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Culture Documents
Ebook Pediatric Primary Care PDF Full Chapter PDF
Ebook Pediatric Primary Care PDF Full Chapter PDF
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Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)
• Figure 1 (1) Birth to 24 months: boys’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: boys’ head circumference-for-age and weight-for-length percentiles. (Published by the
Centers for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards.
Available at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: boys’ stature-for-age and weight-for-age
percentiles. (4) 2 to 20 years old: boys’ body mass index-for-age percentiles. (From the National Center
for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health
Promotion, 2000.)
Birth to 24 months: Girls
Birth to 24 months: Girls Head circumference-for-age and NAME
Length-for-age and Weight-for-age percentiles Weight-for-length percentiles RECORD #
Birth
in cm cm in H
E
A
52 52
D
20 20
50 98 50 C
98 95 I
95 90 R
90 H 19 19
48 75 48 C
75 E U
50 50
A M
25 D 18 46 25 46 18 F
10 10 E
5 5 R
2 C 44 2 44 E
I 17 17 N
R C
C 42
24 E
U 52
16 23
M 40 50
F 22 48
E
15 38 21 46
98 R 98
E 95 20 44
95 N 36 90 42
14 19
90
C
E 75
18 40
34
50 38
75 13 17
36
32 25 16
10 34
50 15
12 5
30 2 32
14
25 30 W
28 13 28 E
10 I
5 26 12 12 26 G
2 11 11
24 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 7 7
16
W
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100102104106108 110 cm
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
Published by the Centers for Disease Control and Prevention, November 1, 2009 Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en) SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)
• Figure 2 (1) Birth to 24 months: girls’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: girls’ head circumference-for-age and weight-for-length percentiles. (Published by the Centers
for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards. Available
at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: girls’ stature-for-age and weight-for-age percentiles.
(4) 2 to 20 years old: girls’ body mass index-for-age percentiles. (From the National Center for Health
Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion,
2000.)
BOYS GIRLS
• Figure 3 (1) Birth to 18 years old: boys’ head circumference percentiles. (2) Birth to 18 years old: girls’
head circumference percentiles. (From Nellhaus G: Head circumference from birth to eighteen years.
Practical composite international and interracial graphs, Pediatrics 41:106–114, 1968.)
• Figure 4(1) Boys preterm infant (2) Girls preterm infant (From Fenton TR, Kim JH: A systematic review
and meta-analysis to revise the Fenton growth chart for preterm infants, BMC Pediatrics 13:59, 2013.)
Pediatric Primary Care
Sixth Edition
Editors
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
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Printed in China
Crisann Bowman-Harvey, CPNP, AC, PC, MSN Karen G. Duderstadt, PhD, RN, CPNP
Instructor Clinical Professor
University of Colorado Coordinator PNP Specialty
Aurora, Colorado Academic Coordinator of International Student Programs
and Special Studies
Donald L. Chi, DDS, PhD University of California San Francisco
Associate Professor School of Nursing
University of Washington, School of Dentistry, Department of Family Health Care Nursing
Department of Oral Health San Francisco, California
Seattle, Washington
Susan Filkins, MS, RD
Cynthia Marie Claytor, MSN, PNP, FNP Nutrition Consultant
Graduate Nursing Faculty Oregon Center for Children & Youth with Special Health
Azusa Pacific University Needs
Azusa California Oregon Health & Sciences University
Portland, Oregon
Sara D. DeGolier, RN, MS, CPNP
Pediatric Nurse Practitioner Leah G. Fitch, MSN, RN, CPNP
Department of Emergency Medicine Pediatric Nurse Practitioner
The Children’s Hospital Colorado and University of Providence Pediatrics, Carolinas HealthCare System
Colorado Denver Charlotte, North Carolina
Aurora, Colorado
iii
iv Contributors
Maxine Fookson, RN, MN, PNP Rita Marie John, EdD, DNP, CPNP, PMHS
Pediatric Nurse Practioner, School Based Health Program Associate Professor of Nursing at CUMC
Multnomah County Health Department PNP Program Director
Portland, Oregon Columbia University School of Nursing
New York, New York
Lauren Bell Gaylord, MSN, CPNP-PC
Pediatric Nurse Practitioner Veronica Kane, PhD, RN, MSN, CPNP
Etowah Pediatrics Clinical Assistant Professor, Coordinator—Pediatric
Rainbow City, Alabama Nursing Specialty
MGH Institute of Health Professions, School of Nursing
Teral Gerlt, MS, RN, WHCNP-E, PNP-R Boston, Massachusetts;
Instructor Pediatric Nurse Practioner, Pediatrics, Urgent Care
Oregon Health & Science University Harvard Vangard Medical Associates
School of Nursing Braintree, Massachusetts
Portland, Oregon
Julie Martchenke, RN, MSN, CPNP
Terea Giannetta, DNP, RN, CPNP, FAANP Pediatric Cardiology Nurse Practitioner
Associate Professor/Chief Nurse Practitioner Oregon Health & Science University
California State University, Fresno/Valley Children’s Portland, Oregon
Hospital
Fresno, California/Madera, California MiChelle McGarry, MSN, RN, CPNP, CUNP
Certified Pediatric and Urology Nurse Practitioner/
Denise A. Hall, BS, CMPE Program Director/Owner
Practice Administrator Pediatric Effective Elimination Program Clinic &
Advanced Pediatrics Associates Consulting, PC
Aurora, Colorado Highlands Ranch, Colorado
Ruth K. Rosenblum, DNP, RN, PNP-BC Elizabeth E. Willer, RN, MSN, CPNP
Assistant Professor, DNP Program Coordinator Pediatric Nurse Practitioner
San Jose State University Kaiser Permanente
San Jose, California Walnut Creek, California
Mary Rummell, MN, RN, CNS, CPNP, FAHA Teri Moser Woo, PhD, RN, ARNP, CNL, CPNP,
Clinical Nurse Specialist FAANP
The Knight Cardiovascular Institute, Cardiac Services Associate Professor
Oregon Health & Science University Associate Dean for Graduate Nursing Programs
Portland, Oregon Pacific Lutheran University
Tacoma, Washington
Susan K. Sanderson, DNP, APRN, FNP-BC
Pediatric Infectious Diseases Nurse Practitioner; Instructor Robert J. Yetman, MD
Department of Pediatrics Professor of Pediatrics
Division of Infectious Diseases Director, Division of Community and General Pediatrics
University of Utah School Of Medicine University of Texas–Houston Medical School
Salt Lake City, Utah UT Physicians Pediatrics—The Kid’s Place
Houston, Texas
Arlene Smaldone, PhD, CPNP, CDE
Associate Professor of Nursing at CUMC Yvonne K. Yousey, RN, CPNP, PhD
Associate Professor of Dental Behavioral Sciences (in Pediatric Nurse Practitioner
Dental Medicine) at CUMC Kids First Health Care
Assistant Dean, Scholarship and Research (School of Commerce City, Colorado
Nursing)
Columbia University
New York, New York
Reviewers
vi
Preface
We are delighted to introduce the sixth edition of Pediatric • NEW full-color design and illustration format to
Primary Care. This book was first developed 20 years ago improve usability and teaching/learning value
as a resource for advanced practice nurses serving the • NEW focus on diversity among cultures in Chapter 3
primary health care needs of infants, children, and adoles- provides greater emphasis on the need for providers to
cents. Pediatric nurse practitioners (PNPs) and family nurse approach differences between themselves and their clients
practitioners (FNPs) are our primary audience. However, with humility and competence
physicians, physician assistants, and nurses who care for • Reorganized application of Gordon’s Functional
children in a variety of settings also find the book to be a Health Patterns to provide a more conceptually consis-
valuable resource. The field of pediatric primary care has tent flow of content (Gordon, 1987, 2010)
also grown and changed since the first edition of this book. • Expanded coverage of health literacy—obtaining,
The interdisciplinary Institute of Medicine (IOM) and reading, understanding, and using health care informa-
the Affordable Care Act have explicitly recognized the criti- tion to make appropriate health decisions
cal role of nurse practitioners and nurses in providing • Expanded, updated coverage of growth and develop-
health care to the population in the United States (IOM ment for greater consistency with contemporary theories
Report, 2010). of development
The book emphasizes prevention and management of • Unique chapter on integrative/complementary thera-
problems from the primary care provider’s point of view. pies promotes the primary care provider’s knowledge
Each chapter is organized to introduce key concepts and about many of the less conventional health care strategies
foundations for care in a narrative format followed by a that families may be inquiring about or using
discussion of the identification and management of diagno- • Refocused Practice Management chapter (Chapter
ses using an outline format. Experienced clinicians can 44) is now available to readers on the Evolve website.
simply jump to the topic or diagnosis in question while the This chapter focuses on content more specific to pediat-
student can read the chapter for immersion into the topic. ric practice management, including the various settings
Additional resources for each chapter include websites to for pediatric primary care, such as school-based clinics
access organizations and printed materials that may be and the health care home. This refocused chapter also
useful for clinicians, their patients, and families. Our con- addresses informatics and other essential topics influ-
tributing authors are experts in their fields. enced by the Affordable Care Act, as well as National
Patient Safety Goals and the growing trend of interpro-
Special Features of the Sixth Edition fessional collaboration.
• Discussion questions and NEW PowerPoint slides are
Some features of the sixth edition about which we are par- available on the Evolve site for educators. These are
ticularly excited include the following: written by nurse practitioner educators to assist students
• Updated content reflects the latest developments in our to think about the implications of the material for their
understanding of disease processes, disease management clinical practice.
in children, and current trends in pediatric health care
• NEW Pediatric Pharmacology chapter Organization of the Book
• NEW Specialist Referral highlights to alert busy
practitioners to cues that signal the need for urgent We recognize that children are a special population and that
referral providing health care to them must be approached using
• NEW graduate-level Quality and Safety Education for several unique perspectives: their developmental changes
Nurses (QSEN) integration (Cronenwett et al, 2009): over time, their dependency on their parents, the differen-
The Safety, Informatics, Teamwork and Collaboration, tial epidemiology of child health, the different demographic
and Evidence–based competencies patterns of children and their families, and the individuality
vii
viii Preface
of their genetic makeup. These themes are carried through- Contributors to the Fifth Edition
out the text.
The book is organized into four major sections—Pediatric These people were instrumental in helping us develop the
Primary Care Foundations, Management of Develop- fifth edition of the book. Although they are not authors in
ment, Approaches to Health Management in Pediatric this edition, their ideas and work have contributed greatly
Primary Care, and Approaches to Disease Management. to our work, and we are deeply indebted to them: Barbara
Each chapter follows the same format. Standards and guide- Deloian, Mary Murphy, Maxine Fookson, Lynn Frost,
lines for care are highlighted, the physiologic and assess- Denise Abdoo, Roberta Bentson Royal, Veronica Kane,
ment parameters are discussed, management strategies are Martha K. Swartz, Anne Albers, Melissa Reider-Demer,
identified, and management of common problems is pre- Shirley Becton McKenzie, Peggy Vernon, Jan Bazner-
sented in a problem-oriented format. The scope of practice Chandler, and Constance Brehm.
of the primary care provider is always kept in mind with
appropriate referral and consultation points identified. Our Thanks to Family and Friends
We hope this text will continue to promote the very best
evidence-based care possible for children and families in • To my husband, Jerry Burns: Thanks so very much for
primary care settings by all the providers with whom they giving me the time and support to work on this text one
come in contact. more time; to my loving daughters Jennifer and Jill and
their families; other family and friends; and to the many
Editors PNPs, FNPs, and NP faculty who have expressed their
Catherine E. Burns, PhD, RN, CPNP-PC, FAAN appreciation for this text and encouraged us to continue
Ardys M. Dunn, PhD, RN, PNP the project. Catherine E. Burns
Margaret A. Brady, PhD, RN, CPNP-PC • To Marvin Dunn; Malcolm and Megan Dunn; Philip
Nancy Barber Starr, MS, APRN-BC (PNP), CPNP-PC Dunn and Liz Flynn, grandchildren Miles, Claire,
Catherine G. Blosser, MPA:HA, RN, PNP Simon, and Eleanor Dunn (from “the craziest Nana in
Dawn Lee Garzon, PhD, PNP-BC, CPNP-PC, PMHS, the whole wide world!”)—thanks for being my joy and
FAANP inspiration; and to so many other family and friends, you
are the spice of a well-flavored life. Ardys M. Dunn
Associate Editor • With deep appreciation for the circle of love and support
Nan M. Gaylord, PhD, RN, CPNP-PC from my dear family and friends who are always there
surrounding me with warmth, laughter, and joy. Marga-
References ret A. Brady
• Aloha and mahalo to my Jon, Jonah, and AnnaMei. I
Cronenwett L, Sherwood G, Pohl J, et al: Quality and safety educa- am ever grateful for the joy you bring to my life as well
tion for advanced nursing practice, Nurs Outlook 5(6):338–348, as your support of my time with “the book.” Likewise, I
2009. am ever thankful for Denise and my APA colleagues who
Gordon M: Nursing diagnosis: process and application, New York, give me the flexibility and challenge to work hand in
1987, McGraw-Hill.
hand to provide model pediatric care. Nancy Barber Starr
Gordon M: Manual of nursing diagnosis, ed 12, Sudbury, MA, 2010,
Jones and Bartlett.
• To my husband, Terry, for his continued love and support
Institute of Medicine (IOM) of the National Academies: The future and my admiration for all the littlest Blosser offspring
of nursing: leading change, advancing health, 2010. Available at: for their years of sharing their humor, strides, and
http://www.iom.edu/Reports/2010/The-Future-of-Nursing- challenges—they are amazing examples of the wonder of
Leading-Change-Advancing-Health (accessed October 28, 2014). growth and development. Catherine G. Blosser
• My thanks to the students, parents, and families who
Acknowledgments make me a better person; to Rachel and Elizabeth Garzon
who give my life meaning; and to Amy DiMaggio,
A book of this size and complexity cannot be completed friends, and family for loving me and giving me wings.
without considerable help—the work of the contributors Dawn Lee Garzon
who researched, wrote, and revised content; the consulta- • To my parents who first loved, supported, and encour-
tion and review of experts in various specialties who cri- aged me. To my husband, Mark, who loved me second
tiqued drafts and provided important perspectives and and continues to love, support, and encourage me in all
guidance; and the essential technical support from those my professional endeavors. To my children, Curtis and
who managed the production of the manuscript and the Leah, who make life fun and will continue to do so with
final product. Lee Henderson and Charlene Ketchum have their own children. Nan Gaylord
provided consistent Elsevier support through the past two
editions.
