The participation roles of children and adolescents in the dietary counseling of diabetics

https://doi.org/10.1016/j.pec.2003.04.008Get rights and content

Abstract

This paper analyses the production and reception roles of 7- to 9-year-old children and 13- to 15-year-old adolescents in two-party, three-party and multi-party encounters in the dietary counseling of diabetics. In the two-party encounters, the adolescents had an active patient role, even though their engagement withered if they had to go through a long examination or if they were asked about a ‘delicate issue’. In the three-party encounters, despite their good interactional competence, they often turned into withdrawn bystanders when the parent spoke on their behalf, complemented or corrected their talk. The 7- to 9-year-old children were mostly silent and the mother spoke for them. However, they were ready to answer the questions that were clearly addressed to them. Furthermore, they had their own interaction patterns. Firstly, even when absorbed in their play, they sharply intervened in the adults’ talk in order to correct an inaccurate detail. Secondly, they participated in the interaction in their playing. In the multi-party encounters with four or five participants, the more adult participants there were, the more marginalised role the child patient had.

Introduction

Dingwall and Murray, in 1983, called for ‘taking children seriously’ in research on health and illness [1]. They pointed out that children formed a significant part of the British health-care services’ clientele, but were mostly invisible in research. In their study on the categorization of patients in accident departments they maintained that children formed a patient category of their own. Children seemed constantly to break the conduct rules of ‘good’ patients.

The authors referred to Jefferys earlier study [2] in which he had argued that the medical staff in emergency departments classified patients in two broad categories. The first one comprised ‘good’ or interesting patients, those who allowed the medical staff to practice their chosen speciality, and furthermore, tested their general competence and maturity. The second category comprised so-called ‘bad’ patients, mostly of four kinds: trivia, drunks, overdoses and tramps. These patients could be considered, at least partly, responsible for their own condition or illness. They did not necessarily see their illness as an undesirable state, neither did they co-operate in trying to get better. Dingwall and Murray [1] pointed out that children did not fit into these two categories of good and bad patients. They formed a patient category of their own. They seemed constantly to break the conduct rules of ‘good’ patients. The vast majority of their injuries were caused by their own courses of action. Many of the injuries that brought them to the accident department did not actually require emergency treatment, but their trivial nature was not commented upon. The children's verbal and nonverbal reactions were not necessarily proportionate to their injuries. The most obvious feature was, however, that the children were often unco-operative in health-care encounters: they frequently protested about, refused or even rejected examination and treatment. Despite this rule-breaking conduct, both the children and their parents were treated in a sympathetic, or at least courteous manner.

Dingwall and Murray explained this deviant conduct in terms of the children's social status. They were described as pre-theoretic actors in the world of health care. Children might be aware of the social setting, but did not yet act according to the adult patient role. The line between pre-theoretic and theoretic status was drawn according to the child's age. As patients, adolescents were not only dealing with the transition from childhood to adulthood, they were also required to adopt the adult patient role.

Strong had pointed to the children's particular participation status in health care in his work on pediatric consultations from the 1970s [3]. In fact, he claimed that children's non-participation in interaction was an essential feature of these encounters. The vast majority of the encounters studied were three-party encounters between the doctor, the mother and the child. In nearly all of them, the adult representative acted and spoke on the child's behalf, and took over most of the patient role. The doctor also addressed his or her talk to the mother instead of the child. The child was systematically excluded from the interaction and given the role of a bystander or overhearer [4] in his or her own medical consultation.

According to Strong, older children were caught in an interactional dilemma. Defined as children, they were labeled as incompetent, and were therefore, accompanied by an adult representative who spoke for them. However, as older children they were expected to know how to behave in a medical consultation. The older children had learned the minimal encounter rules required of subordinate participants in a medical consultation, such as the greeting at the beginning and end of the encounter and to look as if they were ready to participate if called upon to do so [3].

Silverman's studies from the 1980s gave a distinctive picture of health-care interaction with adolescent patients [5], [6]. He studied adolescents with a chronic condition, such as diabetic or cleft-palate teenagers. According to him, chronically ill adolescents’ active participation in interaction was encouraged by the professional participants, whereas the parent's participation was restricted. In practice, the consultations with adolescents were preferably arranged without the parents being present.

Silverman emphasized that the medical staff encouraged these adolescents to take part in the decision making and to take full responsibility for their treatment. Correspondingly, their competence was thoroughly tested. Thus, their identity as autonomous and responsible patients was established in and through the interaction with health-care professionals. Nevertheless, Silverman pointed out that both the teenagers’ and their parents’ status remained somewhat problematic. The dilemma arose in the process of establishing a proper balance between the adolescent patients’ responsibility for their own condition and their parents’ acting as ‘responsible’ parents while respecting their child's autonomy [6].

