Family Practice Advance Access originally published online on May 30, 2008
Family Practice 2008 25(3):146-153; doi:10.1093/fampra/cmn021
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"This is not normal ... "—Signs that make the GP question the child's well-being
a Research Unit of General Practice in Copenhagen, Center for Sundhed og Samfund 5, Øster Farimagsgade, PO Box 2099, DK-1014 Copenhagen, Denmark
b Institute of Education, University of Warwick, Coventry CV4 7AL, UK
Correspondence to Kirsten Lykke, Research Unit of General Practice in Copenhagen, Center for Sundhed og Samfund 5, Øster Farimagsgade, PO Box 2099, DK-1014 Copenhagen, Denmark; email: kirstenlykke{at}dadlnet.dk
Received 27 June 2007; Accepted 21 April 2008.
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Abstract |
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Background. The GPs are uniquely placed to recognise children with mental problems and emotional stress that influence their well-being.
Objectives. The aim of the article is with focus on the GP's daily practice, to descript how the GP separates the healthy normal child's developmental crises from children with problems that need special attention and treatment.
Methods. A qualitative research design is used based on material from focus-group discussions and individual interviews with 28 GPs from a Danish county. Data was analysed descriptively.
Results. The GPs' attention was directed towards the contextual and relational sides. The GPs frequently became aware of a child in need during clinical work as a feeling of "this is not normal". This reaction could be triggered by the child's symptoms and problems, the parents' narrative of the child's daily life, the child's and the parents' communication and behaviour in the consultation, the family's use of the health care system and the doctor's knowledge of the family members.
Conclusion. The GP is used to observe and reflect on what happens in the consultation room. The GP might benefit from a systematic attention to the contextual issues. The GPs are frontline workers; they need a good dialogue with the experts and relevant supervision from them to meet the challenge of recognising children in need. It takes more than insight and will from the professionals, it requires a socio-political and socio-economic effort.
Keywords. Child health services, child protection, doctor–parent–child relationship, general practice, psychosocial problems.
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Introduction |
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The majority of children in affluent countries are in good health and their basic needs are met. However, at least 1 in 10 lives with mental problems and emotional stress that influence their well-being.1–7 Often, the symptoms of individual children and the associated problems represent a combination of interacting somatic, psychological and social problems.8
Estimating the number of children with negative well-being has been done in different ways: number of children with symptoms,1–3 number of families with problems5,6 or young people recalling their childhood.7 Using the Child Behavior Checklist, Briggs-Gowan et al.1 found that 11.2% of 2-year-olds had subclinical/clinical scores for psychosocial problems, Reijneveld et al.2 found 6.5% of toddlers (21 months to 4 years) had clinical scores and Zwaanswijk et al.3 found 20.4% among the 4- to 11-year-olds had psychological problem. In all, 16% of British children experienced serious maltreatment by parent, of whom one-third experienced more than one type of maltreatment.7
There is no central registration of Danish children's well-being available or an account of the number of neglected children. Skovgaard et al.4 found International Classification of Diseases (ICD-10) mental health problems in 16–18% of 1
-year-old children, half of these were parent–child relationship disturbances. Christensen5 found that 5–10% of 7-year-old Danish children had serious, often multi-factorial problems (a cohort investigation of 4000 children born in 1995).
Golden et al.9 defines neglect as ‘a non-deliberate failure to provide the child's needs by the responsible person’. It means that neglect arises when there is an unbalance between the child's need and the parents’ ability to care for the child. The unbalance may arise when the child requires too much from the parents, for instance, children with chronic illness or difficult-temperament children, or the parents themselves are lacking the ability of caring, for instance parents with mental disorder10 or families with accumulated social and personal problems.6,8 A child who is exposed to neglect may develop somatic, developmental and psychosocial symptoms.8
The National Board of Health in Denmark emphasizes that GPs, together with the health visitors, the day-care centres and the teachers, have a central position in recognizing children in need of care.11 Extensive preventive tasks are placed upon the GPs in Denmark, including three health care examinations during pregnancy and seven health care examinations of the child during the first 5 years (at 5 weeks, 5 months and 12 months and every year until the fifth year). In addition to the preventive health care examinations, the GP often sees the child during the first years of the child's life in connection with infectious diseases and other diseases and more seldom during the remaining childhood. In his/her meeting with all children and families, the GP meets the whole range from the normal healthy child to the severely neglected child.
