1. The Child Consultation in General Practice: - getting insights into the child‘s well-being. Kirsten Lykke

2. The GP is expected to have a central position in identifying children with psychosocial problems and health problems due to neglect.

3. Disposition Background Methods and material Results 1.The child consultation 2.Assessment of the child´s well-being 3.What is normal

4. Background Psychosocial problems, i.e. behavioural and emotional problems are prevalent among children

5. Background Psychosocial problems, i.e. behavioural and emotional problems are prevalent among children The GP only identify a minor part

6. Background Psychosocial problems, i.e. behavioural and emotional problems are prevalent among children The GP only identify a minor party The child consultation is different

7. Methods and material qualitative study based on – focus-group discussions – individual interviews – observation of consultations. 28 GPs participated

8. parentdoctor Child Re sul ts: th e chi ld co ns ult ati on 1. Results: The child consultation

9. Child Parent Doctor Re sul ts: th e chi ld co ns ult ati on Results: The child consultation

10. Child Parent Doctor R e s u lt s: t h e c h il d c o n s u lt a ti o n Results: The child consultation

11. Child Parent Doctor Results: The child consultationResults: The child consultation Results: The child consultation

13. 2. Results: The assessment of the child´s well-being

14. The assessment of the child’s well- being was based on the parent’s account about the child

15. The assessment of the child’s well- being was based on the parent’s account about the child – the GPs encouraged the parents to talk about the child

16. The assessment of the child’s well- being was based on the parent’s account about the child the parent-child interaction in the consultation:

17. The assessment of the child’s well- being was based on the parent’s account about the child the parent-child interaction in the consultation – developed experience-based norms

18. The assessment of the child’s well- being was based on the parent’s account about the child the parent-child interaction in the consultation – developed experience-based norms – most GPs did not tell the parents they were being observed

19. The assessment of the child’s well- being was based on the parent’s account about the child the parent-child interaction in the consultation the child’s appearance and behaviour

20. The GPs based their assessment of the child’s well-being on the parent’s account about the child the parent-child interaction in the consultation the child’s appearance and behaviour A small pale child who always just clung to the mother. [...] (She was) two to three years old. She did not say anything and she never did anything. (Male, 54 years, focus group 1).

21. The GPs based their assessment of the child’s well-being on the parent’s account about the child the parent-child interaction in the consultation the child’s appearance and behaviour their own communication with the child Fi rs t: t o a d d r e ss t h e c hi ld. S o t h e y k n o w t h a t t h e y a r e t h e m ai n p e rs o n. [... ] Li k e t h a t I b ui ld u p a tr u st in g r el a ti o n s hi p fi rs t o f al l. B e c a u s e t h a t o f c o u rs e is al p h a a n d o m e g a f o r b ei n g a bl e t o o b s e rv e a n yt hi n g a t al l.

22. The GPs based their assessment of the child’s well-being on the parent’s account about the child the parent-child interaction in the consultation the child’s appearance and behaviour their own communication with the child First: to address the child. So they know that they are the main person. [...] Like that I build up a trusting relationship first of all. Because that of course is alpha and omega for being able to observe anything at all. (female, 58 years, individual interview) s, s

23. The GPs based their assessment of the child’s well-being on the parent’s account about the child the parent-child interaction in the consultation the child’s appearance and behaviour their own communication with the child in particular the physical examination

24. The physical examination served several purposes: to discover or exclude diseases to strengthen the parents’ confidence in the GP to be in direct contact with the child. to observe the child’s reaction to the examination

25. The physical examination served several purposes: to discover or exclude diseases to strengthen the parents’ confidence in the GP to be in direct contact with the child. to observe the child’s reaction to the examination (I) wish to have the children through my own hands. I think one gets very many good experiences – or information, from handling children instead of just talking. (Male, 52 years. focus group 4).

