The Institute of Public Policy Research has published a code of conduct in which children in partnership with their parents and health professionals can participate in decision making during their own medical consultations. A convincing evidenced based argument is presented, that children over the age of 5 years should be presumed competent to be involved in their own healthcare choices.1
Children in this age group are often capable of complex tasks such as playing chess or complicated homework.
The British Medical Association recommends that good practice for health professionals entails encouraging a child patient to express their views and participate in their health care.2
The National Service Framework for children puts the child at the centre of their care and states that: the child and parent should be actively involved in decisions made about the child's health, facilitated by appropriate information; that a child's consent where required should be sought, and also adds a reminder that it is difficult for a child to communicate about abusive experiences if they have had them.3
These policy directives assume that a child should have some involvement when he or she is the patient in the primary care consultation.
Qualitative studies commissioned by the Health Education Board for Scotland found that primary school children were both aware of, and understood, current health issues. These children were receptive to health messages such as the value of a healthy diet, exercise, and not smoking.4
Further evidence of the benefit of children's active involvement in their health care comes from a randomised controlled trial where children aged 8–12 years with asthma were included in a self-management programme. In the intervention group, games were used to teach children to recognise their symptoms and manage their illness. These children's asthma significantly improved compared with the control group.5
It has been suggested that guiding a child towards autonomy in managing their own health problem is practical: by school age children are spending increasing time away from their parents and may have to manage their own medication.6
When asked, some children indicate that they do not feel involved in their medical care and would like more say.7
At the older end of this age range there may be occasions when it is appropriate for the consultation to be held entirely with the child alone, if they are competent, and to do so is in their best interest.8
However, children aged 6–12 years are almost always seen with an adult carer and the consultations are triadic.9
It is known that children are not always treated as active participants in their medical encounters. For example, in a seminal research study on doctor–patient communication, which took place in a paediatric emergency clinic, the researchers stated that the patient in ‘paediatrics’ refers to the patient's parent.10
The child was similarly ignored in a major contribution to research on medical interaction, which produced a detailed analysis of 1020 paediatric encounters. The author explained in his report of the study why children did not feature.11
‘… the reason for my exclusion of children … is that they themselves are largely excluded from the consultation.’
These studies were conducted decades ago. Now there is more interest in children's active participation in medical consultations.12
Strides are being taken to develop means whereby children can evaluate their doctors, and where the children's opinion of their medical consultations matter.13
Consultation skills teaching has been shown to be an effective means of improving a doctor's skills at consulting.14
Specific training in consultation skills for paediatric encounters has been advocated.15
There are many examples of anecdotal writings where authors describe paediatric consultations and give advice on how a clinician should proceed.16,17
This study was carried out to discover more about the paediatric consultations based on research evidence. A literature search was conducted to ascertain the amount and type of involvement children in the 6–12 year age group have in their primary care consultations when the consultation was held with a child, a GP, and an adult.
How this fits in
There is evidence that if children directly participate in their health care it is beneficial for them. Children over 5 years old should be presumed competent to be involved in healthcare decisions concerning them, in partnership with their adult carer and/or parent and health professionals. This review demonstrates that pre-adolescent children have little meaningful involvement in their primary care consultations.