The Danish GP is often doctor for the whole family and has the function of a gatekeeper to the remaining health authorities, but most GPs have only sporadic contact with other primary health care professionals and the social worker and almost none with the day-care institutions (96% of Danish 3-year-old children are in day-care institutions) and the schools.12,13 Through the continuous contact with the child, the GP has an opportunity to recognize children in need.14,15 The GP will often be familiar with the family circumstances and can inspire confidence so that difficult subjects can be discussed. But how do the GPs meet the challenge in their consultations with children and their family?
There is no Danish records available showing how often GPs are becoming aware of a child or how often he/she refers to the social services or other health care professionals due to mental problems and emotional stress. Zwaanswijk et al.3 found that 74% of children with psychological problems had visited their GP within the preceding year but only 7% had been identified as having psychological problems. If the parents express their concerns16,17 and the GP know the child well,15 the GPs are more sensitive to the child's problems. There are many barriers for parents to recognize the problems and to seek help.18 Though 81% of parents believed it was appropriate to discuss psychosocial problems with their child's physician, only 41% actually did when a problem occurred.19
It is a generally shared opinion by the health authorities,11,20 researchers21 and the medical associations6 that the GPs are uniquely placed to recognize the child with psychosocial problems and have a central role to play in child protection. Still, this is not what happens in practice.3,21 GPs experience a number of barriers such as lack of knowledge and training and psychological barriers in the care of maltreated children22. Many GPs have been in situations where they decided not only to report child abuse for the above mentioned reasons. Other reasons for not reporting were lack of confidence in the social services or the GPs thought they could handle the problems better alone.23
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Aim |
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The aim of this article is to present the results from a study investigating the GP's tasks and possibilities in relation to the child with mental problems, behavioural problems and emotional stress. The focus in the article is on the GP's daily practice, how the GP separates the healthy normal child's developmental crises from children with problems that need special attention and treatment and what signs make the GP question the child's well-being.
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Methods |
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Design
A qualitative research design based on material from focus group discussions and individual interviews with GPs was chosen to explore their ideas and perceptions of the GP's tasks and possibilities in relation to children in need.24–26 To initiate reflection in the days up to the focus group discussion, a small audit was conducted. The audit consisted of few questions to consultations with child patients about the child's well-being.
Material
Twenty-eight GPs from the County of West Zealand in Denmark participated in the study. Realizing that participation in this project was time consuming, a vocational and personal challenge and GPs have a heavy workload, we chose to contact a larger group of GPs than needed.
A postal invitation to participate in a focus group interview was mailed to 88 GPs purposefully selected among the GPs in the county as to spreading of age, sex, years in practice and patient population. GPs of 60 years and older, GPs in leading positions and GPs who did not participate in the small group–based supplementary education were deselected. As many as 42 GPs responded positively (In ‘Evaluation of Preventive Health Care Examinations in General Practice’,27 from National Institute of Public Health, University of Southern Denmark, 43% of the invited GPs participated). Four groups, each of seven GPs, were formed (Table 1). These 28 GPs were chosen among the 42 simply because they could be assembled on the same dates. Four of the 28 GPs were interviewed individually after the focus group interview.
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Data collection
The data collection included three steps:
- 1. Two focus group discussions. Each discussion lasted 1 hour. It was led by a moderator and based on a semi-structured interview guide. The main topics of the discussion were How does the GP define children in need of care? What are the possibilities and the barriers to recognizing children in need? The researcher participated as an observer.