Children and adolescents still form a significant part of health-care clientele. Furthermore, longitudinal studies on children's interaction in health care have suggested that their conversational contribution to medical consultations has increased significantly over the years [7], [8], [9]. Child patients today give more medical information, take more initiatives and interfere in adult interaction more often than in the 1970s. This observation challenges future researchers on health-care interaction to focus on the way in which health-care professionals talk with children rather than to them [10], and furthermore, on the children's and adolescents’ own ways of interacting in health-care encounters.

This study focuses on interaction in a specific area in health care, the dietary counseling of children and adolescents with diabetes. The paper analyses the production and reception roles of diabetic children, and adolescents and their own ways of interacting in two-party, three-party and multi-party dietary-counseling encounters.

Public health-care dietary counseling in Finland is limited to patients with complex dietary problems. The most homogenous patient group, consulting dieticians in out-patient clinics consists of children and adolescents with Type 1 diabetes, a chronic disease, which has no cure. After its onset, it requires life-long maintenance and self-management that includes insulin injections, dietary management, and blood-glucose monitoring. Children and adolescents with diabetes all see dieticians on a regular basis as part of their treatment regimen. The dietary-encounters take from 30 to 70 min.

Diabetic children form a challenging patient group in Finnish health care, since their comprehensive care requires substantial resources. Furthermore, the incidence of Type 1 diabetes mellitus in children aged under 15 in Finland has been the highest in the world in recent decades and has even shown an increasing trend [11], [12], [13], [14].

Up until recently, interaction in dietary counseling has been an unstudied area [15], [16], [17]. The main professional tasks involved include the assessment of the patient's eating pattern, the negotiation of possible changes in it, the establishment of a dietary plan, and information and advice delivery. The background of the five dieticians under study reflects the education level of Finnish dieticians working in clinics, which is high by international standards. They all had a university degree in nutrition, and were authorised nutritionists. They are, nevertheless, called dieticians (in American English dietitians) in this report according to the terminology used in international literature [15], [16], [18].

The dieticians working with diabetic children and adolescents are part of a pediatric treatment team consisting of a pediatrician, a nurse specialized in diabetic care, a dietician, and often also a social worker and a psychologist or psychiatrist. As a general rule, the diabetic children and adolescents are invited to a dietary counseling meeting once a year. When special problems concerning their dietary management arise in their other health-care encounters they are referred to the dietician more frequently.

The overall structural organization of the counseling encounter was consistent in the encounters of all five dieticians participating in the study. The activities identified in this dietary counseling were: opening, definition of the problems, dietary recall, descriptive sequences, information delivery, negotiating dietary change, and closing. Dietary recall was the basic and the most specialized activity. The consecutive organization of the interactional activities in the encounter was flexible [17].

The general aim of this study was to provide an empirical analysis of interaction in the professional dietary counseling of diabetic children and adolescents in Finland. The data were collected in dietary counseling encounters with 7- to 9-year-old children and 13- to 15-year-old adolescents. The study examined the specific features of health-care interaction with children and adolescents. On the basis of these general aims, the following research questions were formulated:

  • (1)

    Who participated in the dietary counseling encounters with diabetic children and adolescents?

  • (2)

    How did the production and reception roles of the children and adolescents differ in the two-party, three-party and multi-party encounters?

  • (3)

    What were the children's and adolescents’ own ways of participating in the interaction in their own dietary counseling?

Section snippets

Data collection

The research data for this study consist of 57 audio-taped dietary counseling encounters. The recordings were made simultaneously at the pediatric out-patient clinics of five public hospitals in different regions of Finland. When the data collection started, all the diabetic children and adolescents belonging to the defined target groups who came for a normal follow-up dietary-counseling encounter in these five clinics were asked to participate in the research.

According to the original research

The participants in the encounters

The counseling encounters with adolescent diabetics were expected to be examples of two-party encounters between the dietician and the adolescent, and those with school starters to offer a contrast involving three-party encounters between the dietician, the child diabetic and the mother. It was soon discovered that two-party encounters were relatively rare, and the range of participants was much wider than expected. There were, however, two basic combinations of participants in the data: (1)

Discussion and conclusion

This research focused on the interaction in two-party, three-party and multi-party encounters in the dietary counseling of children and adolescents with diabetes, and emphasized the children's and adolescents’ production and reception roles and their own ways of participating in the interaction. The encounters ranged from two-party encounters between the dietician and an adolescent to five-party encounters between the dietician, the diabetic child, the mother and two siblings. The unexpected

Acknowledgements

I wish to express my gratitude to Professor Emeritus Jaakko Perheentupa, Professor Yrjö Engeström, Professor Anssi Peräkylä, Professor Eero Lahelma, Professor Anne Murcott and the late Doctor Philip Strong for their valuable comments during the different stages of my research project on interaction in the dietary counselling of diabetic children and adolescents. I would also like to thank Milla Kajanne for her indispensable help in transcribing the large amount of data. This research project

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