Contents
Unit 1: Pediatric Primary Care Foundations 16 Values, Beliefs, and Spirituality, 299
ix
x Contents
1
1
T
he health status of all children must be viewed with final section
a global lens. Whether considering pandemic infec available tc-> pcidiatric health care providers to assess and
tious diseases or the global emigration of popula monitor the health and well-being of children from infancy
tions between continents, the health of all children is to young aduldiood.
interconnected worldwide. Inequalities in the health status
of children globally and nationally are largely determined Global Health Status of Children
by common biosocial factors affecting health, which include
where they are born, live, are educated, their work, and their 'lliirty-five million children younger than 20 years old are
age (World Health Organization [WHO], 2014a). The bio r,art of the international migration of populations across
social factors also include the systems in place to address continents (UNICEF, 2014). Emigrant children have
health and illness in children and families. increased health and educational needs that impact the
The biosocial circumstances or social deter inants of health and well-being of communities; many of these com
child health are shaped by economics, soci polic,;ies, and munities have fragile health care systems. The United
politics in each region and country. In order to impact Nations Convention on the Rights of Children (UNCRC)
health outcomes, scaling up the efforts nationally and glob charter was established 25 years ago and declares the
ally to build better health systems is required. Significant minimum entitlements and freedoms for children globally,
progress has been made in reducing childhood morbidity including the right to the best possible health (United
and mortality using this approach. [he framework of the Nations International Children's Fund, 2009). Emigrant
United Nations Millennium Development Goals 2014 children have the right to be protected under this charter
(United Nations, 2015) and the Healthy People 2020 (U.S. (Box 1-1). Governments are advised to provide good quality
Department of Health and Human Services [HHS] Office health care, clean water, nutritious foods, and clean environ
of Disease Prevention and Health Promotion, 2015a) goals ments so that children can stay healthy. The charter is
set the mark for improving child health status. It is for founded on the principle of respect for the dignity and
societies to embrace and prioritize these goals on behalf of worth of each individual, regardless of race, color, gender,
children. language, religion, opinions, origins, wealth, birth status, or
This chapter presents an overview of the global health ability. The UNCRC continues to work on ensuring that
status of children, including the issue of global food inse all children have these basic human rights and freedoms.
curity, child health status in the United States and current Special emphasis is placed on the responsibility and strength
health inequalities, the progress toward achieving the Mil of families and the vital role of the international community
lennium Development Goals and Healthy People 2020 to protect and secure the rights of children, including access
targets, the effect of health care reform in the United States to health care and primary health care services.
on access to care for children and adolescents, and the Health equity is the absence of unfair or remediable dif
important role pediatric health care providers have in advo ferences in health services and health outcomes among
cating for polices that foster health equity and access to populations (WHO, 20146). Although the rate of child
quality health care services for all children and families. The mortality globally remains high, there have been significant
2
CHAPTER 1 Health Status of Children: Global and National Perspectives 3
• BOX 1-1 UNICEF* Summary of the United of reinfections for 2 to 3 months. As a micronutrient, it is
Nations Convention on the Rights of essential for protein supplementation, cell growth, immune
Children function, and intestinal transport of water and electrolytes
[Khan and Sellen, 2015].) Rotavirus is the most common
The UNICEF conventions include 42 articles that are cause of diarrhea globally and Streptococcus pneumoniae is
summarized in the following list. They represent the worldwide
the leading cause of pneumonia (Walker et al, 2013). Both
standards for the rights of children. The conventions apply to all
children younger than 18 years old. The best interests of of these are vaccine-preventable infectious diseases.
children must be a top priority in all actions concerning children. Successful vaccination programs have markedly reduced
• Every child has the right to: the mortality caused by some infectious diseases, particu-
• Life and best possible health larly measles and tetanus. Cambodia serves as a noteworthy
• Time for relaxation, play, and opportunities for a variety of
example. To reduce childhood mortality in children younger
cultural and artistic activities
• A legally registered name and nationality than 5 years old, Cambodia targeted measles vaccination
• Knowledge of and care by his or her parents, as far as due to the high mortality associated with the disease. Within
possible, and prompt efforts to restore the child-parent a decade, health workers were able to increase the rate of
relationship if they have been separated measles immunization by 71% in children younger than
• Protection from dangerous work
1 year old (United Nations, 2015). To achieve complete
• Protection from use of dangerous drugs
• Protection from sale and social abuse, exploitation, eradication of measles, WHO helped the Cambodian
physical and sexual abuse, neglect and special care to national immunization program to identify and reach
help them recover their health if they have experienced communities at high risk for low rates of immunizations.
such toxic life events A national immunization program also began providing
• No incarceration with adults and opportunities to maintain
a booster dose of a measles-containing vaccine after
contact with parents
• Care with respect for religion, culture, and language if not 18 months old. The result was measles eradication in
provided by the parents Cambodia since 2012. Such sustained immunization pro-
• A full and decent life in conditions that promote dignity, grams by partnerships between communities, governments,
independence, and an active role in the community, even and international aid organizations can markedly improve
if disabled
global child health status. However, emerging viral and
• Access to reliable information from mass media,
television, radio, newspapers, as well as protection from bacterial infectious diseases present complex challenges to
information that might harm them public health infrastructure and threaten the global progress
• Governments must do all that they can to fulfill the rights of made on reducing childhood mortality (see Chapter 24).
children as listed above. The majority of the extremely poor live in five
*UNICEF stands for the full name United Nations International Children’s countries—India, China, Nigeria, Bangladesh, and the
Emergency Fund. In 1953, its name was shortened to the United Nations Democratic Republic of Congo. The risk of maternal death
Children’s Fund. However, the original acronym was retained.
from pregnancy-related complications and childbirth in
developing regions is 230 deaths per 100,000 births; this
rate is 14 times higher than in developed countries (United
Nations, 2015).
reductions in the rate over the past few decades. Since 1990,
child mortality in children younger than 5 years old has
decreased by 47% due to targeted policies to reduce child- Global Food Insecurity and Effect on
hood pneumonia, diarrhea, and malaria and also to reduce Children’s Health
the number of preterm births and perinatal complications.
Despite these efforts, 6.3 million children younger than 5 Hunger and undernutrition are often referred to as food
years old die each year worldwide (Wang et al, 2014). To insecurity, which is the condition that exists when popula-
reach the World Health Organization (WHO) target of tions do not have physical and economic access to sufficient,
two-thirds reduction in mortality for children younger than safe, nutritious, and culturally acceptable food to meet
5 years old, more rapid progress is needed, particularly in nutritional needs. Food insecurity occurs in impoverished
sub-Saharan Africa, where the highest rate of infant mortal- populations in developing countries and in industrialized
ity occurs. Currently, sub-Saharan Africa and Southern Asia nations, particularly among migrant populations. Children
account for 81% of the infant mortality globally (United affected by migration and family separation are at risk for
Nations, 2015). food insecurity and are vulnerable to further health conse-
Diarrhea and pneumonia remain the leading infectious quences, including exposure to exploitation and child traf-
causes of childhood morbidity and mortality globally. The ficking. Growing evidence on climate change indicates the
highest proportion of deaths due to these two conditions is dramatic effect on food crops that lead to food distribution
in children younger than 2 years old; undernutrition, sub- issues, which is one of the primary contributors to food
optimum breastfeeding, and zinc deficiency contribute sig- insecurity (Fig. 1-1).
nificantly to the mortality rate from these diseases. (Zinc Globally, undernutrition is an important determinant of
reduces the duration and severity of diarrhea and likelihood maternal and child health and accounts for 45% of all child
4 UNIT 1 Pediatric Primary Care Foundations
Health effects
Temperature-related
illness and death
Regional weather
changes
• Contamination
pathway
Air pollution-related
health effects
• Transmission
Climate
• Heatwaves dynamics Water- and food-borne
change • Extreme weather • Food diseases
• Temperature availability
• Precipitation • Migration Vector- and rodent-borne
diseases
Psychological effects
Adaptation
measures Malnutrition
Research
deaths in children younger than 5 years old (United Nations, One of the main goals of the Millennium Development
2015). Suboptimal breastfeeding remains a problem in Goals framework is to reduce infant mortality by at least
developed and developing nations. Children who are exclu- two-thirds by 2016 in 27 countries. Eight goals consist of
sively breastfed for the first 6 months of life are 14 times 21 quantifiable targets measured by 60 health indicators
more likely to survive than non-breastfed infants (United (see Fig. 1-3). They provide a framework for the interna-
Nations, 2015). Vitamin A and zinc deficiencies also con- tional community to ensure socioeconomic development
tribute to the disease burden in mortality for children reaches all children.
younger than 5 years old. In developing countries, 55
million women are stunted from undernutrition and lack Progress on the Millennium
of micronutrients, including iron, folic acid, vitamin A, and Development Goals
zinc (Save the Children, 2015). Preventable nutritional defi-
ciencies are a compelling case for further implementation Significant progress has been made in many areas, including
of the Millennium Development Goals and increased reductions in child mortality and preterm birth. In 30
support for micronutrient supplementation for children in developing countries, progress toward achieving reductions
developing regions. in child mortality has been faster than predicted due to
income, education, and secular shifts in living and work
environments (Wang et al, 2014). However, increased assis-
United Nations Millennium Development tance in improving economic status and levels of maternal
Goals: Project Goals education is required to sustain the effort.
Since 1990, progress has been made by reducing world
The Millennium Project, a global health project of research poverty by half, access to clean drinking water has improved
and study to improve prospects for a better future for for 2.3 billion people, chronic undernutrition in children
humanity, publishes a framework (Millennium Develop- causing stunting has decreased by 40%, and 90% of chil-
ment Goals) annually to address the challenges, both local dren in developing regions are attending primary school
and global, facing the world populations. Health and access (United Nations, 2015). The achievements are the result of
to health care in the context of social determinants are the collaborations between governments, international
covered in the document. Figures 1-2 and 1-3 and Box 1-2 communities, civil societies, and private corporations. To
illustrate the collaborative action required among govern- make further sustained progress, expansion and acceleration
ments, international organizations, corporations, universi- of the interventions by the WHO are required to target the
ties, and individuals and societies to address the issue of leading causes of death in the target countries.
health equity from a global perspective (The Millennium The economic growth potential remains strong in
Project, 2014). many of the developing regions, and partnerships between
CHAPTER 1 Health Status of Children: Global and National Perspectives 5
Sustainable development
and climate change
Energy 13 Democratization
4
10 7 Rich–poor gap
Peace and conflict
9 8
Education Health issues
• Figure 1-2 Fifteen global challenges facing humanity. IT, Information technology.
young children who are screened for autism and other (CDC) is collaborating with state health departments, uni-
developmental delays at 18 and 24 months old (Annie versity researchers, and private foundations to understand
E. Casey Foundation, 2015; National Center on Birth and reduce preterm births and implement evidence-based
Defects and Developmental Disabilities, Centers for Disease interventions to improve prenatal care in those communi-
Control and Prevention [CDC], 2015). ties and hospitals with high rates of preterm births.
Healthy People 2020 objectives also address the need for
increasing the proportion of practicing primary care provid-
ers, including nurse practitioners, to improve access to Adverse Childhood Events and Impact on
quality health care services. The demand for primary care Child Health Outcomes
services will increase as more children, adolescents, and
young adults qualify for health insurance plans through the There is growing evidence on the disruptive impact of toxic
Affordable Care Act of 2010 (ACA) and seek preventive stress on biologic mechanisms that impact childhood devel-
health care. An integrated workforce can provide appropri- opment. Exposure to chronic stress and high levels of ele-
ate evidence-based clinical preventive services to reduce vated cortisol are believed to play a role in the encoding of
overall health care costs, as well as improve access and facili- memory and other bodily functions. The structural devel-
tate communication and continuity of care for children and opment of the brain in childhood is guided by environmen-
families. Approaches to health care must be interprofes- tal cues; optimum development of the neuroendocrine
sional and must consider the biosocial factors in the delivery system is dependent upon the absence of early toxic stress
of health care to achieve child health outcomes far beyond and toxins (e.g., lead, mercury, alcohol, and drugs) and
the biomedical dynamics of disease (Holmes et al, 2014). adequate nutrition (AAP, 2015).
Early adverse stress is linked to later impairments in
Social Determinants of Health and learning, behavior, and physical and mental well-being
Health Equity (AAP, 2015; Shonkoff et al, 2012). Toxic stress results from
strong or frequent and prolonged activation of the body’s
The social determinants of health result in unequal and stress response systems in the absence of the protection of
unavoidable differences in health status within communities a supportive, adult relationship (Shonkoff et al, 2012). The
and between communities (HHS Office of Disease Preven- adversity can occur as single, acute, or chronic events in the
tion and Health Promotion, 2015b). Individuals are affected child’s environment, such as emotional or physical abuse or
by economic, social, and environmental factors in their neglect, IPV, war, maternal depression, parental separation
communities. Social determinants of health recognize the or divorce, and parental incarceration (Box 1-3). Although
impact of home, school, workplace, neighborhoods, and discussed here as a problem in the United States, adverse
access to health care as significant contributors to child childhood events is a significant worldwide problem.
health outcomes. Many of the Healthy People 2020 leading Toxic stress in childhood has implications that carry over
health indicators address social determinants of health, but into adulthood. Evidence suggests that the results of the
the specific objective targeted for this objective is the prolonged and altered biologic mechanisms lead to chronic
number of students who graduate in 4 years of high school health conditions in adulthood, including obesity, heart
with a regular diploma. The target is 82.4% for the on-time disease, alcoholism, and substance abuse (Shonkoff et al,
graduation rate. Progress has been made toward the goal 2012). A child who has experienced adverse childhood
with a rate of 78.2% over the past 4 years (HHS Office events is also more likely to engage in high-risk behavior,
of Disease Prevention and Health Promotion, 2015b). such as the initiation of early sexual activity and adolescent
However, the target falls significantly below what is required pregnancy. Limiting the impact of adverse childhood events
to decrease the economic inequalities between communities through effective interventions that strengthen the capacity
and neighborhoods. of nations, communities, and families to protect young
The United States has the highest rate of death in the children from the disruptive effects of toxic stress improves
first day of life among the 27 industrialized nations (Save
the Children, 2015). Healthy People 2020 sets targets for
reductions of infant deaths and the rate of preterm births
(infants born at or before 37 weeks’ gestation). Significant • BOX 1-3 Adverse Life Experiences of Children
inequalities exist in communities in the rate of preterm
births—particularly in the Southeastern states (see Box • Emotional abuse or neglect
• Physical abuse or neglect
1-2). The overall rate of preterm births in the United States • Sexual abuse
has only decreased 0.6% since 2002 despite interventions • Mother treated violently
to decrease the incidence. One out of nine preterm births • Household substance abuse
results in complications, including greater risk of breathing • Household mental illness
problems, developmental delays, and vision and hearing • Parental separation of divorce
• Incarcerated household member
problems. All of these complications increase the cost of
health care. The Centers for Disease Control and Prevention
8 UNIT 1 Pediatric Primary Care Foundations
child health outcomes and decreases financial costs to indi- dren and youth across settings and providers. The concept
viduals and societies (Shonkoff et al, 2012). is supported by the American Academy of Pediatrics, the
Institute of Medicine, and the Patient-centered Primary
Child Health and Quality Care Collagorative (PCPCC). The model promotes holistic
Improvement Measures care of children and their families through a collaborative
relationship with qualified pediatric health care providers
As part of the effort in the United States to reform health inclusive of nurse practitioners (National Association of
care, quality and performance measures have gained signifi- Pediatric Nurse Practitioners [NAPNAP], 2009). Exem-
cant importance in the national dialogue. Many measures plary innovative models in pediatric health care/medical
relevant to the overall health of children are tracked annu- home services delivered by nurse practitioners are being
ally in the National Healthcare Disparities Report (NHDR). implemented in several states. Interventions in successful
The report focuses on four components of pediatric health models must address the concepts of family-centered part-
care: (1) prevention, (2) treatment, (3) management, and nerships, community-based systems, and transitional care
(4) access to care. from pediatric to adult services.