- 2. Individual in-depth interviews and observations in the clinic. Four informants were selected among the 14 participants in the first two focus group discussions because of their divergent or surprising points of view. The themes for these interviews based on the analysis of the data from the two group discussions were How does the GP evaluate the child's well-being and the parents’ abilities to care for the child? Before the individual interview, the researcher (KL) observed the GP's child consultations for 2–3 hours. The observed consultations were not analysed but formed a shared frame of reference during the interview.
- 3. Two focus group discussions. On the basis of the analysis of the data from the foregoing two steps, developed the theme for the third and fourth focus group discussion. Each discussion lasted 1
hour. It was led by a moderator and based on a semi-structured interview guide. The main themes in the discussion were How does the GP evaluate the family's welfare and the parent's child-care abilities? The researcher participated as an observer.
- 2. Individual in-depth interviews and observations in the clinic. Four informants were selected among the 14 participants in the first two focus group discussions because of their divergent or surprising points of view. The themes for these interviews based on the analysis of the data from the two group discussions were How does the GP evaluate the child's well-being and the parents’ abilities to care for the child? Before the individual interview, the researcher (KL) observed the GP's child consultations for 2–3 hours. The observed consultations were not analysed but formed a shared frame of reference during the interview.
The focus group discussions and the interviews were recorded. The data were collected during 2004–2006.
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Analysis |
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The interviews were transcribed and the text was compared with the original tape-recorded version. Data consist of the GPs’ accounts of their consultations, which were frequently expressed through case stories. The GPs said repeatedly: "I used to ... , it reminds me of ... " and then they presented a case story. The GPs were initially asked to give examples of children in need of care in form of cases; in the focus group discussions, the exchange of case examples to illustrate their views and experiences turned out to be a common practice among them. The analysis presented here is based on the 89 case stories that the GPs presented. All the authors read the original transcripts and the principles for the coding and the choice of themes and categories were discussed continually. The first author carried out several global readings, coded all text units and grouped them into themes. This article focuses on the doctors’ case stories, reflections on and interpretations of the signs that made them question a child's well-being and the text units dealing with this subject were grouped into five core categories (Fig. 1). Each category was compared with the others and with the interviews. The analysis follows the model developed by Malterud,28 Giorgi29 and Kvale.30 The main results and conclusions from the first steps were submitted to the doctors participating in the preceding steps for validation.
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Results |
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The case stories described children with a broad spectrum of psychological, behavioural and developmental problems and parents with personal disturbing, social problems, somatic and psychological diseases and abuse. Many cases represented mild to severe neglect and abuse. Most cases were about children under six, but some were older. The analyses of the cases demonstrated that the GPs awareness of a child's well-being more often was caused by signs related to the parents and their child care abilities than by signs related to the child.
The GPs found that most child patients lived in families with love, care and adequate challenges. It was usually the parents who contacted the GP for help and advice when the GP became aware of a child with psychosocial problems. The case stories and reflections showed that there were also other ways to become aware of a child in need. These could be grouped in five categories (Fig. 1). The GPs described their instinctive reaction when something caught their awareness as a feeling of "this is not normal." Awareness could occur in a single situation but more commonly it occurred as a result of a series of encounters or events. Awareness could be anything from a brief reflection to serious concern. The GPs gave examples of unique situations, which had made them get sudden insight. "It was as a Jigsaw puzzle" or "as an emergent pattern" were metaphors that the GPs used to describe their experience.
The GPs defined normality as what they ‘usually saw in the consultation’. They based their judgements on a perception of normality rooted in their own experience and personal practical competence and only to a minor extent on vocational skills.
When you see a lot of people, I think you learn some patterns for normality that you haven't really formulated (46 years, female, small town, focus group 2).You are more so to speak (mumbling) an impartial resource person in the family, right, who is self-taught, partly due to one's own experiences (50 years, male, small town, focus group 1).
