Assessment in Primary Care Pediatrics

Carol Green-Hernandez PhD, FNP-C

INTRODUCTION

The practice of pediatric primary care is family centered. Because of the complexities of care delivery in today’s era of significant cost containment, providers must capitalize on this family-centered focus by making the family, to the fullest extent possible, partners in care delivery. Interactions that occur between the child and clinician and between parents and clinician have therapeutic potential. They provide an opportunity for relationships to develop; such relationships subsequently can improve patient outcomes as well as family and practitioner satisfaction (Tresolini & the Pew-Fetzer Task Force, 1994). Family-centered care thus recognizes and values the therapeutic potential of relationships (Singleton, Green-Hernandez, & Holzemer, 1999).

Assessment data, whether of pediatric providers, families, or cultural values and beliefs, are fundamental to the delivery of quality family-centered care. This chapter discusses the processes of self-assessment, family assessment, and cultural assessment.

SELF-ASSESSMENT THROUGH VALUES CLARIFICATION

For assessment of others to be successful, providers first must consider their own values and beliefs to ensure the delivery of appropriate and culturally sensitive primary care. Clinicians may find that clarifying personal values and beliefs assists them to discern possible sources for flawed assessment of children and their families. After discovering what they consider important, providers can focus on the personal values and beliefs that they share with the family. Values clarification may prove especially helpful when caring for families whose values, beliefs, and health behaviors differ from those of the provider. Although clinicians may find areas of value digression with the family, the process of self-reflection in values clarification can help prevent out-and-out conflict when strong differences emerge. Clearly, such conflict can jeopardize the therapeutic relationship. A sample values clarification tool and directions for its use are found in Appendix 2-1.

Values clarification can empower provider and family alike. The goal, of course, is to create and maintain primary care that is relationship centered. Such care must be both legal and ethical, while promoting self-actualization of the child and family (Green-Hernandez, 1997). Providers must be sensitive to both verbal and nonverbal cues and behaviors, including body stance, positioning, and use of eye contact. Similarly, maintenance of body space and use of touch can signal respect or lack of respect. The child’s and family’s feelings, values, and beliefs, including those pertaining to health, are integral to all care management strategies in primary care. Children and their parents are not passive recipients of primary care; they are active partners. By using caring as a deliberate therapeutic model for communicating and working with children and their families (see Chap. 1), practitioners can avoid some of the value-laden conflicts that often emerge when primary care is provider controlled.

FAMILY ASSESSMENT

Like all open living systems, the family is an evolving entity. In the 21st century, the concept of a “typical” family eludes characterization. Today, the head of a family may be an emancipated minor, a single parent, two or more unrelated individuals, same-sex heads-of-household, or parents in a “traditional” or nuclear family. The family is what its members envision it to be. The key to family composition is that the group itself defines membership. This vision for family demography impacts family functioning. Evolving family structures and functions have implications for health promotion and illness management that present important challenges to primary care providers.

The following scenario provides an example of the need to use family-centered primary care within the context of family assessment:

A recent flu epidemic affected a 5-year-old boy and his three younger siblings. Their mother clearly is exhausted from caring for four sick little ones. Now recovered from flu, the 5-year-old comes to the practitioner’s office in ketoacidosis. Following workup and emergency management, the clinician is faced with having to prepare the family for the child’s diagnosis of type 1 diabetes.

The clinician needs to determine what the mother is feeling and what (if any) resources are available to support the family emotionally, physically, and financially through this crisis and beyond. The clinician also must assess the parents’ and child’s reading and comprehension levels to provide teaching that is understandable and, hence, usable. The provider needs to use a perspective that is sensitive to cultural and ethnic influences and to create an individualized plan that actually works for the child and family.

Caring theory as a foundation for family-centered pediatric primary care focuses on each individual family member and the family as a whole at the same time (Green-Hernandez, 1997; 1999). What happens to the child also happens to the family as a unit. Primary care delivered to the individual impacts the family as well. Whether integrating health promotion or confronting illness management, family members experience together the provider’s
professional caring for, communication with, and treatment of one of its members.

Historic View of Family-Centered Practice

Traditionally, primary care pediatric practitioners viewed the child as an individual who required treatment. They treated the family as an extension of the child, insofar as the child might communicate an illness to other members. Some enlightened providers also were concerned about the impact of illness or treatment requirements on family members, but by and large care delivery was individual rather than family focused. The primacy of individual rights and freedoms in western cultures further underscored these traditional health care practices.

A New Paradigm: Relationship-Centered Primary Care

Today the practice of primary care for children has moved toward a paradigm of family-centered health care. This clear and important vision is different from specialty practice, which emphasizes the individual. The family systems approach to primary care of children is at once both caring and respectful. The provider must remember that confidentiality must be at the forefront of care. Family-centered practice does not imply abandonment of the legal and ethical responsibilities the provider owes to the child and the parent(s) or caretaker(s).