Lack of health care insurance is the single strongest pre-
dictor of quality of care for children in the United States— Health Promotion and Evidence-Based
greater than the effects of race, ethnicity, family income, or Clinical Preventive Services
education (HHS Office of Disease Prevention and Health
Promotion, 2015a). Quality of care is measured by the Many children are not receiving the recommended preven-
timeliness and effectiveness of care, as well as the safety of tive services and developmental surveillance required for
the care delivered. Measures of access to care include health health promotion. There are many barriers to effective well
insurance coverage, utilization of health care services, and child care, including time constraints; low level of reim-
barriers to care. Both access and quality are required to bursement for preventive care and developmental screening
eliminate the impact of disparities in health. services; lack of provider education in current strategies to
Understanding the changing demographics of the pedi- identify child development, emotional, and behavioral
atric population is critical to shaping the health care work- problems; and lack of community referral sources to assist
force and health care services for future generations of children, adolescents, and families. These issues have led to
children. Further, the debate on whether to expand health inconsistent quality of preventive health care services affect-
care to immigrant children needs to become part of the ing children and families.
dialogue in order to further decrease health disparities. Much of the basis for primary care practice is not yet
evidence based. Primary care would benefit from strong
scientific clinical research that would strengthen primary
The Role of Advanced Practice Nurses for care principles and prevention. Lack of funding and infra-
Improving Child Health structure to support such primary care clinical research
stands in sharp contrast to the organized commitment and
Advanced practice nurses (APNs) have a key role in advo- emphasis on advancing knowledge in disease entities and
cating for child health locally, nationally, and globally. A treatment options. This gap provides an area of research
growing body of evidence demonstrates that APNs deliver open to pediatric nurse researchers and other pediatric
high-value primary care services (Naylor and Kurtzman, health care providers trained in clinical research. Increased
2010). APNs provide continuity of care in the ambulatory evidence in the primary health care domain would help to
care setting for underserved children with health condi- move the public dialogue toward a greater focus on primary
tions, such as asthma, pneumonia, and vaccine-preventable prevention and away from a disease-focused health care
conditions that might otherwise lead to greater utilization system.
of costly emergency departments and hospitalizations.
Health Supervision Guidelines
Increasing access to APNs who deliver primary care services
would reduce health care costs, improve health outcomes, American Academy of Pediatrics Guidelines
and produce health care savings—all steps toward allowing The AAP publishes the Recommendations for Preventive Pedi-
the United States to lead rather than trail the other eco- atric Health Care annually. However, it became clear that
nomically developed countries in child health indicators. the number of recommended health directives for well child
Additionally, APNs have the potential to influence eco- care had far surpassed the time available to pediatric health
nomic and political decisions to ameliorate health dispari- care providers (Schor, 2004). Recent recommendations
ties and increase health equality among populations and from the AAP to improve the efficiency and effectiveness
communities in order to build a healthier generation of of health promotion and preventive pediatric care have
adults. placed a greater emphasis on behavioral and developmental
Health care reform places a greater emphasis on primary issues. Their recommendations suggest uncoupling the peri-
care infrastructure, including identifying a pediatric health odicity of well child visits with the required immunizations
care/medical home in order to coordinate the care of chil- and providing greater emphasis on healthy growth and
CHAPTER 1 Health Status of Children: Global and National Perspectives 9
developmental surveillance (Tanner et al, 2009). Part of the and the community as partners in health practice” (Hagan
revision includes basing well child care on the evidence- et al, 2008, p 1). Bright Futures helps providers deliver
based research available on child and family development prevention-based, developmentally oriented care in a
rather than the periodicity of required immunizations. This family-focused manner and fosters the aforementioned rela-
necessitates a revision of the current recommendations that tionships. The parent tools included in Bright Futures
guide practice, which can be found in the Bright Futures empower families with greater skills and knowledge to be
publication. active partners in their child’s healthy growth and develop-
ment. Bright Futures is available to health care providers
Bright Futures and parents at www.brightfutures.org.
Bright Futures is a national health promotion initiative
dedicated to the principle that “every child deserves to be For a complete list of references, please visit http://evolve
healthy and that optimal health involves a trusting relation- .elsevier.com/Burns/pediatric/.
ship between the health professional, the child, the family,
CHAPTER 1 Health Status of Children: Global and National Perspectives 9.e1
Save the Children: Surviving the first day: state of the world’s mothers
References 2013 (PDF online): www.savethechildren.org/atf/cf/%7B9def2ebe
-10ae-432c-9bd0-df91d2eba74a%7D/SOWM-FULL-REPORT
American Academy of Pediatrics (AAP): AAP vision of pediatrics: _2013.PDF. Accessed January 5, 2015.
megatrends and scenarios, AAP (website):2014a www2.aap.org/ Schor EL: Rethinking well-child care, Pediatrics 114(1):210–216,
visionofpeds/megatrends_scenarios.cfm. Accessed December 26, 2004.
2014. Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child
American Academy of Pediatrics (AAP): Adverse childhood experiences and Family Health, et al: The lifelong effects of early childhood
and the lifelong consequences of trauma (PDF online), 2014b, adversity and toxic stress, Pediatrics 129(1):e232–e246, 2012.
www.aap.org/en-us/Documents/ttb_aces_consequences.pdf. Tanner JL, Stein MT, Olson LM, et al: Reflections on well-child care
Accessed January 5, 2015. practice: a national study of pediatric clinicians, Pediatrics
Annie E. Casey Foundation: The 2014 KIDS COUNT data book: an 124(3):849–857, 2009.
annual report on how children are faring in the United States, The UNICEF: Convention on the rights of the child: a world of difference:
Annie E. Casey Foundation (website): www.aecf.org/2014db. 25 CRC achievements, UNICEF (website): www.unicef.org/crc/
Accessed January 5, 2015. index_73549.html. Accessed December 26, 2014.
Gundersen C, Ziliak JP: The future of children: research report: child- United Nations: The millennium development goals report 2014 (PDF
hood food insecurity in the U. S.: trends, causes, and policy options online): www.un.org/millenniumgoals/2014 MDG report/MDG
(PDF online): www.princeton.edu/futureofchildren/publications/ 2014 English web.pdf. Accessed January 5, 2015.
docs/ResearchReport-Fall2014.pdf. Accessed August 13, 2015. United Nations International Children’s Fund: The state of the world’s
Hagan JF, Shaw JS, Duncan PM, editors: Bright futures: guidelines for children special edition, www.unicef.org/rightsite/sowc. Accessed
health supervision of infants, children, and adolescents, ed 3, Elk October 20, 2010.
Grove Village, IL, 2008, American Academy of Pediatrics. U.S. Department of Health and Human Services (HHS) Office of
Holmes SM, Greene JA, Stonington SD: Locating global health in Disease Prevention and Health Promotion: Healthy People 2020,
social medicine, Glob Public Health 9(5):475–480, 2014. HealthyPeople.gov (website): www.healthypeople.gov/2020/default
Khan WU, Sellen DW: Zinc supplementation in the management of .aspx. Accessed January 5, 2015a.
diarrhoea, World Health Organization (website): www.who.int/ U.S. Department of Health and Human Services (HHS) Office of
elena/titles/bbc/zinc_diarrhoea/en/. Accessed February 10, 2015. Disease Prevention and Health Promotion: Social determinants,
Millennium Project: Global challenges for humanity, The Millen- HealthyPeople.gov (website): www.healthypeople.gov/2020/leading
nium Project (website): http://millennium-project.org/millennium/ -health-indicators/2020-lhi-topics/Social-Determinants. Accessed
challenges.html. Accessed December 26, 2014. January 5, 2015b.
National Association of Pediatric Nurse Practitioners (NAPNAP): Walker CL, Rudan I, Liu L, et al: Global burden of childhood pneu-
NAPNAP position statement on pediatric health care/medical monia and diarrhoea, Lancet 381(9875):1405–1416, 2013.
home: key issues on delivery, reimbursement, and leadership, Wang H, Liddell CA, Coates MM, et al: Global, regional, and
J Pediatr Health Care 23(3):A23–A24, 2009. national levels of neonatal, infant and under-5 mortality during
National Center on Birth Defects and Developmental Disabilities, 1990-2013: a systematic analysis for the Global Burden of Disease
Centers for Disease Control and Prevention (CDC): Community Study in 2013, Lancet 384(9947):957–979, 2014.
report on autism 2014 (PDF online): www.cdc.gov/ncbddd/ World Health Organization (WHO): Social determinants of health:
autism/states/comm_report_autism_2014.pdf. Accessed February key concepts, WHO (website): www.who.int/social_determinants/
10, 2015. thecommission/finalreport/key_concepts/en/. Accessed December
Naylor MD, Kurtzman ET: The role of nurse practitioners in rein- 26, 2014a.
venting primary care, Health Aff 29(5):893–899, 2010. World Health Organization (WHO): Global health observatory
Ogden CL, Carroll MD, Kit BK, et al: Prevalence of childhood and (GHO) data: about the health equity monitor, WHO (website):
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814, 2014. 26, 2014b.
2
Child and Family Health
Assessment
CATHERINE E. BURNS AND KAREN G. DUDERSTADT
P
atient/family-centered community-based primary primary health care. This assessment is based on knowledge
care for children is recognized as the best possible of child development, family structure and functions,
practice model for providing health care services to culture, anatomy and physiology, pathophysiology, pharma-
children and their families (American Academy of Pediatrics cology, health care delivery systems, communities, and stan-
[AAP], 2014a). The family is the most influential factor in dards of primary health care for children. The assessment
a child’s life, and its functioning is totally intertwined with must also be viewed through the lens of the provider’s expe-
the child’s health and well-being. Providing family-centered rience to allow the provider to modify perceptions and vali-
care demands the highest level of primary care—considering date data on the basis of previous work. When providers
both child and family as the units of care. analyze patient care situations, they are engaged in critical
Delivery of family-centered care for children requires the thinking. This chapter cannot teach critical thinking nor
provider to shift focus from “child as the unit of analysis” does it teach physical assessment. Rather, it provides frame-
to “family as the unit of analysis,” depending on the problem works for gathering data to facilitate expert decision-making
at hand. Although the child’s welfare is ultimately the goal, in areas of pediatric practice.
the family is so integral to a child’s well-being that unless Nursing has declared a set of Essentials of Master’s Edu-
the family is healthy, the child cannot achieve true physical, cation in Nursing (American Association of Colleges of
developmental, and psychological health. Moving from Nursing [AACN], 2011):
child to family and back again during the assessment process • Essential I: Background for practice from science and
is a complex task, but it is an essential one for providing humanities: The child health assessment process must
excellent care. integrate scientific findings from nursing, biologic, psy-
This chapter presents a child assessment model that inte- chological, social, genetic, and public health fields to
grates some family issues and a family assessment model comprehensively understand the health care issues.
that is useful when greater focus on the family is needed. • Essential IV: Translating and integrating scholarship into
The outline for assessment of children in this chapter is practice: The assessment process changes over time as new
consistent with the organization of the entire textbook in knowledge informs practice. Hopefully the experienced
which development, functional health issues, and diseases clinician uses strategies for assessment beyond those
are the three domains for pediatric practice and are learned as a student and the student will learn strategies
the major units of this book. Throughout this book, family recently informed by scholarship as well as the wisdom
is considered integral to the child’s life and care. This of clinician mentors.
chapter provides foundations for an integrated assessment • Essential V: Informatics and health care technologies: In
of the child, using a family-centered community-based order to be comprehensive yet efficient, the primary care
approach. provider (nurse or other) needs to use appropriate health
care and information technologies within the practice
setting, not only as record-keeping and communication
Foundations for Child and tools among providers over time, but also incorporating
the patient and family into the technology network.
Family Assessment Health teaching and monitoring are examples of new
Child Health Assessment Foundations uses. A new term, health-enabling technologies (HET),
more broadly encompasses the uses of the information-
A careful, complete, and thoughtful assessment of the child’s accessing opportunities available in the world today
health status is absolutely essential to provide excellent (Knight and Shea, 2014).
10
CHAPTER 2 Child and Family Health Assessment 11
• Essential VII: Interprofessional collaboration for improving • BOX 2-1 The Classic Health History
patient and population health outcomes: Comprehensive
assessment requires several levels of data gathering, vali- I. Patient-identifying information: name, birth date, gender,
address, record number, and name of historian, along with
dation of data, and decisions about the appropriate data
relationship to the patient stated
to be collected. No one provider is expected to be “all II. Chief complaint (CC)
knowing.” Rather, the clinician should understand the III. History of present illness (HPI)
value of collaboration with other professionals to make IV. Past medical history (PMH)
appropriate clinical decisions and provide the best care A. Prenatal, natal, postnatal
B. Past illnesses
possible. Knowing when and how to collaborate is
C. Allergies
essential. D. Accidents
• Essential VIII: Clinical prevention and population health E. Hospitalizations
for improving health: Sometimes the primary care pro- F. Immunization history
vider focuses on the individual child and family as the G. Nutrition history
H. Growth
target for services, both preventive and restorative.
I. Development
However, sometimes the appropriate target for services V. Review of systems (ROS)
is the community or a population at risk. Assessment A. Physical—body systems
concepts addressed in this chapter focus on the child and B. Psychological—Adjustment to home, school,
family as the basic units of care. However, throughout neighborhood Temperament Sleep—amount, habits,
problems
the text, there are many opportunities for care strategies
VI. Family history (FH)
to be translated into care for communities. The clinician VII. Socioeconomic (SE)
is expected to be able to shift focus as needed to meet A. Occupations of father and mother
the needs of those with health risks. Care may be direct B. Time spent with child by parents, activities together
or indirect. C. Finances—adequacy
D. Persons in the home
These are broadly written for graduates in diverse areas
E. House or apartment living arrangements
of practice. The advanced pediatric assessment process F. General relationship of family members
described in this chapter is consistent with several of these G. Community support systems—friends, church, agencies
tenets. involved with family
H. Safety precautions
• BOX 2-2 Suggested Integrated Classification System of Diagnoses for Use by Primary Care Providers:
Domains and Examples of Diagnoses
Domain I: Examples of Developmental Diagnoses Self-perception and self-concept pattern
Cognitive development • Body image disturbance
• Cognitive delay • Personal identity disturbance
• Learning disorder • Self-esteem disturbance—chronic or situational
Language development Role relationships pattern
• Language delay • Abuse/neglect/family violence
• Speech delay • Caregiver role strain
Motor development • Communication impaired—verbal
• Gross motor delay • Parenting alteration
• Fine motor delay • Risk of alteration in parent-infant-child attachment
Social development • Social interaction impaired
• Social developmental delay • Social isolation
• Attachment failure Sexuality pattern
• Sexual pattern alteration
Coping and stress tolerance pattern
Domain II: Examples of Functional • Anxiety
Health Diagnoses • Depression
Health perception and health management pattern • Grieving—anticipatory, dysfunctional
• Decisional conflict • Hopelessness
• Home-care resources inadequate • Pain, chronic
• Home-maintenance management impaired • Post-trauma response
• Risk of injury—suffocation, poisoning, trauma, aspiration • Substance misuse
• Self-care deficits—dressing, toileting, hygiene • Violence potential, self or others
Nutritional—metabolic pattern Values and beliefs pattern
• Anorexia or bulimia • Spiritual distress
• Breastfeeding ineffective, interrupted, or effective
• Infant-feeding pattern ineffective Domain III: Examples of Pediatric Disease
• Nutrition alterations less than or more than body Categories for Diagnoses
requirements Infectious diseases
• Swallowing impaired Endocrine, nutritional, metabolic, and immune diseases
Elimination pattern Diseases of blood and blood-forming organs
• Constipation Neurologic and sense organ diseases
• Encopresis or enuresis Circulatory system diseases
Activity and exercise pattern Respiratory system diseases
• Activity intolerance Digestive system diseases
• Fatigue Dental disorders
• Physical mobility impaired Genitourinary system disorders
Sleep pattern Gynecologic disorders
• Sleep pattern disturbance Skin diseases
• Obstructive sleep apnea Musculoskeletal diseases
Cognitive and perceptual pattern Symptoms, signs, ill-defined conditions
• Attention-deficit disorder Injury and poisoning
• Sensory-perceptual alteration—visual or auditory deficits Environmental: Exposure to toxin (specify)
Functional Health Problems family really is the primary caregiver for infants and chil-
Functional health problems are derived from Gordon’s dren. NPs and other providers become involved when the
functional health patterns (Gordon 1987, 2010) and are family’s knowledge and experience are insufficient to meet
incorporated into the international taxonomy of nursing the needs of the child or when the family directly contrib-
diagnoses (NANDA International, 2014). These patterns utes to the child’s problems, such as with the role-relationship
provide a framework for thinking about the problems that problem of child abuse.
nurses have always managed independently. Other primary Labels for many problems in the functional health
care providers are also asked to manage functional health domain are found in the NANDA taxonomy terms
problems of children. These patterns represent the universal (NANDA International, 2014), which is expanded and
health behavior patterns of all humans, regardless of culture, updated every 2 years. Many terms are also found in
sex, age, or economic status. Gordon’s 11 patterns include the International Classification of Diseases, Tenth Revision,
health beliefs and behavior, nutrition, elimination, activity, Clinical Modification (ICD-10-CM) (World Health Orga-
sleep, role relationships, coping, self-perception, cognition nization [WHO], 2015) and other taxonomies, such as the
and perception, sexuality, and values and beliefs. All func- International Classification of Sleep Disorders, third edition
tional health problems involve the family, because the (ICSD-3) (2014).