The GPs found that normality defined as the most common had strengths and weaknesses: strengths because normality became something practice based and subjective and weaknesses because their own personal norms became part of their judgement.
The doctor's interpretation of the child's symptoms and problems
The GPs found that they relatively often met children with psychological and psychosomatic problems and children with disturbed development and failure to thrive, but normally it was the parents who presented the problems. When the child presented somatic symptoms, the GPs were accustomed to seeing symptoms and problems in the bio-psycho-social perspective and they found that the parents often shared this broader view.
So talking with parents on their initiative about psychological and social questions was an ordinary part of the GPs’ work, whereas children with signs of neglect and abuse were a rare occurrence, they said.
The parents' ability to handle their child's health and well-being
During the health check visits, the GPs invited the parents to talk about the child's every day routines, habits and relationships. These stories gave the GPs insight into the child's well-being and the parents’ child care abilities. Sometimes, the parents’ stories revealed a limited understanding of children's normal reactions. The GPs’ attention was also alerted when they found that a parent could not provide what the GP saw as even simple facts about their child's development and illness history.
He knew absolutely nothing about her development, where she had been yesterday, or whether she had got medicine before (a father and a four-year-old daughter with a cough) (52 years, female, small town, individual interview).
It was a shared experience among the GPs to be aware of parents that when they had own personal psychological problems they might project these on to the child.
The mother went completely off at a tangent, imagined that the child had a brain disease or some other serious illness. And in reality it was all the result of her own problems (40 years, female, small town, individual interview).
The GPs gave examples of parents who did not want to take their advice or were unable to benefit from what the GP said. Parents may also insist on particular treatments or ask for referrals to specialists on indications that the GP found unnecessary or contradictory.
The child's and the parents’ communication and behaviour during the consultation
During the consultation, the GPs talked and played with the child as a communicative tool to evaluate the child's speech, cognitive development, and behaviour, and they gave several concrete examples.
The GPs also observed the child–parent communication in the consultation, and in the group, they discussed snippets of observations and particular critical episodes they had experienced. For example, one GP illustrated his encounter with a young mother and her distressed 5-week-old infant:
The baby just cried and cried and cried, and so I lifted the baby up and it stopped crying. I was sort of a bit surprised at this, the mother got the baby back ... the way she handled the baby showed that there was something terribly wrong (58 years, male, small town, focus group 2).
The GP reacted intuitively by trying to comfort the crying infant and when he handed the baby back to the mother he notes her inadequacy to hold and care for the infant. The GPs expected parents to be solicitous during the medical examination, but too much expressed affection also attracted attention.
(A) mother who kisses the child a lot while she is in my surgery. Where many others ... where you in a way spontaneously say: it's really great that she is so fond of her child (the GP's internal conversation). [...] compared with the others, this sort of behaviour is strange (49 years, male, town, focus group 2).
In this case, the GP found no reason to intervene. In another similar case, it had transpired that the child suffered severe physical abuse and the doctor had to take steps to intervene.
The parents' use of the health care system
The GPs noticed the frequency of consultations and the reason for them. Frequent visits with mild harmless symptoms were often young insecure parents but could also be families with many problems, without a network and resources for whom even harmless symptoms grew into big problems. Other parents consulted the GP very late in the progress of a child's disease.
They came with a child with asthmatic bronchitis that I immediately have to admit to hospital. Where I've thought, how can they not see that he is nearly suffocating? (42 years, female, town, focus group 2).
Also the appearance and presentation of the family in the clinic may alert the GP to the well-being of the child as parents who were impolite, thoughtless or provocative to the other patients in the waiting room, the staff or the doctor. Their awareness of possible neglect of care could be initiated by the appearance of the child or the parents, e.g. dirty children in poor clothes, but not if the GPs knew the parents as careful and affectionate parents.
