Paediatrics: History taking

History taking

Why have multiple informants?

Neither parents nor their children and adolescents may, be aware of or see the whole picture. They may also withhold information from you. Which of us does not on occasion operate a need to know policy? As an example, the teenage girl with anorexia nervosa who wants to avoid admission may exaggerate the amount she is eating and minimize her level of exercise.

Whom to get information from?

This is a balance between ‘the more sources the better’ and the demands of confidentiality and time.

·  A good starting point is the referral details and information from both the young person and members of the family.

·  Information from the school should also be sought though this may not be practicable in an emergency situation.

·  Where relevant, others should be approached, e.g. social services, child and adolescent mental health services, youth offending teams.

Example 

The child is brought to Accident and Emergency with an unex-plained and suspicious injury. Collaboration with other agencies is essential if child protection concerns exist. Local information-sharing protocols pro-tect practitioners and expedite this work.

Interviewing the family

To an extent the family interview is an efficient way of gathering informa-tion and hearing the views of the patient, siblings, and parents all at one go. However, to see it this way is missing the point. It is an opportunity to learn so much more.

·  Are there obvious tensions or conflicts?

·  Is tension between the parents diffused by the child’s behaviour?

·  Are the children allowed appropriate autonomy, or do they rule the roost?

·  Is one parent a ‘switchboard’ through which all communication is routed?

·  Are family members able to listen to each others’ views?

• Is disagreement tolerated?

·  Is there a family ‘story’ that informs how they interact around the presenting problem? Examples include, ‘no-one listens to us’, ‘we have tried our best and can’t do any more’, ‘it is all this child’s fault’, and ‘he/she cannot be helped, but at the same time someone has to do something about her/him’. This sort of mixed message around a scapegoated child can often be very difficult to work with.

Family structures are variable. Often times the interview is with one par-ent. Sometimes it can be illuminating if grandparents are also present. Are there coalitions across generations (e.g. grandparent and child), in effect combining forces to undermine one of the parents?

A further area to note is how the family responds to you. Are you treated as a threat, a messiah, a parent/grandparent, or just a doctor? Do you feel pulled to take sides in a dispute?