Rationale

The prenatal, childhood and adolescent phases of development strongly influence an individual’s subsequent health, wellbeing and opportunities in life.1 Engagement of children and young people in quality general practice care is important to enhancing future opportunities for all but particularly for those from vulnerable communities such as some Aboriginal and Torres Strait Islander people, refugees and asylum seekers, children in out-of-home care and children from families impacted by addiction and other negative social determinants of health.2–5

Health status evaluation at school entry in 2012 identified that 25% of children were developmentally vulnerable on the Australian Early Development Index and 45% of children had tooth decay. The 2011–12 Australian health survey identified that 25% of children aged 2–17 years of age were overweight or obese. Without early identification and intervention, these and other health inequities lead to significant threats to long-term health and wellbeing.6–8

Socioeconomic status undoubtedly has an impact on health inequity in Australia. Poorer socioeconomic status can result in cumulative health vulnerabilities in young people, such as higher teenage pregnancy and smoking rates.8 These statistics highlight the importance of high-quality primary care provision for all, combined with effective community health education and engagement in improving health outcomes.

It is clear that children are not just ‘little adults’; they differ from adults anatomically, physiologically, cognitively and psychologically. Identification of a seriously ill child is an essential skill for general practitioners (GPs) to develop, as children have a greater capacity for physiological compensation when unwell and so early signs of serious illness may not be visible. Integrating knowledge of normal development into routine screening and assessment of children is also very important.

Understanding each stage of childhood, diagnosis and management of the common presentations as well as uncommon serious presentations, and having the communication skills to engage with children and their families from infancy to late adolescence, are imperative for quality care. Communication difficulties between doctors and young people are barriers to young people accessing medical care in any setting.9–13 Young people may be self-conscious, mistrusting or cautious about authority figures such as doctors. They often have critical concerns about privacy and confidentiality and may be anxious about dealing independently with systems of healthcare that are not familiar to them.

Creating a friendly practice environment that is welcoming to children, young people and their families is important to improving accessibility. Ten per cent of consultations in general practice are with patients aged 15–24 years,14 but many young people do not feel comfortable raising certain important health issues with the doctor,9 while others experience barriers to accessing general practice care. General practitioners often find it challenging to provide optimal care for young people.10–13 Doctors’ confidence in dealing with young people is improved by focused training in communication skills.15 The Australian Institute of Health and Welfare reports that most Australian children and young people lead healthier lives when they have access to appropriate services that meet their needs.16

Being alert to both subtle and more obvious signs of neglect or abuse, and following mandatory reporting procedures if abuse is suspected, is essential for all GPs. In 2013–14, the rate of national notifications to child protection was 27.2 per 1000 children. Aboriginal and Torres Strait Islander children were seven times more likely to be receiving child protection services than non-Indigenous children. Of the notifications made, the suspected types of abuse were 40% emotional abuse, 28% neglect, 14% physical and 12% sexual abuse. Please refer to AV16 ‘Abuse and violence contextual unit’ for further information on the important role that GPs play in identification of abuse and in ensuring that the child at risk is protected from further harm.17

Families consult general practitioners and community nurses more commonly than any other health professional for problems arising in infancy.18,19 The most common presentations in the first three months of life include immunisation, six-week check, upper respiratory tract infections, oesophageal reflux, bronchiolitis, dermatitis, infectious conjunctivitis, irritability and fever.20 Sleep deprivation in the early months is another common presentation that can have a significant impact on the family in a number of measurable ways, including postnatal depression. GPs play an important role in providing support for the family unit and identification and management of health issues during these early months. This care includes the avoidance of inappropriate medicalisation that may result in families missing out on accessing appropriate and effective care.21–23

The rewards of providing care to children are enhanced when the doctor is able to establish an ongoing relationship with the child and their family. Parents report that they value doctors who understand the complexities of family life. General practitioners often see the same young children as seen by community nurses and other healthcare workers, and need to be able to work in teams and to collaborate efficiently for optimal patient care and to support families most at risk.24