She has piercings nearly all over and her hair is stuck out to all sides. And my original impression until I got to know her was that she was someone I would have to be a bit careful with—she is probably in a biker milieu. But she is not that at all, she is a completely ordinary mother (52 years, female, small town, individual interview).
It was a shared experience among the GPs that families with social problems and few resources often had difficulties using the facilities of the health care system. They stayed away from preventive investigations and did not fit well into the well-organized general practice with appointment systems, a fixed consultation time etc.
Discharge summaries and medical letters gave the GPs important information. Information about frequent use of out-of-hours service, many injuries or parents who did not follow the ambulatory treatment would also alert them.
The doctor's knowledge of the family members
The GPs found that knowing the family background was crucial. Through their continuous contact with the whole family, they became acquainted with the family story and situation. As the doctor for the whole family, they got insight not only into health and diseases but also into how the family members tackled health challenges.
The individual interviews with the GPs not only revealed a comprehensive acquaintance but also that the GP often did not know how to react on the information.
She gets anxiety attacks where her throat closes and she cannot breathe. And then she calls for her children to help her [...]. I think that must be an incredible strain and very wrong that the children they have to be there and help her breathing difficulties. But I don't really feel I can do anything (52 years, female, town, focus group 4).
The GP is aware of the inverse care relationship with the child being the parent's parent, but do not know what to do or how the children actually managed.
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Discussion |
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When the GPs in this study became aware of a child in need, it was frequently during clinical work as a feeling of "this is not normal." This reaction could be triggered by the child's symptoms and problems, the parents’ narrative of the child's daily life, the child's and the parents’ communication and behaviour in the consultation, the family's use of the health care system and the doctor's knowledge of the family members. The GPs defined ‘normality’ as the most common, that is an idea of normality based on their own professional experiences.
The study shows that the GPs’ attention was very much directed towards the contextual and relational sides. The GP's eyes were fixed on own context, the context of the consultation, and the child's and family's context.
The GP's attention was roused in the daily consultations when the families visited the GP. The GP did not initially expect special problems, but his attention was roused when something special happened or the GP got acquainted with some specific circumstances in the family. Often it was the situation itself or circumstances around the parents that attracted the GP's attention rather than symptoms or signs from the child. Yerkey and Wildman31 found that attention on maternal distress and negative life events in the child's life improve physicians rate of identification of children with psychosocial problems and Kinsman et al.32 found that children and parents with high health care utilization were more likely to have psychosocial problems than those with low health care utilization.
The GPs found that their own contact and communication with the child was important and described concretely how they communicated with the child. Cahill and Papageorgiou33 have demonstrated how the practical arrangement of the clinic influences the communication. For example, when the doctor sat next to a child without another adult in-between, the child was more likely to participate in the consultation. Studies have shown that doctors in general communicate only rarely with children in the consultation and the communication is mostly of a social character to create a good atmosphere.34 Today, doctors are more inclined to involve the child, but even though investigations have proved that children involved in decision-making and treatment schemes obtain a better compliance, the child is often being involved only in the diagnostic phase.34
The GP has a unique possibility and a professional obligation to track down children in need of special treatment.6,11,21 Still, this is not what happens in practice.3,35 The GP's special opportunity is lying in the regular contact with the child and its parents through which the GP gains an insight in the family's life, resources and problems, all of which contributes to develop a basis of trust and confidence that may open up for a discussion of difficult subjects. What are the reasons why the GPs still do not track down these children and refer only few children to the social system?
It may be difficult to communicate observations and conclusions to the parents when the GPs’ attention is based on hunches and recognition of patterns and is often contextual and directed towards circumstances concerning the parents rather than towards the child itself.
It is important to investigate what it means and how the GPs speak out their observations to the parents. The GP is the whole family's doctor, he is a resource as to tracking down children with lack of care, but how does the GP handle the severe dilemma to present his thoughts to the parents without hurting them and questioning their ability as parents?