CHAPTER 2 Child and Family Health Assessment 13
History
Chief complaint # 1 HPI # 1
Chief complaint # 2 HPI # 2
Physical Examination
Laboratory studies
Other data (e.g.,
developmental test scores)
Problem List
Disease problems
Functional health problems
Developmental problems
Family problems
Plan
Disease problems
Functional health problems
Developmental problems
Family problems
Disposition
• Figure 2-1 Model for data collection using the disease, functional health, and development domains.
HPI, History of present illness.
effects of lack of iron on heme production, red blood cells, facilitated. Further, children and families have the capacity
oxygen transport, and cellular metabolism. The clinician to learn from and grow beyond their limitations when inter-
can diagnose this disease and prescribe an iron supplement ventions are based on their abilities. Finally, preventive
to manage the problem at this physiologic level. However, health care for children includes developmentally support-
if the problem is found to be related to a lack of iron in the ive mental health care.
diet, the provider can choose to intervene at the functional Understanding development, incorporating the physical
health-nutrition level, call the problem “Nutrition: Less as well as psychosocial developmental stages for every child
Than Body Requirements for Iron,” and teach the family on every visit into the assessment and management plan,
how to increase the selection of iron-rich foods for the table. and evaluating developmental outcomes as a measure of
Iron deficiency has also been shown to cause developmental health are the core concepts of pediatric health care. It
delays. If a goal for the visit is to provide additional support cannot be overemphasized that children are not little adults.
in the school setting, a developmental problem may be They must be cared for within the parameters of their own
diagnosed. development. Because children change so quickly develop-
A particular domain can also serve as the context for the mentally, one cannot be lax about including development
problem in another area. For instance, Down syndrome, a as a core domain for assessment. The 6-month-old infant
chromosomal disorder, can be the cause or context for a functioning at a 3-month level is 50% behind!
cognitive development problem. If the intervention is for Monitoring children’s developmental progress brings
cognition, a developmental problem of cognitive delay is pleasure in watching them master expected developmental
listed—not simply “Down syndrome.” Content issues for milestones. With time, many providers develop an intuitive
which the clinician is planning interventions are the diag- sense about the general ages at which particular milestones
noses. The contextual issues are not the diagnoses. should occur. Experience also brings an appreciation of
Most importantly, interventions must be based on or individual differences in infants, families, and ethnic groups.
derived from diagnoses. A situation should never arise in However, many variables can make it difficult to appreciate
which the provider intervenes without explicit reasons for intuitively all the various developmental skills of any par-
doing so. The reasons are stated as diagnoses, either actual ticular child. For example, a premature infant at or below
or potential, and enumerated in the problem list. The pre- the fifth percentile for height and weight may physically
ventive work (i.e., to avoid potential problems) done by appear much younger. The discrepancy between size and age
clinicians also needs to be identified. Diagnoses, in addition can lead to an inaccurate estimate of the child’s abilities.
to interventions, must be recorded. The ICD-10-CM pro- Consider an infant who is 15 months old chronologically,
vides the lists of reimbursable diagnoses, and the Current 12 months old adjusted age, but physically at the 9 month
Procedural Terminology (CPT) codes provide the therapeu- level and developmentally at the 8-month-old level. If the
tic intervention codes. provider evaluated this infant developmentally based on
physical size, the development level might appear appropri-
Developmental Assessment Foundations ate (size and development at 9 months old). Adjusting for
age because of the infant’s prematurity (adjustment to
Several assumptions underlie the concept of development approximately 2 to 3 years though this is an area of poor
in children and are threaded throughout this book. These consensus), the infant might still appear normal, and the
include the following: need for intervention and referral might be missed. When
• Development is a self-fueling, ongoing process that a valid and reliable standardized developmental screening
requires physical and emotional energy. tool is used, it is more readily apparent that the infant
• Development occurs in stages and is dynamic and requires referral and intervention services. Competent
interactional. developmental care requires three strategies: (1) monitoring
• Development is influenced by the child and his or her (surveillance), (2) screening, and (3) assessment. Success
environment. using these strategies begins when the health care provider
• Development occurs in “spurts and lulls.” Periods of builds rapport and a trusting relationship with parent and
disorganization, disharmony, and turbulence are usually child. Gaining the parents’ and child’s trust and engagement
followed by periods of harmony, balance, and organiza- in the interview process are critical to obtaining accurate
tion because all areas of development are interrelated. and reliable information. The parent interview requires the
Children are generally healthy and have adaptive capa- provider to encourage parents to share sensitive informa-
bilities. Therefore, the goal of the provider is to maximize tion, ask questions, and express concerns about their child’s
health and development and a child’s overall potential, development. The child interview requires an understand-
rather than solely to resolve problems. Although develop- ing of child development and ages. The provider must be
ment is judged in terms of milestones, individual differences skilled in the use of age-appropriate strategies, both verbal
among children are reflected in developmental variations and nonverbal, to engage the child and be sensitive to the
that reflect the unique characteristics of families, cultures, unique needs of each child. One example is to sit at the
and social circumstances. Individual developmental varia- same level as the child in order to establish eye contact.
tions and positive adaptations should be appreciated and Targeted questions around daily routines often provide
CHAPTER 2 Child and Family Health Assessment 15
TABLE
2-1 Areas for Developmental Assessment
insight into a child’s daily activities and parents’ areas of et al, 2011)—developmental screening and assessment
concern. Observation of the child and the child’s attention, strategies must also be used.
activities, verbalization, connection with the parent, pro-
cessing of information, quality of movements, cooperation, Screening
and ability to follow requests are all components of devel- Screening is considered a first-level contact with an indi-
opmental screening and assessment. See Table 2-1 for areas vidual to identify potential and actual developmental con-
of development to assess. cerns. Developmental screening is a brief, inexpensive
method to identify children who may need a more compre-
Developmental Monitoring (Surveillance) hensive assessment and diagnostic evaluation. It allows the
The American Academy of Pediatrics (AAP) Council on practitioner to document a child’s progress over time
Children with Disabilities recommends that developmental and objectively identify and reinforce a child’s develop
monitoring be incorporated into each well-child preventive mental strengths. It may also serve as a tool to stimulate
visit (Council on Children with Disabilities et al, 2006). parent questions about development and facilitate parent
Monitoring encompasses all primary care activities related education.
to the development of children, including: Typical areas of developmental screening and assessment
• Eliciting and attending to parental concerns include language, motor, social-emotional, and cognitive
• Obtaining a relevant developmental history skills. Regulatory and sensory systems as a part of the child’s
• Making accurate and informative observations of overall development and functioning should also be assessed.
children Regulation refers to infants’ daily patterns of sleep-wake
Emphasis is placed on monitoring development over cycles, which include sleeping, eating, moving, responding,
time within the context of the child’s overall well-being and reacting to their internal and external environments.
rather than viewing development during an isolated testing Sensory system evaluation includes assessment of the child’s
session. ability to receive, process, and respond to both internal and
One focus of developmental monitoring is to build external stimuli. Finally, although it is conceptually a part
parental competence and confidence, which in turn of the child’s social skill set, it is important to review parent-
enhances the child’s overall well-being. When providers child interactions and the family and environmental context
share their observations of a child’s unique developmental in which the child is living. A comprehensive approach to
strengths and skills, parents increase their knowledge of developmental screening and assessment that includes the
development and create their own parenting style. When areas of regulation and adaptive skills in daily routines is
parents feel success in their current parenting role, they do presented for each age group in Chapters 4 through 8. Table
a better job meeting their child’s future needs. 2-1 provides examples of information to gather within each
of these areas.
Developmental Screening and Assessment
Because developmental monitoring was found to be insuf- Strategies Specific to Developmental Screening
ficient to identify children with developmental problems— A standardized screening test is recommended for children
in some cases lower than a 54% identification rate (Sheldrick at a minimum of 9 months old, 18 months old, and 24 to
16 U N I T 1 Pediatric Primary Care Foundations
30 months old (AAP, 2014a). A parent self-report screening identified by the screening tool, thus requiring a referral for
tool can be completed in the waiting room or examination a more in-depth developmental assessment. In addition,
room, scored by a nurse or medical assistant, and then parent education to facilitate the “next steps” of develop-
reviewed by the provider with the parent. Aspects of the ment for the child may also be needed.
screening should be incorporated into the physical examina-
tion. By doing this, the provider not only sees the child “in Developmental Assessment
action” but also has an opportunity to demonstrate to A developmental assessment, more in-depth than a devel-
parents the infant’s or child’s current or emerging skills. opmental screening, is conducted when a definitive diagno-
After completion of developmental screening, the provider sis and a more individualized approach to guide the plan of
should review the findings with the parents. This discussion care and manage the child’s problems are required. Assess-
helps families focus on concerns that they may have, pro- ment is a second level of analysis, focusing on a narrower,
vides opportunities to answer specific parent questions, often complicated problem. Generally, assessments confirm
addresses parenting issues, and is conducive to providing a developmental problem, identify the type of problem,
anticipatory guidance. describe the level of functioning in one or more develop-
When developmental screening is omitted or delegated mental domains, and provide parents with anticipatory
to medical assistants but not reviewed by the primary pro- guidance and referrals to appropriate therapy, early inter-
vider, the significance of subtle variations of normal behav- vention services, or community resources.
ior or behavior that is very near the abnormal range may be
overlooked. Use of standardized developmental screening Strategies Specific to Developmental Assessment
tools enhances the efficiency and quality of the practice. Developmental assessment tools are significantly different
Such tools provide a consistent, reliable, and efficient from screening tools and are appropriate when concerns
method of documentation of care provided and set stan- require more in-depth developmental or diagnostic evalua-
dards for referral. Use of developmental screening tools tion. Assessment tools for developmental and behavioral
involves engaging other providers and office staff with some diagnosis, home assessment, family assessment, parent-child
minimal training and imparting knowledge of community interaction assessment, parent stress, and parental compe-
resources for referral of children identified with develop- tency are most frequently used in research but may also be
mental problems. Implementing this standard of practice of value in the clinical setting. These tools can be used for
increases parent satisfaction and engagement as experts on a thorough assessment of the child within the family context,
their child and recognizes the provider-parent partnership to look at the parent-child interaction, and to develop a
in the care of the child (Halfon et al, 2011). substantiated diagnosis for the child. The information also
Developmental screening tools should have well- improves the practitioner’s ability to structure individual-
established psychometric qualities, including sensitivity, ized interventions for both the child and the parents, and
specificity, validity, and reliability that have been standard- it can be used to evaluate the effectiveness of recommended
ized on diverse populations. A variety of standardized interventions. Tools used for overall development can
screening tools are available and recommended for develop- include the Bayley Scales of Infant Development (Aylward,
mental screening. Many of these tools have been developed 1995), the Child Developmental Inventory (Ireton, 1992),
to meet the demands of a busy, efficient office practice. and the Mullen Scales of Early Learning (Mullen, 1989).
Chapter 4-8 on the management of the development Tools used to evaluate specific behaviors or characteristics
domain provide suggested developmental screening or may include the Autism Diagnostic Observation Scale-
assessment tools that are age-appropriate. Some recom- Generic (ADOS-G) (Lord et al, 1994) or the Childhood
mended tools include the following (Berry et al, 2014): Autism Rating Scale (CARS) (Schopler et al, 1986). Because
• Ages & Stages Questionnaires, Third Edition (ASQ-3) of the complexity of issues that might need evaluation,
• Ages & Stages Questionnaires: Social-Emotional developmental assessment tools require more knowledge,
(ASQ:SE) practice, and skill to perform reliably, interpret the findings,
• Parents’ Evaluation of Developmental Status (PEDS) and plan appropriate interventions. These tools generally
• Modified Checklist for Autism in Toddlers (M-CHAT) require special training or credentials to administer accu-
• Edinburgh Postnatal Depression Scale (EPDS) rately. Often they are completed by specialists after referral
• Pediatric Symptom Checklist (PSC) from the primary care setting.
• Patient Health Questionnaire-9 (PHQ-9)
Family Assessment Foundations
• CRAFFT and Patient Health Questionnaire-2 (PHQ-2)
are recommended for teens (see Boxes 2-3 and 2-4) The Family’s Role in Health Care of Children
See Chapter 6 and 19 for guides to these resources. Understanding family health promotion begins with under-
Developmental screening strategies are appropriate for standing family dynamics. Research has provided definitive
all children, although culture and life experiences may affect evidence that children, from birth through adolescence,
some outcomes and need to be taken into consideration. need nurturing and attention from the significant adults in
Screening is conducted with the assumption that some chil- their lives. These adults most often are the child’s birth or
dren’s developmental skills will fall outside the normal limits adoptive parents, but they may also be grandparents,
CHAPTER 2 Child and Family Health Assessment 17
extended family members, or foster parents. Factors such as associated with poorer caregiving that results in poorer
a mother’s level of education, her beliefs and attitudes about language development at 3 years old (Paulson et al, 2009;
health, and her own health practices have significant influ- Stein et al, 2008). Maternal depressive symptoms were
ences on the health status of her children. Parental stress and also predictive of asthma symptoms in inner-city African
mental health problems, such as depression, affect health American families (Otsuki et al, 2010). Similarly, paternal
care for children (Earls, 2013; Raphael et al, 2010). Mater- depression also affects a child’s health (Ramchandani et al,
nal depression in the first year of her infant’s life has been 2011).
