The prenatal, childhood and adolescent phases of development strongly influence an individual’s subsequent health, wellbeing and opportunities in life.1Engagement 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