Family-centered care is an optimum model for the practice of primary care to children. Providers recognize parents’ feelings and responses to their child’s health status. They view care management as important to the family’s interactional function. Providers evaluate care given to the child within the context of other family members’ responses to and connectedness with the child, while keeping in mind that the community is part of that connectedness. This kind of care delivery model is inherently more holistic than the traditional family practice model, wherein care is individual focused.

Assessment Data

Family assessment data help providers to deliver individualized, family-centered pediatric primary care. Such data can enhance the provider’s understanding of the family and its needs both from individual and interpersonal perspectives. Display 2-1 summarizes important areas for collecting data in family assessment.

DISPLAY 2–1 • Areas for Family Assessment

List information about the child and family, including immediate and extended members. Include individuals who, though perhaps not legally related, the patient may consider as part of the family matrix, including valued pets.
Identify affectional and social networks of informal significance to the child. A matrix delineating the family’s sources for immediate social support can be valuable in times of crisis. Its ready availability can enhance care delivery. Also identify distant or extended sources for social support because, in emergencies, the more sources of assistance known, the better the provider will be able to facilitate their implementation.
Attempt to clarify life events of significance to the child and family. Examples include the child’s own milestones (eg, grade progression) and family milestones (eg, births, deaths, marriages, remarriages, past and present informal domestic arrangements).
Delineate important neighborhood factors to the child and family, including safety, stability, and social and economic variables that may affect health and well-being.
How do family members make decisions affecting the group? Does each member have input? What resources (eg, financial, emotional, spiritual, professional) do they believe are available?
What satisfaction(s) do members derive from family life? What stress(es) do they have?
What does each member feel he or she contributes to the family?
What is of importance to the family? Does a “higher power” support or guide them? What beliefs and value structures guide or do not guide them?
What roles do gender and birth order play in family functioning, including member status? Are these variables sources for conflict? (Be clear about personal beliefs and values in collecting and analyzing this data. The provider must clarify differences—and even obvious conflicts—between personal and professional beliefs and values to maximize the provider’s capability to analyze and use this data objectively and effectively).
What (if any) change in cultural or ethnic identity has the family lost to or assimilated within a country’s larger cultural expression? If loss has occurred, does it impact individual and family function and, in the wider arena, community identity? How has it affected health beliefs, health values, and in turn health function?

Green-Hernandez, C. (1999). Family and cultural assessment measures in primary care. In J. Singleton, S. Sandowski, C. Green-Hernandez, T. Horvath, R. DiGregorio, & S. Holzemer (Eds.), Primary care. Philadelphia: Lippincott Williams & Wilkins.

Providers should place family assessment data in the child’s permanent record along with family demographic information. They should review such data annually, updating information as needed, because these data give valuable insights when the clinician interacts with the child and family. Data derived from a family assessment are quick and easy to obtain, especially when the provider combines a self-assessment questionnaire with interview content from the child’s comprehensive history. In the case of multiple family members who are treated in the same practice, providers can copy the family assessment so that each person’s chart contains this important information.

Family Assessment Tools

Family assessment tools provide contextual details about the objective information obtained in a standard genogram, which providers collect during the child’s history. They also can clarify immediate and extended familial relationships and social and community networks that might impact family-focused care. Such data help foster a coparticipative relationship between the provider and family to meet primary
care needs (Artinian, 1994). Several published family assessment tools are available; Appendix 2-2 gives one example. Providers can use these instruments as they are or modify them to fit the needs of their practice.

The Family Circle

The Family Circle is a visual representation of a parent’s, older child’s, or adolescent’s perception of the direction and importance of family relationships at a certain point and should be appended to the family assessment. The process for gathering a Family Circle diagram is quick and straightforward (Thrower, Bruce, & Walton, 1982). At a minimum, the clinician asks the parent to complete a Family Circle; alternatively, the provider gives each family member who is old enough a pen and paper. Each family member dates the paper and draws a large circle representing the family. The person then draws smaller circles inside or outside the large circle, representing the self, individual family members, and if desired, any other significant relationships, including pets. As each person constructs them, the circles suggest the emotional relationships inherent in the family matrix at that particular point. Each circle’s size may indicate an individual’s significance, while distance between circles may indicate the extent of affection one member feels toward that family member. The circles are not static. Anytime that the clinician perceives that family dynamics have changed is a good time to solicit a new diagram.

The parent may want to write a brief statement that describes personal feelings about the circles and their meaning. The provider and parent then discuss the Family Circle diagram together, with the parent confirming or explaining interpretation of the Circle. These subjective data can be extremely valuable to the provider’s overall family assessment. Figure 2-1 illustrates a Family Circle for the family described earlier in this chapter. It helps to show what efforts may be needed to meet the child’s and mother’s needs, as well as those of other family members within the context of the wider community.

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