CHAPTER 2 Child and Family Health Assessment 19
• BOX 2-4 Symptom Analysis and temporally bound, determine who is and who is not
family, and can profoundly affect assessment, treatment,
1. Onset—initial and episodic; date and time, sudden or and outcomes. Providers might find it useful to periodically
gradual, setting
examine their own assumptions and beliefs regarding fami-
2. Location of pain—local, radiation, generalized, superficial, or
deep lies and use the knowledge gained to foster increased sensi-
3. Duration—how long, has it eased, gotten worse? tivity and openness to the rich diversity that their families
4. Characteristics and course: present.
• Symptom quality: Nature of symptoms Legal definitions of family usually address bonds of
• Symptom quantity: Severity, frequency, volume, number,
blood, marriage, and adoption. A significant number of
size or extent, degree of functional impairment
• Course: Continuous or intermittent, pattern of variation contemporary families do not fit such restrictive definitions.
5. Activating (precipitating) and aggravating factors To address this reality, Whall defined family as “a self-
6. Relieving factors identified group of two or more individuals whose associa-
7. Tests and treatment, including complementary therapies: tion is characterized by special terms, who may or may not
What, when, where, who, and results, including
be related by bloodlines or law, but who function in such a
complications and sequelae
8. The meaning of the symptoms to patient and family and way that they consider themselves to be a family” (Whall,
patient’s reactions to symptoms 1986, p 240). Wherever practitioners’ personal definitions
might fall on a continuum of inclusiveness, it is imperative
that they know and understand the implications of that
definition in practice.
Evidence is strong that when children are raised without
consistent, affectionate attention and without sensitive Family Structure and Roles
interactions with a caring adult, the results can be devastat- Assessment of a family’s structure and roles includes the
ing for both child and society (Kazak et al, 2010). For composition of the family or household, demographic data,
example, family cohesion, beyond dyadic family relation- intergenerational data, and information about family roles.
ships, is a protective factor for adolescent violence against Implicit in the data is the way the family defines itself and
authority (parent abuse and student-to-teacher violence) how the family gets its work done.
(Ibabe et al, 2013).
Although inadequate or poor parenting is linked to Family Life Cycle
factors such as poverty, substance abuse, and minimal edu- Family life cycle assessment includes data on the present
cation, research suggests that a poor “fit” between a child family life cycle stage (such as, a family with young chil-
and a significant adult can occur in any family, including dren), family life cycle transitions or developmental crises
those in which the adults are well educated, socially com- (such as, serious illness of a frail, elderly grandparent), and
petent, and economically successful. In contrast, when a family life cycle events that are untimely or “out of sync”
parent or another significant adult responds consistently (such as, the terminal illness of a young wife and mother).
and sensitively to a child’s needs, such as a need to play, to
eat, to sleep, to be comforted, or to be left alone, the child Family Functioning
is likely to grow up competent to initiate and build strong, Healthy family functioning should result in what Terkelsen
nurturing relationships. Issues of family relationships and (1980), in his classic paper, called the “good-enough family.”
family disruption are discussed more fully in Chapter 17. Families have both strengths and limitations, but the major-
ity of families are able to meet most of their members’ needs
Family Assessment Basic Elements most of the time. This is a hopeful stance, one that allows
Family assessment begins with the assumption that families for the less than perfect family to feel successful and
are central to and inseparable from the health of children. empowered.
It is based on a family health promotion framework that Family resilience is a helpful concept referring to healthy
assumes that the vast majority of family members are com- family functioning (Benzies and Mychasiuk, 2009). On a
petent, want to do what is best for their children, and desire broad definition, family resilience is the ability of the family
to be active participants in their children’s health care. to rebound from adversity stronger and more resourceful
Family assessment in a primary care practice with children than before. Walsh (2006) sees nine keys to resilience in
requires attention to family structure, family life cycle stage, three different areas: (1) family belief systems, (2) family
family functioning, and social network. In other words, a organization and resources, and (3) family communication.
basic family assessment addresses characteristics of the Within the belief systems, resilient families view crisis as a
family, transitions that the family is experiencing, how shared challenge, something that can be manageable and
family members interact and accomplish tasks, what they meaningful when family members work together. Such
believe and value, and how they interact with the families maintain a positive outlook and find meaning in
community. moral and spiritual values. Within the family organization
It is important to recognize that providers’ own defini- and resources area, resilient families are flexible, connected
tions of family and healthy family functioning are culturally with one another, and supported by social and economic
20 U N I T 1 Pediatric Primary Care Foundations
resources. Finally, resilient families share clear consistent nonthreatening way around potentially complex and diffi-
messages, express their emotions openly, and work together cult issues. The genogram is inherently appealing to families,
to solve problems. Protective factors for family resilience because it helps them see themselves in new ways and pro-
include individual, family, and community supports. Some vides a way for families to be partners in their own diagnosis
individual factors include internal locus of control, emo- and management. Even if not explicitly constructed during
tional regulation, and effective coping skills. Some family a visit, conceptually, the genogram assists the provider to
factors include structure, stable partner relations, cohesion, organize family data for analysis and identification of prob-
social support, and adequate income, whereas some sup- lems. It is a subjective, interpretive tool to help generate
portive community characteristics include community tentative hypotheses for further systematic evaluation.
involvement, peer acceptance, supportive mentors, a safe Providers who use genograms in their practice frequently
neighborhood, and access to a quality school, day care, and come to the conclusion that the tools are as useful for inter-
health care (Benzies and Mychasiuk, 2009). vention as they are for assessment. In addition, those
Characteristics of healthy family functioning have been working with children find that including the children in
identified by a number of researchers. Open communica- the construction and updating of genograms helps children
tion, mutual respect and support, differentiation, shared be active in their own care and provides data on family
problem-solving, shared decision-making, flexibility, enhance interactions. Although the genogram looks similar to a
ment of members’ personal growth, sense of play and genetic pedigree, its purpose is to understand the family’s
humor, and a shared value of service to others are some of structure and function—not the family’s genetic risk factors.
these assets. The AAP states that a child will thrive best
when cared for by two mutually committed parents who Genogram Construction
respect and support each other, who have adequate social Genograms are sociometric paper-and-pencil tools used to
and financial resources, and who both are actively engaged depict a family’s composition and history across generations
in the child’s upbringing. Characteristics of the successful (Fig. 2-2). Although not essential, computer programs to
family are described by the AAP as being cohesive, endur- facilitate genogram data management are available and can
ing, and mutually appreciative. Such families communicate be easily included in computerized patient records. These
effectively and often, adapt to changing circumstances, programs have made updating genogram data easy and
spend time together, are committed to the family, and efficient (e.g., Genopro).
embrace a common religious or spiritual orientation (Schor Priorities for organizing genogram data for clinical use
and AAP Task Force on the Family, 2003). “Family members rely less on formal blood and legal links and more on repeti-
share their lives emotionally and together fulfill the multiple tive symptoms in members and relationships or patterns of
responsibilities of family life” (AAP, 2014b). functioning seen across the family or over generations. They
are most effective when constructed during an initial visit
Family Social Network with children and their families and then revised as new
Positive social support exists when the family feels emotional information becomes available.
support, has tangible help, and is informed (Benzies and The provider begins by drawing a basic family tree, with
Mychasiuk, 2009). The family’s social network includes the present family members guiding identification of family
those individuals, activities, agencies, and institutions that members. It is clinically useful to identify members of the
have the potential to support, harm, or drain energy from current household in which children live. In fact, it can be
the family. Assessing the family’s relationships with extended more informative and useful to learn who is living in a
family, friends, and the community provides information on household than who is related by blood or birth. This objec-
which to base recommendations and further assessment. tive can be met by drawing a circle around the members of
the genogram who currently live together (e.g., the circle
Genograms may include parents and three children, or it may include
A genogram is an approach to developing a family database. one of two parents, two of three children, and a grandpar-
It does not require the purchase of standardized assessment ent). It is also useful to include at least three generations of
tools, and it can be updated over time, which is a character- the family. Standardized symbols and a sample can be found
istic making it valuable to pediatric providers in understand- at www.genogram.org/gmm_sample_win.html.
ing patterns in the lives of children and families. Genograms Health history information, including serious medical,
provide graphic representations of complex family data; they behavioral, and emotional problems, can be noted on the
allow the providers to map the family structure and roles, genogram (e.g., drug or alcohol problems, serious problems
life cycle transitions, family functioning, and social networks with the law, and causes of death). Likewise, family infor-
clearly and to update the picture as it emerges. Further, mation that is significant to the health of the child can be
genograms provide efficient clinical summary, making it included, such as ethnic background, language spoken in
easier for providers to keep in mind family members, pat- the home, education of parents, occupations, religious affili-
terns, and events that may have recurring significance in a ation, major family moves, and current location of family
family’s ongoing care. They provide a means for interacting members. Significant others who live with or are important
with children and their family members in a focused, to the family should be included (for example, family
CHAPTER 2 Child and Family Health Assessment 21
b. 2/14/1979 b. 11/11/1982
Key
Male b Birthdate Service
dog
m Marriage
Female
d Death
Divorce or Deceased
Stillborn
• Figure 2-2 A three-generational genogram of a blended family.
friends, foster children, and babysitters). In some cases, the or may not be successful, the genogram is a highly recom-
significant other is a family pet. mended tool.
Practical pointers include using pencil instead of pen,
unless there are legal or institutional requirements to use a
pen; leaving space at the bottom of the page for notes; and The Environment for Data Collection
including a key to notations or unusual symbols. It also is Setting up the Assessment Environment
useful to provide children with their own paper and pencils
or crayons to use while conducting the interview; ask them Health care is a family event in pediatrics, and pediatric
to draw a picture of their family for you. primary health care is delivered in many settings, not just
The genogram interview can begin with an open ques- examination rooms in outpatient clinics. Wherever the
tion, such as, “Tell me about your family.” It can be addressed child and the family are to be cared for, privacy must be
to children, parents, or both. As the genogram is being ensured. People should have places to sit down, and the
constructed, questions can be used to elicit information room in which the examination is conducted should be well
about family functioning. Some examples of questions that lit and allow the patient to lie down comfortably. The
may help to understand the functioning of various family examiner must be able to work comfortably, too. The health
forms are found in Table 2-2. They are examples only and care provider should sit down during the history to make
should not be viewed as exhaustive. data collection a conversation, to equalize the status of
The Ecomap is a similar tool that is used to construct a patient and examiner, and to help the children and their
picture of the family structure and relationships within the families feel that they have time to talk. Sitting also helps
family and in the community that are supportive or harmful. the provider conserve energy for a busy day. The environ-
For those interested in pursuing how individual family ment must be safe, given the developmental ages of the
members work together or against one another and use children to be cared for, and should present an atmosphere
outside resources to support themselves as a family that may of warmth and welcome.
22 U N I T 1 Pediatric Primary Care Foundations
TABLE
2-2 Some Suggested Family Assessment Questions for Genogram
Communication with Children and Families and adaptation to challenging situations. “Poor communi-
cation, on the other hand, can prompt lifelong anger and
“Communication is the most common ‘procedure’ in regret, can result in compromised outcomes for the patient
medicine” (Levetown and AAP Committee on Bioethics, and family, and can have medicolegal consequences for the
2008, p 1441) and is identified as critical to the provision practitioner” (Levetown and AAP Committee on Bioeth-
of health care. It must be responsive to the needs of the ics, 2008, p 1441).
child and family within the context of their own dynam- The three elements they identify as essential to excellent
ics. It is essential to diagnosis and successful treatment communication are as follows:
planning and results in better patient outcomes, including • Communication needs to provide information.
physical and psychosocial benefits, increased patient satis- • Communication should be sensitive interpersonally, with
faction, patient knowledge, adherence, functional status, affective behaviors indicating the provider’s attention
CHAPTER 2 Child and Family Health Assessment 23
to and interest in the parents’ and child’s feelings and any missing data should be made so that further baseline
concerns. data can be collected at the next visit.
• Communication should help to build a partnership Interpreter services must be available if the clinician and
among the three parties, allowing discussion of concerns, family are not fluent in each other’s languages. These ser-
perspectives, and suggestions from all. vices are mandated by law. Use of family members as inter-
Health care communication is different from normal preters is never recommended. Family members may try to
discourse because very personal issues are discussed—hopes protect the patient or themselves by hiding important infor-
and fears; sexuality; mental health issues; painful issues such mation. Legally, the provider may be at risk if information
as abuse, drug use, school and personal failure; and serious was not transmitted correctly or completely either to or
or terminal illness. Communication involves both cognitive from the clinician.
and affective elements. When drug use, alcohol consump-
tion, and smoking were addressed with mothers, parent- Redesigning Primary Care to Achieve
provider relationships were positively affected (Garg et al, Assessment Goals
2010). Similarly, discussion of maternal stress also results in
greater maternal satisfaction with care (Brown and Wissow, Although the data that needs to be collected during a first-
2008). time primary care health care visit is extensive, many well
The pediatric health history has several unique aspects. child visits are of very short duration—11 to 20 minutes
First, the participants in the conversation may include the (47%). Longer visits are associated with more anticipatory
child, caregiver, or both, and provider—more than just the guidance, more psychosocial risk assessment, and stronger
patient and provider as in the adult care model. Second, family-centered care ratings (Halfon et al, 2011). Receiving
the topics emphasized vary significantly depending on the a developmental assessment, having enough time to ask
child’s developmental stage. Third, the process of commu- questions, and satisfaction with the provider are all associ-
nication with the child and the extent to which he or she ated with longer visits. Some efforts are being made to
is involved with health care decisions vary with age. The redesign clinical practices to provide for developmental-
provider should introduce himself or herself at the start of behavioral promotion and family-oriented services (Glascoe
the interview. Families typically want to be addressed by and Trimm, 2014). For example, health educators may do
their last names and to shake hands with the provider more anticipatory guidance and developmental/behavioral/
(Amer, Fischer, 2009). For young children, the conversation psychosocial surveillance and screening (Coker et al, 2014).
time gives them the opportunity to become familiar with Health literacy is a concept discussed in several chapters
the examiner and setting, which is essential for cooperation of this text. If the family or child does not have the skills
when needed. Remember that young children are learning to understand, read, write, and discuss health issues in the
the “script” for health care visits. The visit should help them language required, communication may be broken with
learn a script that is understandable and not too stressful. possible, including jeopardized, quality of care outcomes
When the script is to be varied (e.g., no immunizations this and misunderstandings.
visit), alert them to the change with cues and explanations
for the new experiences of this visit and the likelihood that
the new script will be repeated at future visits. The Database
The provider is also observing parent-child interactions The Child Health History
during the visit. For example, are the parents responding to
their baby? Do the parents contribute to the school-age It is a common saying in medicine that 80% of diagnoses
child’s self-esteem? Cues to mental health problems in any are made on the basis of the history. The physical examina-
family member or the child should be addressed. tion only provides a partial view of the situation as it is at
For adolescents, the history can be started with the the moment. It is often a cloudy picture because the body
parents and teen together; however, they then need to sepa- frequently responds similarly to different assaults. It is the
rate, with the provider getting information from the parents history of the problem—its onset, duration, progress, asso-
and the teen independently. Interviewing teens requires ciated symptoms, meaning, and effects on daily living—that
patience, because they are learning to take responsibility for brings the health care provider to an understanding in suf-
their own health care. Interactions will change as teens ficient depth to choose appropriate management. Func-
mature developmentally or as the situation is modified. tional health and developmental problems present the same
Data can be collected verbally, through record review, via issues for the provider. A thorough, thoughtful history is
written forms completed by the family, or through a com- essential.
