Now and in the future
GPs’ trusted role within a family’s life can keep children well and help them grow into healthy, balanced adults.
The term ‘cradle to grave’ can sound unusual, maybe even a little menacing, to people outside of healthcare. In general practice, however, it represents one of the profession’s most treasured and desired aspects.
The ability to treat people from the time they are born, forming a deep and meaningful connection along the journey, is a genuine privilege of a life in primary healthcare. In some cases, that relationship can begin before a patient is born.
‘What you hope for in general practice is that you have a relationship from antenatally on,’ Dr Karyn Alexander, a GP with a special interest in children’s health, told Good Practice. ‘I am now seeing patients I treated as children who are adults and having their own children.’
GPs have the unique opportunity to make a genuine difference in a child’s life from its earliest stages. It is important to engage with children, treating them as individual patients and involving them in consultations, no matter how young.
‘Children deserve a good relationship with their doctor,’ Dr Michael Fasher, GP and Chair of the RACGP Child and Young Person’s Health Specific Interests network, told Good Practice. ‘Just as the GP warmly greets the parent, they should warmly greet the child in a way that’s age and developmentally appropriate, even if that child is a few weeks old.
‘Most parents will be delighted to see the doctor actually engaging with their baby, let alone with their five-year-old.’
The GP must also be fully engaged in consultations with children. Childhood is a crucial time in which to detect developmental and health issues that can have a lasting impact on the child’s life, in the present and into the future.
‘A GP remains one of the few – if not the only, in some cases – professional sources that can give educated feedback on whether a child’s development or behaviour is normal,’ Dr Melita Cullen, a GP with a background in paediatrics, told Good Practice.
It is vital that developmental problems of any kind are identified as early as possible to enable effective intervention.
‘Issues like ADHD [attention deficit hyperactivity disorder], allergies, mental health problems, and overweight can certainly track into later childhood and adolescence,’ Dr Alexander said. ‘If you don’t pick up that a child’s vision is defective at certain crucial times, you might miss a window of opportunity to do something about it. The same goes with autism.
‘If we don’t get in with early intervention for these sort of developmental problems, then we’ve missed the best chance of doing the most for the child. That’s why my focus is on the early years, because it’s where you can make the most impact.’
A dynamic approach
Children were once perceived as ‘little adults’, with the approach to their medical care accordingly similar to fully-grown people. But the view of children, including how they develop as people and the ways in which they should be treated, has come a long way.
‘Children are constantly growing and developing, and their risk profiles for what may happen to them in terms of illness or injury change over the years. So [treating them] is a dynamic process,’ Dr Nicole White, a GP who runs a clinic focused on children’s health, told Good Practice. ‘An adult will come in with a set of symptoms and concerns which we will manage, but there’s a lot more to consider in the paediatric context.
‘Children’s disease profile is different to adults. The things they tend to suffer from and the presentation of common illness is different, so it’s a different approach.’
While developmental screening is especially important in consultations with children, the fact young people are unlikely to regularly present just for a check-up presents a major barrier for GPs. Dr White believes this means GPs must approach consultations with children in a proactive and opportunistic fashion.
‘We see babies for immunisations early on, and that provides a regular period for review. But, as the child gets older, they tend to only come in when they’ve got a cold or an ear infection,’ she said.
‘It’s important that we check their height, weight, how their developmental trajectory is going, how they’re going at school, and keep an eye out for subtle features of some of those other lifelong things which can be important. That feeds into health promotion as well, and the opportunity to talk about the other influences in life, such as obesity and mental health.’
The relationship GPs develop with parents can also be an extremely helpful resource in terms of treating the child and picking up on developmental issues.
‘The parents are often the people who first recognise there is an issue with the child,’ Dr Alexander said. ‘Even first-time parents often recognise concerns.
‘So if we can help them articulate those concerns and feel comfortable about doing that in general practice, it should be easier to follow them through. And you build a relationship that way; you build a conversation about those sort of issues.’
However, GPs can often also help by reassuring parents when they have no need to worry.
‘There’s such a range of what’s normal in each age group, particularly in school situations, where the kids can be separated in age by a year,’ Dr White said.
‘The younger kids are sometimes being picked up as having developmental problems, but maybe they’re just young. So I try to reassure parents while also keeping a close eye on things, and getting appropriate assessments done.’
A growing issue
It is no revelation that rates of overweight and obesity in Australia’s population have been rising over the past several decades. While this is worrying enough in adults, these increases are also taking place in children – one in every four Australian children is classified as overweight or obese.1
Obesity in children has extremely concerning implications for their health and wellbeing in the future, not to mention its serious effects in the present.
