Child and youth health

Note: the focus of this unit is to cover content specific to this population group that does not fall under the headings of other systems-based units that include adult health, such as cardiovascular health, or gastrointestinal health. The child and youth unit includes content on childhood and adolescent stages of development and specific needs. For common paediatric conditions, for example, asthma, please refer to the relevant systems-based unit.

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Families consult general practitioners (GPs) and community nurses more commonly than any other health professional for problems arising in infancy.1 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.2

To provide quality care to children and young people, it is imperative that GPs understand the stages of childhood and can recognise, diagnose and manage both the common presentations of childhood, as well as recognise an acutely unwell child. Identification of a seriously ill child is an essential skill for GPs to develop, as children have a greater capacity for physiological compensation when unwell. GPs must be able to provide age-appropriate care and be aware of the special clinical, ethical and medico-legal considerations that apply to children and young people.

Effective communication skills to engage with children, young people and their families is an essential skill for GPs. Establishing rapport and building a trusted relationship with a GP during childhood years is important so that it may continue across the lifespan.3 This continuity of care places GPs in the ideal position to address the main drivers of healthcare for young people, advising on preventive health strategies, including vaccination, development of protective factors and addressing the social determinants of health to remove barriers to young people accessing medical care in any setting.4 GPs need to be proactive about discussing topics, such as contraception, sexual health, gender identity and body image concerns with young people.5 Explaining confidentiality to young people is imperative, as is understanding determination of capacity for informed consent in mature minors.6

GPs play an essential role in screening and supporting families to promote long-term physical and mental health and wellbeing in children and young people. With recent evidence indicating a rising prevalence of metabolic risk factors, such as obesity and inadequate exercise,5 and the rise of childhood neuropsychiatric conditions,7 early recognition and management of developmental or psychological issues – and appropriate referral to support and therapeutic services –generally leads to improved outcomes for children and their families.7 Neurodivergent individuals can benefit from extra support and recognition; however, it is important to recognise that neurodiversity does not require a cure.8 For children with chronic, ongoing or rare conditions that require long-term care, GPs play a critical role in care coordination over a patient's lifespan, including transition from child to adult services.

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 2017–18, approximately 26,400 children aged 0–12 years had one or more child protection notifications substantiated, with emotional abuse being the most common form of abuse reported at 59%.9 Aboriginal and Torres Strait Islander children were seven times more likely to be receiving child protection services than non-Indigenous children. The cause for this disparity is complex and likely due to issues such as healthcare access, intergenerational trauma, disempowerment and loss of culture.10 Without early identification and intervention, health inequities lead to poor outcomes in long-term health and wellbeing. Low socioeconomic status and lack of access to services can result in cumulative health vulnerabilities in young people, such as higher teenage pregnancy and smoking rates.11,12

The use of a trauma-informed approach is essential when working with vulnerable children and young people who may be impacted by adverse childhood experiences.13 This may include children in out-of-home care; children from families impacted by addiction, abuse or violence; Aboriginal and Torres Strait Islander children; and refugee and asylum seeker children.