General practice provides the highest proportion of childhood vaccinations when compared to other health services at 67.7%. Immunisation coverage rates for children aged 60–63 months as at 30 September 2015 were at 92.6%.25 With the increasing propagation of anti-vaccination information through social media, general practitioners require skills in effective counselling about vaccinations with children and families and non-judgemental strategies to address any concerns.26

Recent evidence has indicated a rising prevalence of childhood neuropsychiatric disorders, which has resulted in an emphasis on healthcare providers supporting families in the early years of child–parent interaction for the long-term promotion of mental health in children and young people.27 Early recognition of developmental or psychological issues and appropriate referral to support and therapeutic services generally leads to improved outcomes for children and their families.22,28

Adolescents are psychosocially vulnerable to health risks, largely as a result of risky behaviours.29 The gains in the health of young people in recent decades need to be contrasted against rising rates of diabetes and sexually transmissible infections, high rates of mental disorders and, for males, road transport accident deaths. Many young people are overweight or obese, not physically active or eating enough fruit and vegetables, drinking alcohol at highrisk levels and taking sexual risks. Many young people are also victims of alcohol- or drug-related violence, or are homeless.30

General practitioners need to be able to non-judgmentally assess risk and protective factors in the context of the developmental tasks of adolescence and develop a respectful and trusting therapeutic relationship in order to provide support and assist the young person in improving health and wellbeing outcomes.31,32 Being proactive, providing support and discussing issues such as sexual safety, contraceptive options, sexually transmissible infection screening, gender identity and body image concerns, and management options for unplanned pregnancy with young people are all very important parts of providing quality care. Ensuring that the role of confidentiality is explained to young people is imperative as is understanding determination of capacity for informed consent in mature minors.33 The HEADSS assessment tool is a useful framework for psychosocial risk assessment in this population in general practice.29