bination of these methods. It might not be practical for data The database described in this chapter summarizes the
to be fully collected on the first visit; rather, the collection child health history and physical examination and the
can be staged according to the visit priorities. When time family assessment. The model presented uses a basic
with patients is limited, it is common to ask new families problem-oriented format that begins with subjective data
to come early for their first appointment to complete a (the history), moves to objective data (the physical examina-
written history before meeting the clinician. Notation of tion, laboratory, and test data), then lists the problems by
24 U N I T 1 Pediatric Primary Care Foundations
domain (identified through the subjective and objective developmental. At visits for minor illnesses, health promo-
data), and finally, outlines plans of care, problem by tion and disease prevention issues should be considered in
problem. The items listed under each topic are suggestions; addition to the problem at hand. An immunization history,
they are not required data to obtain from every patient. As if appropriate, should be completed at every visit.
children age, the emphasis will change (e.g., less time spent Disease Domain Database
on birth and infancy histories). The history needs to be Past Medical History
individualized, considering family, culture, health status, • Prenatal: Planned pregnancy? When did prenatal care
and environment. The complete format should be mastered begin? What was the mother’s health during pregnancy?
so that it becomes core to the provider’s approach to all Drug, alcohol, and tobacco use? Illnesses and medica-
patient situations. If data are omitted, the omissions should tions? Weight gain? Accidents? (With age and history of
be by choice, not by an error committed through haste, a healthy baby, these sections may become less
distraction, ignorance, or habit. The adolescent history significant.)
needs special modification because adolescents’ health care • Perinatal: Where was the baby born and who delivered
needs, risks, and developmental characteristics are so differ- the infant? Duration and process of labor? Vaginal or
ent from those of infants and young children and because cesarean delivery and process? Infant response to labor
adolescents are interviewed directly. Box 2-3 shows a modi- and delivery (breathing, crying)? Resuscitation needed?
fication of the initial health history for adolescents. Apgar scores? Birth weight, length, and head circumfer-
ence? Gestational age? Neonatal course: infections or
The Initial (Complete) Health History other health problems, physiologic stabilization, feeding,
Patient-Identifying Information responsiveness? Jaundice? Weight at discharge? Hospital
Data here are standard to medical records: date, name, duration? Neonatal follow-up over the first few weeks?
medical record number, birth date, gender, address, phone (Again, with age and health, this section is given less
number, and names of other family members. Data about attention.)
the informant are designed to give the reader a sense of the • Past disease profile: What health problems has the child
probability that the history is accurate, complete, and from experienced, and what have the outcomes been? Who
a knowledgeable source. Health literacy can be determined has provided care? Infectious diseases?
with “the newest vital sign,” which is a single question, • Other current health problems (not related to the chief
“How many children’s books are in your home?” An answer complaint): What problems does the child have now?
of less than 10 is a meaningful indicator of inadequate What was the date of onset? Who is the principal health
household health literacy (Driessnack et al, 2014) care provider for each problem, and what is the current
status (e.g., medications, awaiting surgery, problem in
The Database: Subjective Information remission)?
Chief Complaint and History of Present Problem • Operations, hospitalizations, emergency department visits:
• Concerns: The health care visit should begin with open- Has the child been hospitalized for any reason? Why,
ended questions to allow the child and family to voice when, where, outcomes? Response to hospitalization?
their concerns. What brings the child to the clinic today? Problems resolved? Emergency department visits? Why,
The chief complaint is a brief statement of the problem when, and outcomes?
and its duration. Remember that new concerns can arise • Injuries: What significant injuries has the child experi-
at any point during the visit. Agendas can be hidden or enced? What care was needed, was care sought at emer-
unconscious. The chief complaint or complaints can gency department(s), and does the child have any
involve disease, the functional health pattern, or develop- sequelae?
ment, and the problem may lie primarily with either the • Allergies: Allergies to foods, medications, or environmen-
child or family. tal factors? How are the allergies manifested? When did
• Present problem history: For each concern, a chronologic the allergies develop? What care is given?
description should be made that includes a symptom • Growth: What has the child’s growth pattern for height,
analysis (i.e., onset, duration, characteristics or symp- weight, and head circumference been? (Always plot
toms, exposure to illnesses or other causative factors, growth data and body mass index [BMI] on a growth
similar problems in other family members or neighbors, grid to assess progress.) Is the child similar in size to
previous episodes of similar illnesses or symptoms, previ- peers? Are clothing sizes changing? Has growth been a
ous diagnostic measures, pertinent negative data, things worry for the child or family?
that have been tried in attempts to manage the concern • Immunizations and laboratory tests: Obtain a record with
and their success, and the meaning of the concern for dates for all immunizations received in the past. Reac-
the family and child). Box 2-4 shows symptom tions? Blood tests and screening tests?
analysis. • Medications: Is the child taking any medications (pre-
Even though the child comes in for a specific problem, scription drugs, over-the-counter agents, or folk reme-
always ask some screening questions that tap into the other dies)? What? Why? How much? Responses to the
domains of the history—disease, functional health, and medication?
CHAPTER 2 Child and Family Health Assessment 25
Review of Systems. Remember that this section docu- three-generation pedigree an important component of the
ments the history of body system functioning, not the health history.
physical assessment findings. The goal is to seek information • Mother and father: Ages and health history.
about all the body systems that may be related to the present • Mother’s pregnancy history: Number of pregnancies,
problem or the child’s general health status. births, status of offspring.
• General: Is the child considered to be well, happy, and • Familial diseases: Age, sex, and health status of each
developing normally? family member. Familial and communicable diseases,
• Skin: History of birthmarks, lesions, or skin conditions, such as diabetes, epilepsy, tuberculosis, hypertension or
including hair and nails? heart disease, cancer, sickle cell anemia, birth defects,
• Head: Head trauma? Head growth—microcephaly, mac- known genetic disorders.
rocephaly? Headaches? • Genogram and/or pedigree: Draw out a genogram of the
• Eyes, ears, nose, throat: Vision and eye problems? Hearing family members, including sex, age, and health status of
and ear problems? Nose—discharge or bleeding epi- each member. (See Chapter 41 for pedigree notations.)
sodes, breathing interference? Throat problems or Environmental History. This section is used to consider
infections? toxic exposures. What foods does the child eat and how are
• Respiratory: Breathing problems? Respiratory infections? they prepared? What is the quality of the child’s living
Blue spells? Cough? Snoring at night or obstructive sleep environment(s)—water and air quality? Pesticides used? Are
apnea? chemicals or heavy metals stored in or near the home? Has
• Cardiovascular: Heart murmur history? Cyanosis? Blood the child been exposed to tobacco smoke or lead? Exposure
pressure problems? Activity intolerance? Syncope? to other toxins? What are the noise levels in the child’s
• Gastrointestinal: Infections, diarrhea, constipation, vom- environment?
iting, or reflux? Structural problems? Anal itching or Functional Health Domain Database. The questions in
fissures? Stomachaches? Weight loss? this section are organized by functional health patterns.
• Genitourinary: Infections, discharges? Structural prob- Health Maintenance and Health Perceptions. All people
lems? Stream appearance? Frequency or burning? take steps to influence and protect their health. These
• Gynecologic: Menarche and menstrual history including choices include selection of health care providers, use of
length of menses, frequency of cycle, cramps, and clots? safety devices, learning how to take care of oneself, and daily
Vaginal discharge or bleeding? Itching? care of the body. Problems identified might include health-
• Musculoskeletal: Movement or structural problems? seeking behavior, altered health maintenance, or noncom-
Broken bones or joint sprains? Joint inflammation? pliance with a preventive or adaptive health care regimen.
• Neurologic: Seizures? Movement disorders? Tremors? Usual data include the following:
Tics? Loss-of-consciousness episodes? Headaches? • Usual primary care provider: Last visit?
• Endocrine: Problems with growth or pubescence? • Dentist: Last visit?
• Hematologic: Anemia history or symptoms? Blood trans- • Child’s self-care or caregiver needs for more knowledge
fusions? Bleeding disorders? of caregiving?
• Dentition: Number of teeth and eruption pattern? Dental • Health care recommendations that the family chooses
trauma? Dental care? Use of fluoride? Teeth brushing and not to follow or is unable to follow?
flossing? Toothaches? Use of appliances? • Safety measures used: Car seats or seat belts? Smoke and
Family History of Diseases. Classically the three- carbon monoxide alarms? Window screens? Home safety
generation pedigree is used to map out risks for genetic measures? Pools? Firearms in the home? Helmet use?
diseases in families, but can be used more broadly to detect • Routine health promotion regimens?
conditions with modifiable risk factors. The family history • Home and health management resource issues for the
is a good proxy for the genetic, environmental, and behav- chronically ill or handicapped child? Home nursing?
ioral risks to health (Doerr and Teng, 2012). It can be Equipment needs? Transportation needs?
helpful to individualize preventive care for a variety of con- Nutrition. Quality and quantity of the daily diet and the
ditions, such as obesity and diabetes. It requires patients to processes of feeding and swallowing, in addition to data to
report reliably and is somewhat time-consuming though it support diagnoses, such as nutrition, less than or greater
is a reimbursable process (CPT code 99202 for a new than body requirements; anorexia; bulimia; impaired swal-
patient and one return visit [99213]). Families can use lowing; and breastfeeding issues would be found in this
checklists to note conditions or construct a pedigree online section.
(www.familyhistory.hhs.gov) although they need access to • Daily diet: Breakfast, lunch, snacks, and dinner? Aver-
the Internet and the record may not work well with the sions and preferences?
electronic medical record in use (Doerr and Teng, 2012). • Cultural patterns related to nutritional preferences and
Health literacy is essential. It is discussed in greater depth eating?
in Chapter 9. • Supplements and vitamins?
Now that the human genome has been mapped out, • Feeding patterns: Mealtimes and snack times? Feeding
genetic diseases are receiving more attention, making the strategies? Self-feeding skills?
26 U N I T 1 Pediatric Primary Care Foundations
Part A
During the PAST 12 MONTHS, did you: No Yes
1. Drink any alcohol (more than a few sips)? (Do not count sips of alcohol taken during family or religious events.)
2. Smoke any marijuana or hashish?
3. Use anything else to get high?
(“anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”)
For clinic use only: Did the patient answer “yes” to any questions in Part A?
No Yes
Ask CAR question only, then stop Ask all six CRAFFT questions
Part B No Yes
1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol
or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. Do you ever FORGET things you did while using alcohol or drugs?
5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or
drug use?
6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
100%
80%
Probability of
60%
40%
20%
0%
1 2 3 4 5 6
CRAFFT Score
References:
1. Knight JR, Shrier LA, Bravender TD, et al: A new brief screen for adolescent substance abuse, Arch Pediatr Adolesc Med 153(6):591–596, 1999.
2. Knight JR, Sherritt L, Shrier LA, et al: Validity of the CRAFFT substance abuse screening test among adolescent clinic patients, Arch Pediatr Adolesc Med
156(6):607–614, 2002.
3. American Psychiatric Association: Diagostic and statistical manual of mental disorders, ed 4, Washington DC, 2000, American Psychiatric Association.
28 U N I T 1 Pediatric Primary Care Foundations
Psychometric Properties*
MAJOR DEPRESSIVE DISORDER (7% PREVALENCE) ANY DEPRESSIVE DISORDER (18% PREVALENCE)
PHQ-2 Score Sensitivity Specificity Positive Predictive PHQ-2 Score Sensitivity Specificity Positive Predictive
Value (PPV†) Value (PPV†)
1 97.6 59.2 15.4 1 90.6 65.4 36.9
2 92.7 73.7 21.1 2 82.1 80.4 48.3
3 82.9 90.0 38.4 3 62.3 95.4 75.0
4 73.2 93.3 45.5 4 50.9 97.9 81.2
5 53.7 96.8 56.4 5 31.1 98.7 84.6
6 26.8 99.4 78.6 6 12.3 99.8 92.9
†
Because the PPV varies with the prevalence of depression, the PPV will be higher in settings with a higher prevalence of depression and lower in settings with a lower
prevalence.
*Kroenke K, Spitzer RL, Williams JB: The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener, Med Care 41:1284–1294, 2003.
©1999 Pfizer Inc. All rights reserved. Used with permission.
problems—another level of issues. Family problems might they are in the family life cycle is also important. Are there
include impaired communication among family members, family problems that put the family at risk—“out of sync”
social isolation, family violence, impaired parents, altera- issues, such as a seriously ill parent, young teen parent, or
tions in parenting, caregiver role strain, and others. In grandparenting by an ill elder?
general, families appreciate concerns and inquiries related Extended Family Context. Data about the extended
to the health of their family. For some topics, such as family may not seem relevant to parents or children, but
domestic violence, mothers may prefer to discuss the issues patterns that can have an effect on children’s health often
away from the children. Providers should not hesitate to ask do not become evident until this kind of intergenerational
questions about the family. mapping is done. This more extensive mapping of a family
Family Composition and Structure. Who lives in the may be used when the clinical picture includes conflicting
home—family and others? How are they related? What is information or when the effectiveness of a prevention activ-
the meaning of the family structure to the child? In other ity is a concern. For example, knowing that both the mother
words, does the child feel like a member of the family— and grandmother of the young adolescent in your office
cared for and supported? Does the family feel whole or became pregnant at 14 years old and dropped out of
is it missing members from the child’s or another’s point high school may be helpful in deciding how to best use a
of view? brief visit. “It would help me to help your child if I knew
Current Family Situation. An understanding of the more about your child’s grandparents, aunts, uncles, and
current family situation is helpful, especially if a significant other relatives. Let’s begin with your mother’s family…”
period has elapsed since the child and family were last seen. Knowledge of the timing and repetition of significant family
Understanding changes that the family is facing and where events or behavior may be helpful. For example, adolescent
CHAPTER 2 Child and Family Health Assessment 29
pregnancy, alcohol abuse, dropping out of high school, and (Hagan et al, 2008). The PHQ-2 is a rapid screen for
suicide may be patterns of behavior in a family’s intergen- depression in adolescents (see Box 2-6). The Rapid Assess-
erational history. ment for Adolescent Preventive Services (RAAPS) is a
Genogram Data. Demographic data include dates of 21-item questionnaire that assesses the risk behaviors con-
birth, death, adoption, marriage, separation, divorce, signifi- tributing most to morbidity, mortality, and social problems
cant illness, and major family events; culture and ethnicity; of teens. It has been positively evaluated by primary
religion; education; and occupations. The provider can probe care providers (Darling-Fisher et al, 2014; Yi et al, 2009).
for more information about specific data as they appear to It is available as a proprietary product via the website
be significant in a given situation. For example, faith and www.raaps.org.
strength of adherence to a specific religion may have an
unexpected effect on care decisions for a child. Disagreement The Interval History
about adherence within a family may result in mixed mes- The complete history usually needs to be completed only
sages and uneven follow-through with a treatment plan. once for new patients. After that for routine scheduled
If gaps in data become evident, they need to be explored. health maintenance visits, the history is updated only from
It is also helpful to keep in mind events external to the the last contact to the present. The format remains the same
family that may have influenced family choices. For example, as for the complete history; however, questions are modified
the years of conflict in Iraq and Afghanistan have inter- to verify that the situations are as they were in the past or
rupted many life plans. Immigration, voluntary or forced, to add new information. All areas of the history should be
can have an effect on family health status. Natural disasters assessed.