References
  1. Quach A. Common neonatal presentations to the primary care physician. Aust J Gen Pract 2018;47(4):193–98.
  2. Charles J, Valenti L, Britt H. Infants – Encounters and management in general practice. Aust Fam Physician 2012;41(5):267.
  3. Turner L, Spencer L, Strugnell J, Di Tommaso I, Tate M, Allen P, Cheek C, Cooper J, Chang J. Young people have their say: What makes a youth-friendly general practice? Aust Fam Physician 2017;46(1):70.
  4. Chown P, Kang M, Sanci L, Newnham V, Bennett D. Adolescent health GP resource kit. 2nd edn. North Sydney, NSW: NSW Health, 2016 [Accessed 10 September 2021].
  5. Australian Institute of Health and Welfare. Australia's children. Canberra: AIHW, 2020 [Accessed 20 August 2021].
  6. Sanci L, Webb M, Hocking J. Risk-taking behaviour in adolescents. Aust J Gen Pract 2018;47(12):829–34.
  7. Bradshaw P, Pickett C, van Driel M, Brooker K, Urbanowicz A. ‘Autistic’ or ‘with autism’? Why the way general practitioners view and talk about autism matters. Aust J Gen Pract 2021;50(3):104–08.
  8. Believe:NeuroDiversity. What is neurodiversity: Variations within the brain. Balaclava, Vic: Believe:NeuroDiversity [Accessed 26 November 2021].
  9. Australian Institute of Health and Welfare. Child protection Australia: 2017–18. Child welfare series no. 70. Cat. no. CWS 65. Canberra: AIHW, 2019.
  10. Lewis N, Burton J, Lewis P, et al. Family Matters report 2017: Measuring trends to turn the tide on the over-representation of Aboriginal and Torres Strait Islander children in out-of-home care in Australia. Melbourne: Secretariat of National Aboriginal and Islander Child Care and Family Matters, 2017.
  11. Australian Institute of Health and Welfare. Teenage mothers in Australia 2015. Cat. no. PER 93. Canberra: AIHW, 2018.
  12. Guerin N, White V. ASSAD 2017 Statistics & trends: Australian secondary students’ use of tobacco, alcohol, over-the-counter drugs, and illicit substances. Melbourne: Cancer Council Victoria, 2018.
  13. Kezelman C, Stavropoulos P, Blue Knot Foundation. Practice guidelines for clinical treatment of complex trauma. Milsons Point, NSW: Blue Knot Foundation, 2019 [Accessed 26 November 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • tailor communication style to effectively interact with young patients and their family and carers
1.1.3, AH1.3.1, 1.3.1, 1.4.1
  • develop rapport with, and offer a safe space for, children and young people to communicate their needs
1.1.1, 1.1.2, 1.3.2, AH1.4.1, RH1.4.1
  • demonstrate an approach to counselling children and young people about risk-taking behaviours that is evidence-based and free of discrimination
1.4.1, 1.4.4, AH1.4.1, RH1.4.1
  • adopt a clinically sound and age-appropriate approach that is free of stigma when discussing sexual relationships and contraception
1.4.1, 1.4.3
  • identify and discuss common behavioural or developmental concerns with parents and carers with consideration of cultural differences in parenting approaches
1.4.3, 1.4.4, RH1.4.1
  • adopt a trauma-informed care approach to the consultation, as appropriate
1.4.1, AH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • monitor growth and development in children and young people to ensure early recognition and management of conditions
2.1.1, 2.1.2, 2.1.7, 2.1.8
  • screen for and recognise signs of developmental delay in children and young people to ensure timely recognition and referral
2.1.1, 2.1.2, 2.1.7, 2.1.8
  • recognise and appropriately triage and/or refer an acutely unwell child
2.1.1, 2.1.2, 2.1.3, 2.1.4, 2.1.8, 2.1.10, RH2.1.1, AH2.1.2
  • identify and manage nutritional and feeding issues appropriate to the age of the child or young person
2.1.1, 2.1.2, 2.1.3, 2.1.8
  • screen for and manage signs of mental health distress, self-harm and suicidality in children and young people
2.1.3, 2.1.6, 2.1.8
  • provide continuity of care, support and resources to parents, families and carers
2.3.4, AH2.3.1, RH2.3.1
  • ensure safe prescribing for children and young people with ready access to appropriate resources
2.1.9
  • identify and manage behavioural concerns appropriately and formulate age-appropriate management plans
2.1.1, 2.1.2, 2.3.1, 2.3.2
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • provide advice on accessing health-promotion resources and programs appropriate to children and young people
3.1.2, 3.1.4, AH3.2.2
  • advocate for the use of telehealth to improve access for young patients and their families and carers
RH3.2.1, 3.2.2, 3.2.4
  • inform and encourage age-appropriate vaccination
3.1.1, 3.1.3
  • determine age-appropriate screening based on current guidelines; for example, screening for metabolic risk factors and sexually transmissible infections
3.1.1, 3.1.3
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • access relevant training and education in the care of children and young people
4.2.1, 4.2.2, RH4.2.3
  • recognise and consider own beliefs and values when discussing and managing risk-taking behaviour in children and young people and their families
4.2.2, 4.2.3, 4.2.4, AH4.2.1, AH4.2.2, RH4.2.3
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • assess for Gillick competence in young people when discussing consent in accordance with relevant jurisdiction, and maintain confidentiality as it pertains to the medico-legal context
5.2.1, 5.2.2, 5.2.3
  • adhere to mandatory reporting requirements and jurisdiction legislation
5.2.3, 5.2.4
  • ensure effective recall systems for routine childhood vaccinations and health assessments
AH5.1.3, 5.2.3
  • create a safe practice environment for children and young people
AH5.1.2, 5.2.5

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Looking after children and adolescents involves continuity of care. Allow time to build rapport and engagement at an age-appropriate level. Mention this strategy to parents at the beginning, especially for issues that concern growth and development, and they will be appreciative of the approach.
  2. It’s important to consider the child or young person’s environment. Is their condition a symptom of other problems at home or school? It’s also important to identify vulnerable children and offer support not just to them but to their families and carers as well.
  3. Consider the concerns and expectations of both the patient and their parent or guardian when seeing paediatric patients.
  4. Issues of consent and potential child abuse are always tricky. In these situations, make sure you get help and gather information and advice from appropriate local pathways or your colleagues. Remember to debrief about cases that you’re concerned about. When seeing adolescents, if appropriate, consider conducting the consultation without the guardian/parent present after consent has been given.
  5. Listen to the parent or guardian; they are often able to pick up subtle changes in behaviour that may not be obvious in the consultation room. Try to manage a parent or carer’s concerns and expectations along with the presenting issue for the patient.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Child and youth health

Hunter, a 20-month-old toddler, has been brought in by his mother, who is new to the area. She is concerned that Hunter is not eating much and has temper tantrums around mealtimes. She is also concerned about his speech, as she feels that Hunter’s speech is falling behind that of other children in his age group.

