Surveillance or Engagement: Children's Conflicts During Health Maintenance Visits.

OBJECTIVE: School-aged health maintenance visits seek to prevent or intervene early with health issues of lifelong importance. Little is known about what children expect to happen in these visits or how they experience them, factors related to their engagement as active collaborators in care. METHODS: Thirty children (53% Latino, 27% African-American, and 20% white) ages 7 to 11 years were video recorded during a health maintenance visit and then interviewed while reviewing the videos. Interview transcripts were analyzed for understanding the purpose of the visit, feelings of comfort and discomfort, and decisions about how much to participate. RESULTS: Children expected doctors to be helpful, caring, and a source of important information. They anticipated visits to include immunizations, a physical examination, and praise for accomplishments, but could be surprised by questions about behavior, family function, and lifestyle. During visits, feelings varied from warmth toward providers to embarrassment, wariness, irritation, and boredom. Even when bored or irritated, children hesitated to interrupt parent-provider conversations or correct perceived provider misunderstandings, not wanting to be seen as inappropriate or rude. When asked questions they considered off topic, likely to reveal sensitive information, or that could lead to changes in their lifestyle, some were silent or answered evasively. Some said they would have spoken more freely without their parent present but valued parental support and wanted parents to make important decisions. CONCLUSIONS: School-aged children's limited knowledge of what to expect in health maintenance visits, uncertainty about conversational norms with adults, and desire to assert control over their lives compete with their desire to access expert advice and form bonds with providers. Engaging children in health maintenance visits might require more relationship-building and education about the visit's goals.

Mental health communications skills training for medical assistants in pediatric primary care.

Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.