Respectful Interaction
Working with Children and Adolescents
The important thing about you is that you are you. It is true that you were a baby, and you grew, and now you are a child, and you will grow, into a man, or into a woman. But the important thing about you is that you are you.
—M.W. Brown1
Chapter Objectives
• Discuss in general terms the key developmental tasks of children and adolescents
• Describe how the five types of play introduced in Chapter 14 are relevant—or not relevant—to respectful interaction with older children
• Describe high-risk behaviors in adolescence that can lead to long-term health problems
Much of the material related to respectful interaction with the infant or toddler and his or her family can be applied to older children. As a child grows, however, some new challenges confront the child, parents, families, and health care providers. Therefore, in this chapter we add some dimensions to the groundwork we laid in Chapter 14 to highlight some of the most important differences, as well as focus on the situation of adolescent patients.
Childhood Self
A young child’s psychosocial tasks in moving from infancy to childhood focus on the need to recognize that one has a “self,” separate from others, but that ultimately many aspects of that self must survive and thrive in relationships with others. Therefore, much activity and energy are focused on being different from others at the same time that much is invested in learning how to be accepted by others and having some say in relationships. As we address later in this chapter, these tasks become paramount during the adolescent years, but the fundamental building blocks begin much earlier.
Needs: Respect and Relating
Writer Annie Dillard poetically describes the first part of the child’s developmental task, that of becoming a “self” different from others. She recalls it this way in her autobiography, An American Childhood:
I woke up in bits like all children, piecemeal over the years. I discovered myself and the world, and forgot them, and discovered them again. … I noticed this process of awaking and predicted with terrifying logic that one of these years not far away I would be awake continuously and never slip back and never be free of myself again.2
Children, in general, want to make it alone and have learned not to accept the full dependence of infancy and the toddler years but are not independent yet. When they become patients they regress. The dependence side of the scales tips heavy, and the good fit of selfhood that the child is slipping into suddenly escapes. In this confusing never-never land of being neither infant nor fully child nor adult, children must try to reestablish some sense of equanimity and self-identity during their time of being patients.
Most children beyond the preschool years have learned to communicate verbally and have many more experiences upon which to rely compared with an infant or a toddler. Thus, their resources for effective relating are greater than those in their earlier years. The school-age years open up the child’s world to interactions with many new and different people. These are mainly authority figures, such as teachers, coaches, and other role models, with whom the child will interact.
However, for the most part health professionals present types of authority that are often unfamiliar to the child. Family and school authority figures usually do little to prepare him or her for the health professions setting and its unique challenges and choices.
The Importance of Play
Play is a child’s primary occupation.3 Play appropriate to the child’s age and social development can be an important vehicle to help ease the tension a child is feeling about relating to people in the health care setting. In Chapter 14 we introduced six types of play. As children develop new motor and cognitive skills, their play changes. Gender is an important contributor to play, as is age, peer group, and play opportunities. In their study of 7- to 11-year-old children, Miller and Kuhaneck3 found that friends, siblings, and even pets figured prominently in children’s descriptions of play and fun. This and other studies remind us that regardless of environment (hospital, school, or home), children need to play. Some older children who become patients may regress to an earlier stage of play, but many will be able to assume roles at the higher levels of play, which will allow them to act out their predicament of being in such a new situation. For example, associative play can involve playing “hospital” with a professional or family member and assuming the powerful role of the nurse or someone else in charge, thereby revealing children’s own anxieties and how they perceive their situation. Clues to how they think their tension could be eased may be revealed in their attempts to minister to the play partner who has now become the patient. Cooperative play can involve table games, card games, or sports, using their participation and mastery as an effective way of relating.
Young patients often play with toys, too, so a truck, doll, puzzle, or other object may be an effective means of helping to establish a relationship. At the same time, children can be sensitive about being “too old” for certain types of toys, so health professionals and others must think carefully about which toys to offer and how to best integrate family and siblings into their sessions. Health professionals must also be sensitive to the fact that some children may not have access to toys and books. Twenty-one percent of children ages 0 to 17 in the United States live in families with incomes below the poverty level ($22,050 a year for a family of four).4 These children are vulnerable to environmental, health, educational, and safety risks. They are also at particular risk for developmental challenges. Thoughtful considerations on how to help families modify environments and maximize access can bring about meaningful change in the number of opportunities for children to engage in play (e.g., repurposing everyday use items as toys, accessing library services).
REFLECTIONSSchool Issues
When school age children become patients, health professionals are faced with additional challenges. Even a short illness or injury may disrupt school attendance and may not only put the child behind in schoolwork but also have devastating consequences socially. During the school years children organize most of their relational activity around family and school; therefore, they are at risk of being “out of the action” in every way when removed from the educational environment. At the very least you should be aware of this loss and show interest in his or her school-related activity if, indeed, any is being carried on at the moment.