(such as, floods, hurricanes, and droughts) have changed
family histories and the health status of family members. The Episodic History
Family Relationships and Roles Families often bring their children in for help with specific
• Primary caregiver? Who helps? Stresses of caregiver: Is problems. The history includes the chief complaint with
the caregiver well both physically and emotionally? symptom analysis and history of present illness sections of
• Does anyone require more attention from the primary the complete history. The other areas of the history should
caregiver than the child? be updated since data were last collected. Always listen for
• How much time do parents and child spend in the home emerging problems and developmental progress. The
together? symptom analysis assists with organization of presenting
• How are family decisions made? How are arguments problem data (see Box 2-4).
worked out?
• What is the relationship between caregiver and partner? The Psychosocial Problem History
Family Social and Community Network Psychosocial or behavioral problems also must be assessed.
• What community resources and family support systems Some considerations are summarized in Box 2-7. Much of
are used? the data related to psychosocial concerns will be collected
• What agencies work with this child and family? in the functional health pattern domain database.
• Where does the child go for day care, school, work
(teens), and is each setting safe? The Physical Examination
Family Environment and Resources The physical examination is conducted following the history,
• What is the home environment: Apartment, home, or although younger children might do better with developmen-
farm? tal testing preceding the physical examination. Height, weight,
• Fenced yard or perceived unsafe neighborhood? head circumference, BMI, and vital signs, including a pain
• Family financial resources: Health insurance? Money for assessment, are recorded. A list of principal findings that the
necessities? provider is expected to identify is presented in Box 2-8.
• What are the sources of money for the family? Jobs or Screening tests for hearing and vision, in addition to labora-
government assistance? tory data and data from other disciplines, are included as other
• Family stresses over resources and home environment? types of objective information. More experienced providers
collect some of the history while conducting the physical
Adolescent Health History Adaptations examination. Content of the examination varies depending
For adolescents, the SSHADESS (Strengths, School, Home, on the child’s age and the various problems under consider-
Activities, Drugs/substance abuse, Emotions/depression, ation. Further discussion of physical examination techniques
Sexuality, Safety) is recommended as a psychosocial screen- and findings are found in specific disease chapters.
ing test (Ginsburg and Carlson, 2011). The CRAFFT
screening tool (see Box 2-5) consists of six questions that Other Data
screen for adolescent substance abuse (Center for Adoles- Laboratory and Radiographic Data
cent Substance Abuse Research [CeASAR], 2014). It is rec- Record hearing, vision, hematocrit or other blood tests,
ommended by the AAP in Bright Futures: Guidelines for lead, urinalysis, newborn screening tests, and tuberculosis
Health Supervision of Infants, Children, and Adolescents screening.
30 U N I T 1 Pediatric Primary Care Foundations
Data from Other Disciplines considers all the possible diagnoses for the problems pre-
Summarize social work, nutrition, physical therapy, occu- sented by the child. Then the factors that support or rule
pational therapy, medical specialist, speech pathology, edu- out each of the various options considered are analyzed.
cation, and other reports. Identification of the best fit of the subjective and objective
data with the possible diagnoses is the goal. If further data
Creating the Problem List are needed to confirm a diagnosis, collection of these data
The problem list is derived from analysis of the subjective is incorporated into the plan. For example, the differential
and objective data collected. Differential diagnosis is the diagnoses for coryza (a runny nose) include, among others,
clinical decision-making process used to derive the prob- allergic rhinitis, upper respiratory infection, and a foreign
lems listed (Fig. 2-3). To use this process, the provider body in the nose. The clinician uses data about related
symptoms (e.g., itchy eyes, a sore throat, systemic symp-
toms, or bilateral or unilateral drainage from the nostrils)
• BOX 2-7 Suggestions for the Psychosocial to choose which diagnosis best fits the child’s picture. That
Complaint History analysis for fit is the diagnostic reasoning process.
Functional health problems and developmental prob-
1. Use good communication skills—listen. Nonjudgmental
lems are also subject to the notion of differential diagnosis.
approach. Seek a balanced give and take of information.
2. Interview the child or adolescent alone and with parents. For example, a child who is not sleeping well might be
Time alone with the preschooler may be used for play or fearful, a trained night feeder, or might experience episodes
drawing. of obstructive sleep apnea. The interventions for each
3. Have questionnaires or checklists from parents, teachers, problem are different. Thus the provider must use the dif-
and child care workers available. Use the information in the
ferential diagnosis process to identify the problem or prob-
interview.
4. Be alert to emotional tone and interactions among family lems at hand. A problem should never be included on the
members. problem list that is not supported by subjective and objec-
5. Review the context for the concern: tive data found and recorded in the database. “Rule out”
• Information about parents and family members: Illnesses, should not be listed as a diagnosis. (It may be considered
mental health problems, poverty, employment, violence,
part of a plan.) The diagnosis would be the unexplained
social isolation
• Information about the child: School, peer relationships, symptom (e.g., “dysuria”).
temperament, neglect or abuse history, foster home
placements, losses Avoiding Diagnostic Errors
• Information about child-parent relationships: Attachment Data collection for clinical practice, just as for research,
unrealistic expectations, poor family communication, lack
must be as reliable and valid as possible. To assist with reli-
of knowledge of child development and appropriate
parenting ability, consider the following techniques:
6. The history of present illness becomes an amalgam of • Test-retest: Ask the question again later. Take a blood
information from the multiple sources—child, parents, others. pressure or a head circumference reading twice. Look for
Do not assume that both parents have the same views of the the physical finding a second time a bit later.
issues.
• Interrater reliability: Ask someone else to listen, palpate,
7. Remember that the interview itself may be therapeutic.
and so on for the same finding. Does someone else get
the same answer to the same question you asked?
Clinician
National Guidelines
• Knowledge
Evidence-Based
• Experience
Patient Concern Practice
• Skills
"Very well indeed. And I'll tell you how it was; but I don't want
Maynard to know his dirty job be found out, and I'll beg you to keep dumb
about it till things are a bit forwarder. I can get forty shillings or a month
out of him, and give him a damned good hiding and disgrace him for his
underhand, blackguard conduct—stealing another man's girl—but I want to
do a bit more than that if it's in my power. And so long as you're not on his
side no more, you'll be the best one to help me. I'd do a lot to break this off
and punish Dinah, same as she punished me; and why not? She deserves it
quite so well as him."
"Begin at the beginning," said Joe. "Tell me what you know. I'm your
side without a doubt in this matter. There's a lot hid here you don't
understand, and, for the credit of human nature, I hope you're wrong. This
may be something that you've given ear to, out of ill feeling against Orphan
Dinah. You must be terrible sure of your ground, for there's very good
reasons why you ought to be mistaken. But if you're right, then you be the
tool of Providence and it's well you came to me."
Johnny, who had learned everything from Jane, told the story with only
one addition contrary to facts. Jane lied in a minor particular and concealed
the incident of looking into Dinah's letter. Instead she declared that she had
hidden herself, and watched, and seen Maynard come for the letter and
leave another on the following evening in late dusk. The conclusion
amounted to the same thing.
Joe was deeply impressed.
"I always held him a bit sly," he said, "and I've lived to find him
ungrateful and hard-hearted where I'd every right to expect something very
different. He struck me at the very moment when a decent man would have
scorned to do so, with all my own troubles thick upon me. But this is
something a lot deeper than his conduct to me, and even a lot worse."
"I'm glad you think so," answered John. "I'm very glad you see he's a
secret, cowardly sort of one. He kindiddled Dinah away from me no doubt;
and very like it is Providence, as you say; and if you don't think he ought to
marry her, then I hope you'll help me to prevent it."
Johnny felt exalted. He had not expected much from his visit to his
kinsman; he had even feared that Joe might already know the facts and
attach no importance to them; but it seemed that Mr. Stockman was quite of
John's opinion. Indeed he declared so.
"I certainly think they ought not to marry," he answered. "And I think a
great deal more than that. Keep your mouth shut close for the present.
There's plenty of time—unless."
"My mother was put out when Dinah went off a bit ago. She got the
idea from Jane that Dinah had gone to be married then. But when they taxed
her, she swore she had not."
"She couldn't tell a lie if she was paid to," declared Mr. Stockman, "and
Maynard certainly weren't in that, because he was here and I saw him every
day about his business. We must rest the blame on the right pair of
shoulders. And it'll break 'em without a doubt. But we'd best to go careful.
Don't you take a step alone. How many know?"
"Then tell your sister and Withycombe to keep dumb as mice for the
minute; and so will I. This is a very serious thing indeed—and a great shock
to me. To think he was that sort!"
John was pleased but mystified. He failed to see why this event should
make so tremendous an impression on Mr. Stockman.
"I'm very glad you think it is so bad," he said. "I was in a bit of doubt if
you'd take my side."
"As to sides," answered Joe, "I'm going to take the side of right, which
is no more than to say I'll do my duty. And that looks pretty clear. I dare say
you are a bit astonished, but understand me. I'm not making your quarrel
mine, and I don't hold at all with your talk about forty shillings or a month
out of Lawrence Maynard. This goes a very great deal deeper than forty
shillings or a month, I may tell you. I'll say no more for the minute; but I
shan't do naught till I've seen you again. Only keep this in mind: Maynard
ain't planning this hookem snivey job and doing it all in secret, because he's
afraid of you, but because he's afraid of me."
Johnny became more and more puzzled. It was clear, however, that he
had won a powerful friend and might now hope to strike a harder stroke
than any with his fist.
"So long as you be going to queer the man's pitch, and punish him, and
get Dinah away from him, I don't care a damn," he said. "If Dinah finds out;
but perhaps he's made her think——"
"Yes; he's made her think a lot, and he's told her a great many dark and
devilish falsehoods—that's very clear indeed," answered Joe.
"And if her eyes be opened, she may come back to sense yet!" cried the
sanguine youth. "Shame will show her the truth perhaps."
Mr. Stockman did not answer. He was occupied with his own
reflections.
They had descended from the Beacon and were walking on the
Buckland road. Then Joe stopped.
"You go your way now," he said, "and leave me to put this together. You
do naught and I'll do naught for the minute. But there may not be any too
much time. He was going at Michaelmas. 'Tis certain now that's a blind.
He'll take French leave presently and we've got to be before him. Come to
supper o' Wednesday, John. Then us'll see how it looks. That poor woman—
as honest a creature as ever stepped."
"He is, by God! Now I'll leave you. And be so silent as the grave till you
see me again."
A trap from Ashburton descended, flashing its lights through the leafy
darkness of the road; and when the ray illuminated Mr. Stockman, he heard
a woman's voice bid the driver pull up. It was Mrs. Honeysett who spoke,
and she seized an opportunity to relieve the existing painful conditions. For
she had not seen Joe since she declined him; but here was an excuse and she
took it.
"You'll be wondering what I'm doing at this time of night," she said,
"but I can't pass you."
A huge figure towered in the gloom over Joe and a heavy hand grasped
his own.
"I remember you," said the farmer, "but I forgot you were such a
whacker. Sailed all the Seven Seas, I suppose, since you was last to
Buckland?"
"He's two inches taller than what dear father was," declared Melinda,
relieved to find Mr. Stockman in a humour apparently amiable. "Robert's
going to take a nice rest along with me. In fact he doubts sometimes if he'll
go back to sea at all."
"No, no—I don't doubt that," answered the sailor. "But I be going to
give work a rest."
"And find a wife, if he can," continued Melinda. "Us must help him,
Joe."
"I always swore as I'd marry a maiden from the Vale," said Robert
Withycombe.
"The puzzle will be to find one, I tell him," laughed Melinda "I know a
likely girl all the same, and so does Mr. Stockman, Bob."
Joe guessed to whom she referred, and it showed him that Melinda
knew nothing of the threatened tragedy.
"I reckon you mean Orphan Dinah," he said. "Well and why not? A very
sensible young woman. The man that gets her will be lucky."
"They'd be a proper pair and I hope Bob will think well of her. But he
must be warned that she's already changed her mind in one quarter."
"That's not against her," replied Joe. "That shows strength of character
and she had every right to do so. I only hope I know another woman who'll
be wise enough to change her mind."
Before this veiled attack, Melinda was silent and Robert spoke.
"My girl, when she comes along, won't have no time to change her
mind. She've got to marry me and be quick about it. Then us must find a
little house to Southampton, or else Plymouth."
"Come and welcome," promised Robert, while his sister wondered what
might be behind this invitation. They parted; the trap with the sailor and his
kit-bag rolled down the hill and Joe proceeded home. He was gloomy and
his thoughts concerned themselves with Melinda, but not hopefully. All had
changed with her refusal. Even if she did, indeed, find herself in a mood to
accept him on another invitation, it would never be the same to Mr.
Stockman. He did not care for her enough to let any future 'yes' make him
forget the grave rebuff already suffered. Indeed he did not very much want
her now. Like a skeleton between them must ever persist the recollection of
her refusal. He only realised the attractive features of the old arrangement at
the moment when it was about to end, and he still smouldered with intense
heat when he reflected on his daughter's marriage. In the light of this
evening's revelation he was disposed to add another sin to those upon the
head of Lawrence Maynard. It occurred to him that the cowman might have
had a hand in Susan's romance and urged Thomas forward upon his hateful
course. He began to be convinced that Lawrence had inspired Thomas,
possibly for private ends hidden from Joe. He suspected that these men had
made a cat'spaw of him, and since Thomas was certainly not equal to any
such task single-handed, to the subtler Maynard might chief blame be
assigned.
CHAPTER XXXIV
AN OFFER
Now force was ranged against force, and while Dinah and Lawrence
Maynard matured the final details of their exodus, half a dozen men had
become aware of their secret enterprise and were concerned to upset it in
the name of right. Only the manner of doing so offered material for
argument. The situation was reached on the Wednesday night of Joe's
supper party, for when John Bamsey duly arrived to learn the secret, he was
surprised to find Jerry Withycombe and his brother, Robert, also of the
company. Mr. Stockman had so far accepted the inevitable that his friends
might discuss Susan's approaching wedding in his presence, and to-night
Robert Withycombe chaffed Mr. Palk and Susan while he ate. Presently,
indeed, he drank to their united bliss and challenged the rest of the company
to do so. Thomas was gratified and Susan felt much moved to see her father
humbly drink the toast with the rest. Then the diplomatic Joe asked Robert
if he had called at Green Hayes, and what he thought of Jerry's future wife.
"She's a bowerly piece," he said, "and clever as they make 'em. What
the devil she finds in this chap I can't guess; but love's blind no doubt. I
shall see 'em hitched up afore I go."
"'Tis odds he won't find nobody good enough," declared Jerry. "He
fancies himself something cruel, because he's sailed pretty near round the
world."
"There's one good enough for any living man at Green Hayes," asserted
Mr. Stockman. "Have you seen Orphan Dinah, Robert?"
"I have, and I ain't wishful to talk on that subject in public—not yet,"
answered the sailor guardedly.
"He's hit—he's hit!" cried Joe. Then he remembered that Johnny was
present and turned with a great show of innocence to Maynard, who took
his supper with the rest.
"Here's a man that knows Dinah Waycott, and have took a walk or two
with her for that matter. And a very clever man too, and I'm terrible sorry
he's going to leave me. What would you say of Orphan Dinah, Lawrence?"
"Lucky the man who gets her," he answered; "she's one in a thousand."