The GPs in this study clearly expressed that their knowledge was based on experience; in line with other studies they had received only limited training and theoretical lessons.35–37 The lack of training and theoretical knowledge is an obstacle to the GP's possibility to act, which is even worsened by the fact that the GP works isolated without contact to other professionals around the child.12
Strengths and weaknesses
Efforts were made to obtain a demographic spread when the informants were chosen. It was unexpectedly positive that half of the invited GPs wanted to participate. Participation was both time consuming and a personal and vocational challenge. A contributing factor to the high percentage of GPs who wanted to participate was that they found the subject relevant and unexplored and that the study was headed by a colleague. The selection criteria aimed at a generally high vocational engagement, the purpose being to investigate what the GPs themselves see as their objective and opportunities when it comes to children with negative well-being, and therefore, it carried weight that the participating GPs had turned the subject over in their mind. To ensure this, the participants were also asked to make a small audit in the days prior to the interview.
The focus group design was chosen to get insight and appreciation. A focus group discussion reveals many aspects of a theme in a short time, and the discussion inspires new reflections in the individual participant.25 The semi-structured interview guide encouraged discussion between the GPs. The discussions were probably facilitated by the fact that the GPs practiced in the same county and knew each other from other activities. All participated in small group–based continuing education (in different groups) and were thus used to discussing vocational subjects and uncertainty.
Knowing each other may on the other hand have refrained some from expressing strongly divergent opinions and thereby induced a tendency to agree about ‘the right opinions’. An effort was made to minimize this by the moderator by raising provocative statements and questions in the discussion and through the individual interview with four focus group participants reflecting the diversity in the group.
KL, who conducted the investigation, is a GP; the continuous discussion with PHC (anthropologist) and SR (GP and anthropologist) has constantly widened the perspective though out the study.
Implications
The GP is used to work in multiple contexts and to observe and reflect on what happens in the consultation room. It is important in general and for each individual GP to realize the great impact the contextual issue has on the GP's awareness of children's well-being. The GP might benefit from a systematic attention to the contextual issues. It would be valuable to investigate in which way and to which extent a systemic attention to the context may strengthen the GP's awareness on children with negative well-being.
It is important that GPs listen to and respond to own hunches, but it is important as well that the GP makes it clear to himself to which extent his evaluations are based on own experience and norms. It is necessary to be able to combine practical experience with training and theoretical insight in order to understand and act in a relevant way.
There is some evidence available that guidelines and written procedures improve the efforts to detect neglect37 and it is recommended to develop such papers in Denmark, too.13 Guidelines and written procedures should be accompanied by further training, but how the latter should be conducted is still to be clarified.37 In a project conducted over 2 years for the National Board of Health, it was established that the GP's vocational skills may be strengthened through supervision,13 a study that also has confirmed the GP's contextual approach to child health.
It is concurrently necessary to create a basis for a dialogue with other professionals in the children's network. The health visitor, the day-care centre, the schoolteacher and the GPs are frontline workers. They need a good dialogue with the experts and relevant supervision from them to meet the challenge of recognizing children in need. It takes more than insight and will from the professionals; it requires a socio-political and socio-economic effort.
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Declaration |
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Funding: The Danish Research Foundation for General Practice and The Quality Development Committee of the Count of West Zealand.
Ethical approval: None.
Conflicts of interest: None.
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Acknowledgments |
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We thank the participating GPs from the County of West Zealand.
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Notes |
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Lykke K, Christensen P and Reventlow S. "This is not normal ... "—Signs that make the GP question the child's well-being. Family Practice 2008; 25: 146–153.
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References |
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1 Briggs-Gowan MJ, Carter AS, Skuban EM, Horwitz SM. Prevalence of social-emotional and behavioral problems in a community sample of 1- and 2-year-old children. J Am Acad Child Adolesc Psychiatry (2001) 40:811–819.[CrossRef][Web of Science][Medline]
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