Questions for you to consider Clinical exam assessment area Domains

What communication strategies would you use to make sure you cover all the mother’s ideas, concerns and expectations about her son?

What strategies would you use if English was not the mother’s first language?

  1. Communication and consultation skills
1,2,5
 

How would you assess Hunter’s growth and development?

How would you look for any missing information?

How would you screen for signs of abuse?

What approach could you use to gather information if the patient were an adolescent?

How would you look for adverse events in the parent/carer’s history that might impact their parenting?

  1. Clinical information gathering and interpretation
2   

What are some of the differentials you would consider? What if Hunter were a teenager?

  1. Making a diagnosis, decision making and reasoning
2   

When would you consider referring Hunter to a non-GP specialist or allied health professional?

Where would you find information on local referral pathways?

What factors might make you consider a developmental delay?

How would you help Hunter’s mother manage his challenging tantrums?

How would you manage Hunter’s behaviour if he were 13 years old and refusing/restricting his meals?

How would you manage Hunter’s eating patterns and nutrition?

  1. Clinical management and therapeutic reasoning
2   

If the patient was of Aboriginal or Torres Strait Islander background, where would you look for additional culturally appropriate resources?

How would you manage linking the family with Aboriginal healthcare workers/liaison workers?

How would you screen for carer/parent stress in this situation?

  1. Preventive and population health
1,2,3      
 

If Hunter’s mother were not satisfied with the consultation, how would you approach the situation?

Can you identify any of your own biases towards parenting that might impact the consultation?

  1. Professionalism
4   

How would you make sure that Hunter is followed up appropriately, and that you safety net?

If Hunter were in foster care, how would you ensure that the management plan is appropriately adhered to?

If you were concerned about abuse or neglect, who could you contact for advice and assistance?

  1. General practice systems and regulatory requirement
5   

How would you do a urinalysis on Hunter (screen for diabetes)?

  1. Procedural skills
2   

How would you manage this case if you couldn’t make a diagnosis after the first consultation?

  1. Managing uncertainty
2   

If Hunter presented with poor fluid intake and output, what would your acute management be and when would you urgently refer?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Audit your clinical notes for five paediatric patients you have done vaccination checks for at 12 months, 18 months and four years of age.

  • Did you document a check for each of the four domains of development, their growth on centile charts, your examination findings and acknowledge any parental concerns? Did you document who the children were accompanied by? How would you evaluate if the developmental milestones you checked were appropriate for age?
  • How did you ensure the right vaccination was administered? Did a nurse assist you, and if so, how would you carry out some of these processes yourself within the time constraints of general practice?
  • Did you review a child’s psychological wellbeing at the four-year-old check?

For the next five patients you see who are either children or young people, ask the parents for feedback about how you handled the consultation, and if they felt their ideas, concerns and expectations were acknowledged.

  • Use that feedback to form the basis of your next consultation.

Review the information in the Therapeutic Guidelines on prescribing (and not prescribing, as appropriate) antibiotics for paediatric patients for otitis media, upper respiratory tract infections, pneumonia, urinary tract infections and gastroenteritis.

  • Have there been situations in your recent practice where you might not have adhered to the guidelines? What circumstances in the consultation might have caused that?
With a supervisor

Ask your supervisor about a case of child abuse they might have seen/reported in their own practice. If they don’t have one, then discuss a hypothetical one and discuss issues around screening for abuse, how to obtain advice, when to report it and how to debrief after managing the case.

  • What did you learn that you can use in your next consultation?

From the practice software, review a care plan completed for a chronic condition in a child or adolescent; for example, type 1 diabetes, autism or cerebral palsy. Review the notes and check if the MBS requirements for formulating the care plan have been met.

  • Discuss with your supervisor what these requirements are and how you can reduce fragmentation of care in the management of chronic conditions in young patients.
  • Discuss when adolescents can make informed consent regarding contraception, immunisation, etc. Ask your supervisor about their experience with this.

Discuss procedural skills in this population; for example, intra-aural or intranasal foreign body removal, laceration closure, catching urine, and examining ears and throat.