The talk ranged and John grew more and more impatient to know when
vital matters would be reached; but he perceived that Mr. Stockman could
not speak before the company. After supper Maynard disappeared and then,
when his daughter had cleared away, Joe beckoned John and took him
outside.
"I don't trust my family circle in this matter," he said, "and so we'll light
our pipes and go out. 'Tis a moony night and to walk a mile after supper is a
very good rule, thought I don't practise it. Call them two men. They've got
to know so well as you."
In ten minutes Thomas and Susan had Falcon Farm to themselves, while
Joe, with John and the Withycombe brothers, strolled through a still and
moonlit night.
Then he told them that Lawrence was married, and had run away from
his wife.
"It's all clear enough now. He remembered, no doubt, that he'd told me
his secret, and so he's running this job on the quiet and have doubtless
forged good reasons for Dinah's ear why they should bolt presently, instead
of proclaiming the thing like decent people would. It's because Maynard be
married that he's doing this; and now good chance puts the secret into the
hands of honest men and we must act according. I always leave a rogue to
Providence myself, and never yet found I could do anything better than
what Providence done; but in this case there's a victim, and the victim can
be saved, thank God."
They talked and poured their indignation into the moonlight. Johnny
abounded in drastic suggestions. He desired, above all, to face Maynard
with Dinah, then let her hear the truth and beat the cowman before her. But
one, who as yet knew the least of Dinah, raised a question.
"How if he's told her and she's willing to chance it and don't care?"
asked Robert.
"You little understand the sort she is. She'd die rather than sink to such a
deed. No; he's caught her with a parcel of lies, and he merits a pretty good
punishment no doubt. You might say the loss of her will be punishment
enough; but there's more to it than that I dare say."
"If he's catched and headed off in time, the law can't touch him," said
Robert.
"Then 'tis for us to take the law in our own hands," added Johnny, "and
we will."
"All in good time," he answered. "It's life or death for Dinah, and
therefore we be called to act; but what we shall do and how we shall both
save her and be evens with this rogue will take some planning. Rough
justice must be done I grant. He must have rope enough to hang himself
with, and he must get the surprise of his life presently; but we must be
clever, else we'll spoil all. I've got ideas, but he's a downy chap and nobody
must do anything to make him smell a rat."
"While we're talking and planning," he said, "they may give us the slip
any night and be out of reach and vanished off the earth so far as we're
concerned. And I say this: 'tis time we knowed what was in their letters.
They be keeping apart very clever indeed, so as nobody should link up their
names, though my sister always swore they was up to something; but they
write, and Jane has watched Dinah go up for a letter more'n half a dozen
times; and now it's time we know what's doing, else we'll get left."
They all agreed that to read the secret correspondence was permissible,
for Dinah's sake. Indeed Joe held that this had become a duty.
Robert expressed sorrow for her; but he knew the situation with respect
to John Bamsey and did not, therefore, say much. His own emotions to
Dinah, if any had been yet awakened, cooled rapidly. He had no mind to
seek a maiden so much involved.
They parted presently; but John was going to tell Jane the truth that
night, and impose upon her the task of reading letters when she could, to
gather what definite information of Maynard's plans they might contain.
"I hate for Jane to do anything so mean," declared Jerry, "but I see it did
ought to be done."
"It ain't mean, my son; it's for the sake of justice, and to come between
Dinah and living death," explained Joe.
Then the younger men went their way to Buckland, and John, leaving
the brothers there, started for home. He passed Maynard on the way and
guessed that he had left, or brought, a letter. Much he longed to challenge
him, and fully he intended to play an active part in the future proceedings;
but he hid his secret knowledge, and said 'Good night' and passed down the
hill, while the unsuspecting cowman, who had just posted a letter to Dinah,
responded with friendly voice.
But Maynard did not overtake his master, and hearing Tom's slow voice
droning in the kitchen with thin interjections from Soosie-Toosie, he retired
on returning home.
Indeed matters of some moment for Joe awaited him, for the time
brought his thoughts sharply back to himself. Susan hastened to pour out his
evening drink when he came back, and Thomas, who always rose to his feet
when his master entered the kitchen, now asked if he might be permitted to
say a few words.
"You see things be risen to a crisis," began Tom, "and I feel very much
that the time's ripe for an understanding. It's mournful to keep on like this,
and to-day, by the post, there came a very fine offer of work for me to a
gentleman's farm nigh Exeter. Everything done regardless, and good money
and a cottage. So now's the appointed time to speak, and Susan and me feel
very wishful to pleasure you, and we've come by an idea."
"Go on then. It don't much matter putting your ideas before me, as I'm
not axed to influence them. You'll do as you want to do."
"No," said Thomas; "in reason we want to do your will if it can be done.
You've been very harsh of late, master, and, of course, I can well understand
your feelings about losing Susan. But I never shall see why you was so
cruel rude about it. You may treat people like dirt, if you do it kindly, and
they won't mind; but if you call 'em dirt, then they get a bit restive; and
restive I've got, and so have she. But here it is—an offer in a very friendly
spirit; and we haven't come to it without a lot of thinking and balancing the
bright side against the dark. And, on the whole, for Susan and me it's a
bright thought, and we hope you may think so too."
"But there's one little thing, father," began Susan, and Mr. Palk stopped
her.
"Leave all to me," he said, "I'll set it out. There's several little things for
that matter, and if the master don't see his way, so be it. First, there's what
we be offering, and next there's the conditions to set against it. And we offer
to stop after we'm married and to go on just as usual. As a son-in-law I
know you've got no use for me; but as a hossman, you've been suited. And
as a hossman I'll willingly bide and do all I know regular and steadfast for
the same money as I'm getting now. And I pray God, if that happened, you'd
come to find me a good son-in-law likewise. And that means your darter
bides at your right hand so long as you want her there. And I'll go farther
than that. I'll say if at any time in the next five years you take a wife and
want us away, we'll go."
"I wish it too, with all my heart, father," declared Susan. "I'd be lost
away from you, and worriting all the time to know whose hands you were
got in. And marrying Thomas won't make no difference, except there'll be
two to think about you instead of one."
"I'll give you this credit," he said, "I dare say you mean well."
"And now for the powder. I expect that, even if I was to see my way,
you've got a barrelful of ugly things you'll demand. And I tell you at once
that it just hangs on a razor-edge whether the idea be good enough as it
stands, without any conditions to it at all. I should have conditions also, and
one of them would be that you undertook to stop and not change your
minds after a year, or bolt off and leave me at your own will."
"Don't say 'no' without thinking over it and giving us the benefit of your
wisdom, dear father," pleaded Soosie-Toosie, her large eyes fixed upon him.
"I never say 'no' to anything, without thinking it over, Susan. 'Tis all the
other way, and I'm prone to give people the benefit of the doubt too often.
I'll turn this over. You've put the case very clear. We shall see. I'm one for
the long view, as you know. I'll look all round it."
CHAPTER XXXV
And then, two days before the wedding, he received certain secret
information concerning the matter of Lawrence Maynard. He expected it,
for during the same week Maynard had specified a date for leaving.
Then came the vital news from Jane, who dipped into the secret letter-
box from time to time and skimmed the lover's letters to glean facts. These
she had now learned, and they embraced the time of departure and details
concerning it.
Thus Jane and John, with the Withycombe brothers and Mr. Stockman,
heard what was planned, and the younger conspirators now waited for Joe
to determine what actions should be taken. For him zest had already
dwindled out of the adventure. He had secured a new cowman and the
maid-of-all-work was skilled in the dairy; therefore Joe felt satisfied, so far
as his own comfort and welfare were concerned. But there remained Dinah
to be saved, and various courses of action offered themselves, the simplest
being to make all publicly known at once.
Joe, however, decided to take another party into the secret before any
final action, and he was inspired to do so by the visit of Arthur Chaffe, who
arrived at this time, to look into the matter of the dry rot in the stables.
"I wish one old leaf would fall," answered the carpenter. "It's among the
saddest things I've known that Ben Bamsey lives on—a poor spectrum and
shadow of his former self. A very harrowing thing for all concerned, and
I've prayed on my knees daily, for a month now, that it may please God to
take him. What a man prays for will show you the measure of his wits, Joe,
and the nature of his character; and for my part I've always made it a habit
to pray for others more than for myself, and found it a very good rule."
"No doubt, no doubt, Arthur. But most people have looked upon Ben as
dead ever since last spring. There's only the outer case of the man left: the
works be gone. And a good thing here and there. He's took from some
shocks and surprises. Run your eye over this job and see what's to be done,
then I'll have a tell with you about something else that calls for a lot of brain
power. Right must be done in a certain quarter; but the question is how best
to do it."
Chaffe proceeded, and when he had settled the matter of the dry rot, he
spoke of the approaching wedding and declared his immense satisfaction
that Soosie-Toosie would stop with her father.
"It's like your good sense, and there's no doubt at all you've done a wise
thing. And Thomas Palk's mind be opening out very well I find. He's a very
good man and, in your hands, though old for a learner, can't fail to enlarge.
In fact I'm very glad about it, and so's everybody. You'd have missed her, of
course, and she'd have felt a lost creature away from you."
"So I believe, and so I acted," answered Joe; "and now list to me,
Arthur, and face a very critical affair. 'Tis understood you don't mention it
again to a living soul for the minute; but I'll ask you to give it your full
attention. I'll tell you now, and after a bit of dinner, which you'll take with
me, please, you can say what you think about it."
"If a soul's the matter, you must speak and I must hear," answered the
old man; and then he listened to the story, from the moment of Maynard's
arrival at Falcon Farm up to the present and the secret flight, planned to
take place within ten days.
"Maynard goes from me," concluded Joe, "and the next morning he
meets Orphan Dinah at Shepherd's Cross, on Holne Moor. From there they
get down to the in-country, take train for Plymouth, at Brent I expect, and
sail that night, or the next day, to Australia. A very simple and easy plan if
it wasn't interfered with; but of course it ain't going to happen, and the
question is how best to stop it in a righteous and seemly fashion."
"Who can say he's ever fathomed man or woman?" he asked. "This
throws a light into darkness, Joe, and shows me many things that have
troubled me. Not about Dinah, for she's above board and a good Christian
by nature and upbringing; but about Maynard. He's foxed her into this dark
and dangerous deed, and I'll be bold to say the blame's on his shoulders
only, though nothing ought to have made her agree to run away
unbeknownst from her friends. That shows a lightness; but no doubt the
man have made her love him, and love blinds the best. There's a lot to thank
God for, however. You can see Providence looking far ahead as usual. For if
Maynard hadn't confided the truth to you years ago, we should never have
known, and he'd have brazened it out and committed bigamy in our midst
no doubt."
"He would—the rascal; and I feel his crime did ought to be punished,
whether it succeeds or not. He's tried to do a blackguard act, and it is for us
just men to make him feel his proper reward and chasten the wretch—if
only for his future salvation. But seeing that I've fallen out with him already
in a manner of speaking, when he gave notice, I'm in the position where it
wouldn't become me to smite him, because people would say it was
revenge. And so I put it to you, who stand for nothing but the cause of
religion and justice."
Mr. Chaffe nodded.
"No," said Mr. Stockman. "In my view that would be paltry. We've got
to keep the man and woman apart and read him a sharp and bitter lesson.
That's well in our power without going to the police. They couldn't lock him
up if he hadn't done the crime, so it's for us to make justice on the spot and
fall on the man like the trump of doom, just when he thinks he's triumphed.
That's how I see it. And we don't give him no long drawn out punishment,
but just crush him, like you'd crush a long-cripple,* and leave him to his
bad conscience. And as for Dinah, when she finds out the size of her danger
and sees the brink she was standing on, she'll soon forget her troubles, in
thankfulness to God for her great escape."
* "Long-cripple"—viper.
"It calls for a fine touch," declared Arthur. "There's no doubt our duty
stands before us, Joe, and, at a first glance, I'm minded to see with you, that
this feat is within our power and we needn't call for no outside aid. The
thing is to know just how to strike. Your idea of falling on the man like the
crack of doom be good on the whole. But we mustn't overdo it, or forget
we're sinful creatures ourselves. He's got a fearful punishment afore him in
any case, apart from what we may do, because he loses Dinah just at the
very moment when he thinks he's got her safe for evermore. And that's
enough to go on with for him. But the right thought will certainly come to
my mind, since we be acting in the name of religion."
"I'm all for mercy as a rule," answered Stockman; "but not in this case.
Mercy's barred out, because of Maynard's wickedness."
"There don't seem no very loud call for mercy certainly, when you think
of the far-reaching thing he's led the poor girl into. No; we may stop at
justice I reckon. I'll brood upon it, Joe. I see the line, I believe; but I'll take
it afore my Maker. We want a bit of physical force—we may even have to
handle him, as I see it."
"Yes. For the sake of argument, would John Bamsey and the
Withycombe brothers be strong enough to withstand him?"
"If they surprised the man, they would. Robert Withycombe's a huge,
strong chap. What be in your mind?"
"Wait till it takes a clearer shape. Put by the thought till after the
wedding. That must be all happiness and joy; and when that's well over and
the happy pair are away, we'll turn to Maynard. We must come to it with
clean hands, Joe, as humble, willing tools of Providence. Us mustn't allow
ourselves no evil hate, or anything like that, but just feel but for the grace of
God us might have been tempted and fallen into the pit ourselves. There's a
bright side, even for him, and I hope in time he'll live to see what we saved
him from."
"We must have a masterpiece of cleverness, and I'll think too," added
Mr. Stockman. "Don't squeak, Arthur; don't tell a living soul about it. We
must just teel a trap for the beggar and catch him alive. And we must spare
Dinah all we can."
"As to Dinah," answered Mr. Chaffe, "if what I see rising up in my mind
be the right course, we may have to give Dinah a pinch also. I quite agree
she must be spared all shame if possible; but I always go the way I'm led by
the still small voice, Joe; and if the ideas creeping in me blaze out and
command to be followed, then very like Dinah may have to be in it—for her
own good. You must remember that Dinah's only a part of human nature,
and we can read her feelings very clear when this bursts upon her."
"How can we?" asked Joe. "I never can read any woman's feelings very
clear at any time. They never feel about anything same as we do, and their
very eyes ban't built to look at the shape and colour of things as ours be.
They're a different creation in fact, and 'tis folly to pretend they ain't."
"A different creation, no," answered Arthur. "They feel and suffer same
as us, and Dinah Waycott, afore this great downfall, will take the ordinary
course of human nature. Her Christianity will help her to keep a tight hand
on herself; but, being a woman, she'll want to give Lawrence Maynard a bit
of her mind, and he'll deserve it and didn't ought to be spared it."
"By God, that's true," he said. "And I'm rather glad you thought of it and
not me, Arthur. For if I'd hit on that, people would without doubt have said
'twas the poison of revenge working in me. But coming from you, of course
it can be no more than justice. It's just a thing a bachelor might have hit
upon. The average married man would have felt a twinge of mercy, and
only your high sense of justice would screw you up to such a pitch."
"In fact, mercy would be weakness and false kindness," admitted Joe.
"And if we want a couple more strong men presently, I know the proper
ones. We must all be ministers of right in this matter, and I'm glad of your
clear head and high opinions. For now I know we shall come through with
credit to ourselves and the respect of the people."
"There again, we must take care our feet don't slip," answered Mr.
Chaffe. "It may hap that this ain't a case for the people. As a lesson and