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References

  1. Committee on Integrating the Science of Early Childhood Development, National Research Council, National Institute of Medicine. From neurons to neighbourhoods: The science of early childhood development. Washington DC: National Academy Press, 2000.
  2. Ward AM, de Klerk N, Pritchard D, Firth M, Holman CD. Correlations of siblings’ and mothers’ utilisation of primary and hospital health care: A record linkage study in Western Australia. Soc Sci Med 2006;62(6):1341–48.
  3. Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: Randomised controlled trial. BMJ 2000;321(7261):593–98.
  4. Ward A, Pratt C. Psychosocial influences on the use of health care by children. Aust N Z J Public Health 1996;20(3):309–16.
  5. Janicke DM, Finney JW, Riley AW. Children’s health care use: A prospective investigation of factors related to care-seeking. Med Care 2001;39(9):990–1001.
  6. Australian Institute of Family Studies. Growing up in Australia: The longitudinal study of Australian children. Melbourne: AIFS, 2011.[Accessed 23 August 2015].
  7. Australian Bureau of Statistics. Australian Health Survey: Updated results, 2011–2012. ABS cat. no. 4364.0.55.003. Canberra: ABS, 2013. (Accessed December 2015).
  8. Australian Institute of Health and Welfare. A picture of Australia’s children 2012. Canberra: AIHW, 31 October 2012. [Accessed 1 November 2015].
  9. Booth ML, Bernard D, Quine S, et al. Access to health care among Australian adolescents: Young people’s perspectives and their sociodemographic distribution. J Adolesc Health 2004;34(1):97–103.
  10. Veit FC, Sanci LA, Young DY, Bowes G. Adolescent health care: Perspectives of Victorian general practitioners. Med J Aust 1995;163(1):16–18.
  11. Veit FC, Sanci LA, Coffey CM, Young DY, Bowes G. Barriers to effective primary health care for adolescents. Med J Aust 1996;165(3):131–33.
  12. Kang M, Bernard D, Booth M, Quine S, Alperstein G, Usherwood T, et al. Access to primary health care for Australian young people: Service provider perspectives. Br J Gen Pract 2003;53(497):947–52.
  13. Kang M, Bernard D, Usherwood T, et al. Access to health care among NSW adolescents: Phase 2. Research report. Sydney: NSW Centre for the Advancement of Adolescent Health, 2005.
  14. Britt H, Miller GC, Charles J, et al. General practice activity in Australia 2009–10. Canberra: Australian Institute of Health and Welfare, 2010.
  15. Sanci LA, Coffey CM, Veit FC, et al. Evaluation of the effectiveness of an educational intervention for general practitioners in adolescent health care: Randomised controlled trial. BMJ 2000;320(7229):224–30.
  16. Australian Institute of Health and Welfare. Australia’s health 2010. Australia’s health series no. 12. Cat. no. AUS 122. Canberra: AIHW, 2010.
  17. Australian Institute of Family Studies. Mandatory reporting of child abuse and neglect.  [Accessed 24 November 2015].
  18. Gunn J, Lumley J, Young D. Visits to medical practitioners in the first 6 months of life. J Paediatr Child Health 1996;32(2):162–66.
  19. Goldfeld SR, Wright M, Oberklaid F. Parents, infants and health care: Utilization of health services in the first 12 months of life. J Paediatr Child Health 2003;39(4):249–53.
  20. Charles J, Valenti L, Britt H. Infants – Encounters and management in general practice. Aust Fam Physician 2012;41(5):267.
  21. Hiscock H, Wake M. Infant sleep problems and postnatal depression: A community-based study. Pediatrics 2001;107(6):1317–22.
  22. Hiscock H, Wake M. Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ 2002;324(7345):1062–65.
  23. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. BMJ 2000;320(7229):209–13.
  24. Mbwili-Muleya C, Gunn J, Jenkins M. General practitioners: Their contact with maternal and child health nurses in postnatal care. J Paediatr Child Health, 2000;36(2):159–63
  25. Department of Human Services. Australian Childhood Immunisation Register (ACIR) statistics. Canberra: DHS, 2 November 2015. [Accessed 24 November2015].
  26. Danchin M, Nolan T. A positive approach to parents with concerns about vaccination for the family physician. Aust Fam Physician 2014;43(10):690–94.
  27. Australian Infant, Child, Adolescent and Family Mental Health Association. Improving the mental health of infants, children and adolescents in Australia. North Adelaide, SA: AICAFMHA, 2011. [Accessed 3 December 2015].
  28. KPMG. Reviewing the evidence on the effectiveness of early childhood intervention: Report to the Department of Families, Housing, Community Services and Indigenous Affairs. [Place unknown] KPMG, 2011.[Accessed 24 November 2015].
  29. Sanci L, Chondros P, Sawyer S, et al. Responding to young people’s health risks in primary care: A cluster randomised trial of training clinicians in screening and motivational interviewing. PLoS One 2015;10(9):e0137581.
  30. Australian Institute of Health and Welfare. Young Australians: Their health and wellbeing 2011 Canberra: AIHW, 2011.
  31. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm. JAMA 1997;278(10):823–32.
  32. Christie D, Viner R. Adolescent development. BMJ 2005;330(7486):301–14.
  33. Bird S. Consent to medical treatment: The mature minor. Aust Fam Physician 2011;40(3):159–60.

Useful children and young people’s health resources and tools

  1. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 8th edn. Chapter 3. Preventive activities in children and young people. East Melbourne: RACGP, 2012
  2. Alexander K, Mazza D. How to perform a ‘Healthy Kids Check’. Aust Fam Physician 2010;39(10):761–65
  3. HEADSS psychosocial assessment tool
  4. Danchin M, Nolan T. A positive approach to parents with concerns about vaccination for the family physician. Aust Fam Physician 2014;43(10):690–94
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