also can be true, especially in teens with delayed puberty or chronic illness.

Issues of confidentiality are important in adolescence. Explain to both parents and adolescents that the best health care allows adolescents some degree of independence and confidentiality. It helps if the clinician starts asking the parent to leave the room for part of the interview when the child is age 10 or 11 years. This prepares both caregivers and young people for future visits when the patient spends time alone with the clinician.

Before the parent leaves the room, get any relevant medical history from the parent, for example, certain elements of Past History, and clarify the parent's agenda for the visit. Also discuss the need for confidentiality. Explain that the purpose of confidentiality is to improve health care, not to keep secrets. Adolescents need to know that you will hold in confidence what they discuss with you. However, never make confidentiality unlimited. Always state explicitly iat you may need to act on information that makes you concerned about fety ... "I will not tell your parents what we talk about unless you give me ermission or I am concerned about your safety—for example, if you were to talk to me about killing yourself and I thought there were a risk that you would actually try it."

Your goal is to help adolescents bring their concerns or questions to their parents. Encourage adolescents to discuss sensitive issues with their parents and offer to be present or help. While young people may believe that their parents would "kill them if they only knew," you may be able to promote more open dialogue. This entails a careful assessment of the parents' perspective and the young person's full and explicit consent.

Talking With Aging Patients. At the other end of the life cycle, aging patients also have special needs and concerns. Their hearing and vision may be impaired, their responses and explanations may be slow or lengthy, and they may have chronic illnesses with associated disabilities. Elderly people may not report their symptoms. Some may be afraid or embarrassed; others may be trying to avoid the medical expenses or the discomforts of diagnosis and treatment. They may think their symptoms are merely part of aging, or they may simply have forgotten about them. They may be inhibited by fears of losing their independence.

As you proceed with the interview, give elderly patients time to respond to your questions. Speak slowly and clearly but do not shout or raise your voice. A comfortable room, free of distractions and noise, is helpful. Ask about turning off the radio or television. Remember that visual cues may be important, so make sure that your face is well lit. If they wear glasses, make sure they put them on. Do not try to accomplish everything in one visit. Several visits may be less fatiguing and more productive.

From middle age on, people begin to measure their lives in terms of the years left rather than years lived. Older people often reminisce about the past and reflect upon previous experiences. Listening to this process of life review can give you important insights and help you support patients as they work through painful feelings or recapture joys or accomplishments.

Although some generalizations are useful, learn to recognize and avoid stereotypes that block your appreciation of each individual patient. Find out how patients see themselves and their situation, as well as each patient's unique priorities, goals, and patterns for handling problems. This knowledge will help you as you collaborate on treatment plans. For example, "Can you tell me how you feel about getting older?" "What kinds of things do you find most satisfying?" "What kinds of things worry you?" "What would you change if you could?"

Functional Assessment. Learning how the elderly, and those with ronic illness, function in terms of daily activities is essential and provides a aseline for future comparisons. There are two standard categories of assess-lent: physical activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

Can the patients perform the ADLs independently, do they need some help, or are they entirely dependent? Instead of asking about each area separately, have the patient go through a typical day, in detail. Start with an open-ended


Physical ADLs

Instrumental ADLs


Using the telephone




Preparing food







Managing money

Taking medicine

request—"Tell me about your day yesterday"—and then guide the story to a greater level of detail. "You got up at 8? How is it getting out of bed?" "What did you do next?" Ask how things have changed, who is available for help, and what helpers actually do. Remember that increasing dependence on others is very difficult for most people to accept, but promoting safety is one of your important priorities.

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