Most children with chronic illnesses or long-term disabilities will receive special attention regarding education through the school system itself. Over the past 30 years, the definition of disability has changed. In the 1970s and 1980s, the concept of a disability referred to an underlying physical or mental condition that reduced one’s abilities. Today, disability is seen as a complex interaction between a person and his or her environment. The development of the international classification of functioning, disability, and health (ICF) by the World Health Organization (introduced in Chapter 14) reflects this new perspective. In this classification, disability is an umbrella term for impairments, activity limitations, and participation restrictions. This perspective acknowledges that any individual can experience a decline in health at various points in his or her lifespan, hence experiencing disability. It is a biological, individual, and social perspective of health rather than a diagnosis or label.5 A significant portion of children, estimated to be 6% of all those 17 years or younger, have experienced some degree of disability.6 The number of U.S. children with developmental disabilities is on the rise. Developmental disabilities were reported in approximately one in six children in the United States in 2006-2008. The prevalence of any developmental disability in 1997 to 2008 was 13.87%.7 This increase is significant because it will have a direct bearing on the need for health, educational, and social services for this population and their families.
The Americans with Disabilities Act (ADA) and the ADA Amendments Act of 2008 (P.L. 110-325) prohibits discrimination on the basis of disability in employment, state and local government services, public accommodations, commercial facilities, transportation, and telecommunications.8 You can find out about the different components of the ADA at http://www.ada.gov/. The Individuals with Disabilities Education Act (IDEA) (formerly called Public Law 94-142 or the Education for all Handicapped Children Act of 1975) is the federal law that governs the provision of special education services. It requires public schools to make available to all eligible children with disabilities a free, appropriate public education in the least restrictive environment appropriate to their individual needs.9 However laudatory this is, the law does little to address the accompanying problems that sometimes arise: Able-bodied children may be cruel toward peers who have medical conditions, parents may believe that their child is not getting care as good as they would like or disagree with the individualized education program that has been developed for their child, teachers may feel that they do not have enough time to devote to the needs of all the children in their classrooms, and children with serious but not permanent conditions may not qualify.10 When you come into contact with families who are trying to work through some of these issues, you can often encourage them and direct them to the appropriate resources when problems arise. For example, if parents disagree with the individualized education program, they can request a due process hearing and a review from the state educational agency if applicable in their state.
In short, during the school-age years a child’s feelings of self-worth and experiences of relatedness usually are tied to school. Any means by which you can convey empathy for the child’s predicament and respect for his or her capacities will enhance the child’s self-esteem and help ensure success in the relationship.
Family—A Bridge to Respectful Interaction
All of the family dynamics described in Chapter 14 apply as the child grows older. The growing child, however, does present some additional challenges to the family and health professional working with the family. The needs of the school-age child revolve around tasks, hobbies, and activities. It is during this stage that 7- to 12-year-olds develop a sense of values to guide decision-making and interests.
It has been noted that the child’s desire to become more independent is one of the major developmental tasks of this growth period, while at the same time he or she may feel extremely lonely and insecure when illness strikes. The family is often torn between wanting to support the child as an independent “big girl” or “big boy” while being attentive to his or her needs. They may also be dismayed by the child’s obvious regression or respond to their own feelings of guilt for the child’s illness with overprotectiveness. Your awareness of their struggles and needs is essential if you are to be successful. Remember, you must always show family members the due respect they deserve. They are the people who are most knowledgeable about the child and are key collaborators in clinical decision-making. Lawlor and Mattingly11 put this best when they stated: “Collaboration is much more than being nice. It involves complex interpretive acts in which the practitioner must understand the meanings of illness or disability in a person and family’s life and the feelings that accompany these experiences.”
Children as Active Participants in Care
Respect for the child’s input, especially when his or her opinions seem to differ from those of parents, is essential, too. Although developmental psychology has often used age as an indicator of competency, this view is being challenged and replaced by the principle that social experience is a more reliable marker of maturity and decision-making ability.12,13 Although the legal age of consent is 18 in the United States, many policies now acknowledge the importance of listening to children and having them assent to care decisions. Assent in children honors respect for persons and should be sought from the age of 7 upwards. It ensures that they can communicate a choice and have a say in what happens.14 Children often express their preferences through body language and actions. However difficult the discussion may be, many children should be invited to be active participants in the care planning process. It is through this participation that they learn the life skills necessary for decision making and illness management. Children often are aware of their parent’s anxiety, opposition, or denial, and they try to act as referees among family members or between health professionals and family. Children can participate in a meaningful way in discussions about their health care (Figure 15-1). “The challenge is to provide appropriate techniques that neither exclude nor patronize children. Notions of children’s incompetence are reinforced by methods that oversimplify and ‘talk down’ to them.”13
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