26. 3. Results: What is normal

27. The normality in the child consultation the normal was defined as “the most frequently seen” When you see a lot of people, I think you learn some patterns for normality that you haven’t really formulated (female, 46 years, focus group 2). [1]

28. The normality in the child consultation the normal was defined as “the most frequently seen” Normality was expected

29. The normality in the child consultation the normal was defined as “the most frequently seen” Normality was expected the deviation from the normal could be a sign of lack of well-being. I have experienced a couple of times and I don’t know what it means when I sort of felt that a child of about two years old wanted to get up on me, really without me trying to do anything. And I thought that is not normal for a 2-year-old child. (Male, 56 years, small town, focus group 2).

30. The normality in the child consultation the normal was defined as “the most frequently seen” Normality was expected the deviation from the normal could be a sign of lack of well-being. experience with normal, well-functioning children and families, was a valuable reference

31. The normality in the child consultation the normal was defined as “the most frequently seen” Normality was expected the deviation from the normal could be a sign of lack of well-being. experience with normal, well-functioning children and families, was a valuable reference These well-functioning families with happy, lovely youngsters. To get an idea of these good relationships that should be there, because then I can quick as lightning see if it’s wrong. (Female, 51 years, focus group 4).

32. Conclusion GPs approached the child consultation as a triad They relied on observations of the interaction between the three parts as well as the examination of the child, but they seldom involved the parents in their observations The physical examination served several purposes The assessments of the child´s well-being is based on a perception of normality rooted in their own experience and personal practical competence.

33. Thank you for your attention.

36. Overview of GPs’ experience with the conversation with the parents. The GP may describe what he or she sees, experiences and feels, specifically, without interpretation and speak plainly so the parents do not misunderstand involve the parents as early as possible, ask what the parents see, experience, feel and how they understand and interpret what is experienced reflect with the parents, be transparent in his or her reflections, appreciate the parents’ interpretation and understanding as a help for the GP conclude with the parents plainly and specifically and not more than has been experienced

37. The normality in the child consultation “These well-functioning families with happy, lovely youngsters. To get an idea of these good relationships that should be there, because then I can quick as lightning see if it’s wrong”. (Female, 51 years, small town, focus group 4).

38. The GPs’ conversation with parents traditional form of practice 1.Covertly investigation of the child’s well-being 2.observe the child during subsequent contacts. 3.exchange of information and interpretations. 4.remained watchful and distanced 5.an all or nothing scenario: a wide-ranging criticism or continued observation. 6.more concerned with their own role reflective form of practice 1.Sharing the observations with the parents. 2.ask for the parents’ interpretation. 3.tried to be clear and specific and to avoid interpretation. 4.need the parents’ knowledge and interpretation. 5.the conversation as a sharing of knowledge between two experts. 6.tried to understand the parents and to build up trust and confidence.

39. 3. Results: Ethics and normality in the child consultation

40. The child’s well-being as dependent on the family’s resources the parents’ caring abilities. knowledge about the parents problems without knowing the child´s well-being not to increase stress on the family not to stigmatize the child.

41. The need and use of practice and theory knowledge Theoretical training versus the continuous work with families and children Underlying is knowledge development theories Assessment on bio-medical references

42. The ethics in the child consultation maintaining and developing trust – trust in the GP – trust in the parents respect for the family’s autonomy responsibility not to cause harm

43. Four assessment systems were particularly central to the GPs’ judgement: The ethics in the child consultation The normality in the child consultation The need and use of practice and theory knowledge The child’s well-being as dependent on the family’s resources

44. (I say) that it is also a check of the parental role, that this is part of the 5-week examination. In a way they are very happy with that. Very few become a bit frightened and say: Good Lord is it really? They had not imagined that [...] (I say) to the parents, that - I can see that you hold the child properly and you talk to the baby when you’re doing it. And there is good contact to the baby. So the mother is also praised because they need that too [...] If there is something or other that I think they are doing wrong, I always say that in my experience if you do such and such, then you get a quicker result from it. (Male, 54 years, focus group 3).