  • What are the issues around consent for these procedures?
  • Ask your supervisor about practical ways to conduct these procedures, and attempt them under supervision.
  • Consider how you will accurately document these procedures in your notes, and when you will refer to a tertiary hospital for management.
In a small group

Role-play doing a HEEADSSS assessment (see learning resources section) for an adolescent who is being bullied at school.

  • How did you build rapport?
  • How do you make sure the patient is safe from harm?
  • Consider the issues around consent, and discuss as a group when you might have to break confidentiality.

Encountering challenging behaviours in young patients in general practice is common. In your group, discuss resources and ways to manage behaviours, such as restrictive food behaviours, school refusal and sleep disturbances.

  • How do you screen for more serious underlying conditions? How do you empower parents? When do you consider investigations? How do you ensure continuity of care and follow-up?
With a friend or family member

Role-play safety netting common conditions in unwell paediatric patients; for example, upper respiratory tract infections, croup, bronchiolitis or gastroenteritis. Ask your friend to relay the information back to you.

  • Did you communicate red flags effectively? Ask your friend for feedback on how you gave advice.
  • How will you check if the safety plan you provided is correct?

Do a role play in which your friend or family member is the parent of a child. Discuss with them the impact of their smoking on their child. Another option is to discuss the nutritional status of their child.

  • Ask them for feedback. Was your approach free of judgement and bias? Did you offer appropriate and easy-to-understand support and resources?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

General health issues, including context of care and specific populations
  • Through a detailed history and examination, and focusing on current evidence-based guidelines, conduct an appropriate developmental assessment of a child or young person at all stages of life, and include their psychological wellbeing.
  • Develop communication skills to build rapport with young patients and their parents/carers.
  • Understand the current guidelines for healthy lifestyle advice and immunisation and apply these to consultations (including respectful counselling of individuals who are opposed to, or concerned about, vaccination).
  • Understand the principles of prescribing medication in children and be aware of resources to access specific prescribing information.
  • Understand the importance and unique challenges of early intervention/support for children and young patients from vulnerable backgrounds, such as:
    • Aboriginal or Torres Strait Islander background
    • living in out-of-home care
    • living out of home
    • refugee background
    • children/young people who identify as LGBTIQ+.
  • Identify and screen for signs of abuse and parent/carer stress and understand when to report concerns about the safety of a child or young person, including knowing the mandatory reporting laws in your local area.  
  • Understand the medico-legal issues around capacity for consent for mature minors (Gillick competence), confidentiality in young people, medical power of attorney and guardianship, and the appropriate and ethical involvement of family and carers.
  • Identify an acutely unwell child through history and examination, and arrange appropriate recalls, follow-up, and referral.
Nutrition and feeding
  • Identify and help manage common feeding issues, including breastfeeding and formula problems, constipation, dietary deficiency (eg iron deficiency), failure to thrive, food intolerances, introduction of solids, and food fussiness and refusal.
  • Identify and manage children who are overweight and obese with an appropriately holistic approach that looks at individual and environmental risk factors, while maintaining positive self-image and a healthy relationship with food and daily activity.
  • Rule out serious underlying conditions, such as cow’s milk protein intolerance, food allergies, coeliac disease and inflammatory bowel disease.
Behaviour and development
  • Identify physical, social, verbal and/or congenital delays early to allow for early intervention for conditions, such as attention deficit hyperactivity disorder, autism spectrum disorder, cerebral palsy and intellectual delay.
  • Understand the issues related to premature birth.
  • Identify and manage common behavioural presentations, including excessive crying, temper tantrums, school refusal, separation anxiety and other anxiety issues, and challenging temperament and parenting styles.
  • Empower parents to manage sleep problems and toilet training difficulties (enuresis, encopresis).
  • Recognise issues within the parent’s/carer’s own medical or mental health history that might be presenting as a child’s behavioural issue.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
These journal articles collectively look at unique and challenging issues in Australian general practice and offer guidance on assessment and management.
Online resources
Medico-legal issues regarding child protection laws. Managing risk factors in young patients, which can be tricky when parents and carers are involved. Alphabetical evidence-based guidelines for managing paediatric issues; a great resource to refer to during consults. A comprehensive toolkit looking at adolescent health and the unique challenges of managing this patient cohort. A useful resource for health management and promotion for Aboriginal and Torres Strait Islander children.
Modules
These three units comprehensively look at the assessment and management of some common and important issues in paediatric patients in general practice.
  • The Royal Australian College of General Practitioners, gplearning activities:
    • check, unit 577, November 2020: Paediatric health
    • check, unit 550, June 2018: Child development
    • Paediatric sleep disorders
Other
Information about vaccine schedules and vaccination of high-risk populations. A common tool used in general practice to specifically assess an adolescent patient’s history.
This contextual unit relates to the other unit/s of:
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/child-and-youth-health 29/11/2022