‘There are lots of health consequences, even at a young age,’ Dr White said. ‘I’ve seen children with diabetes, they can get orthopaedic problems, hip problems. There are psychological issues as well.’
Dr Cullen has found that as average weights increase, people’s perception of what is ‘normal’ has also changed. This makes it all the more vital for GPs to ensure they weigh children in consultations rather than rely on their own ‘eye test’.
‘Most of the time what we think is a normal weight child is actually one whose BMI [body mass index] is at the upper end of normal, or even overweight,’ she said.
Raising issues of weight can be sensitive, but Dr Fasher has found a positive emphasis on healthy eating and activity, rather than weight itself, helps to remove at least some of the difficulty from the conversation.
‘Talking about healthy eating and healthy drinking is not very emotionally charged, and talking about healthy exercise can be fun, too,’ he said. ‘All of those things need to be construed in terms of fun and opportunity, rather than duty and difficulty.’
Obesity and overweight is something usually best approached as a whole-of-family issue, as it tends to come from the environment in which the child is raised.
‘Children are part of their family. Unless there’s change made within the whole family, often nothing happens,’ Dr White said. ‘But there’s been good studies done that show intervention at a family level can confer reasonable results.’
This can also involve education for children about diet and physical activity, which can help set them up with good habits into the future.
‘Kids need to be educated about what’s healthy and unhealthy in terms of food and exercise and screen time,’ Dr White said. ‘Basics like drink lots of water, eat breakfast every day, don’t drink soft drinks, make sure you’re active for an hour every day.
‘I talk to kids about earning screen time with activity. So, for every hour of physical activity they can have 15 minutes or half an hour of screen time. That’s trying to get them to be a bit more accountable for that sort of stuff as they get older.’
Dr Cullen is careful to emphasise that these interventions are quite different for children than for adults, with less focus on shedding excess weight.
‘One thing I stress with parents is that the aim is never for the child to lose weight,’ she said. ‘The aim in childhood obesity is that the kids grow into their weight, ie their weight remains static or goes up at a slower rate compared with their height.’
Shaping the mind
The stresses of life can be a lot to handle at any age, but many people may not think of mental health as an issue that affects children before they reach school age. Indeed, Dr Alexander has found parents are often surprised by just how early such problems can be detected in younger patients.
‘Most parents think the age of four is a bit early when it comes to social, emotional and behavioural questions to gauge a child’s mental health. But most GPs will actually say that four is quite late,’ she said. ‘We’d be happy to do it from the age of two and just keep a check on child behaviours.
‘That change in development from 18 months to four years is an enormous trajectory. Within that is social development, so how the children get on with their peers, their self-help, their sleep behaviour, their eating behaviours.
‘All of these things tie in with some of the developmental disorders and also some of the mental health disorders.’
Dr Fasher emphasised the potential impacts of adverse childhood experiences on mental health and future development.
‘Children are very dependent on the nurture they experience in the environment,’ he said. ‘If that nurture isn’t there, it will not only impact on their mood or state of mind; because their brains are developing, adverse experience in the environment can actually damage that development … and that can have lifelong consequences.’
Dr White has found early detection and intervention is very important when it comes to mental health issues in children.
‘[Mental health issues are] not as easy to pick in kids, they present differently from adults.
‘Children won’t always say, “I’m feeling anxious” or “I’m feeling depressed.” It’s generally indicated by changes in behaviour or sleep patterns, or school performance or tummy pains,’ she said.
‘I think it comes back to early screening we should do at every opportunity in terms of how the child is getting along, what their teachers are saying, how is school and everything at home. A general review of those things.
‘It also helps to have an awareness of the different ways mental health can present during the different age groups: in babies, we tend to see separation issues; in primary school, we see a lot of behavioural issues, children presenting with oppositional-type behavioural traits; in the teenage years, the risk of depression and anxiety is much higher.’
Mental health issues can also be an indicator of very serious things taking place in a child’s life, such as sexual or physical abuse. In the event a GP suspects these types of issues are present, there are agencies to which they can turn. They do not have to confront the issue alone.
‘It’s important for a GP to know how to contact their local tertiary child abuse and neglect team,’ Dr Cullen said. ‘When I get a case of suspected sexual abuse, I usually ring them and follow their advice. I will not examine the patient unless medically indicated. I will also take extensive notes at the time of consultation.’
- Australian Institute of Health and Welfare. Australia’s health 2016. Canberra: AIHW, 2016.