Shared decision-making and assent in children

Overview & Definition

A parent brings you a decision, not just a child. Should we start the stimulant? Should we do the scan? Do we switch to the biologic? Each of these is a fork in the road where evidence, fear, family circumstance and the child's own view must meet. Shared decision-making is the deliberate process of bringing those things together so that the choice fits the person in front of you. [4]

The trap in paediatrics is that you can run a perfectly warm conversation with the parents and forget that there is a small person in the room whose body this is. That child usually cannot give legally binding consent, but they can give assent — a developmentally appropriate affirmative agreement — and they can refuse. The American Academy of Pediatrics Committee on Bioethics frames assent and parental permission as two distinct goods that should both be sought when the child can take part. [1] [2]

In practice the job is to name the decision, share the options honestly, elicit what the family and child actually care about, and land on a choice you write down and revisit. SDM is clinical skill, and like any skill it has a structure you can defend in an exam. [4] [3]

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1. [1]COMMITTEE ON BIOETHICS Informed Consent in Decision-Making in Pediatric Practice. Pediatrics, 2016.PMID 27456514
2. [2]Katz AL Informed Consent in Decision-Making in Pediatric Practice. Pediatrics, 2016.PMID 27456510
3. [3]Levetown M Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics, 2008.PMID 18450887
4. [4]Wyatt KD, List B, Brinkman WB, Prutsky Lopez G, Asi N, Erwin P, Wang Z, Domecq Garces JP, Montori VM, LeBlanc A Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis. Academic pediatrics, 2015.PMID 25983006
5. [5]Dodds CM, Britto MT, Denson LA, Lovell DJ, Saeed S, Lipstein EA Physicians' Perceptions of Shared Decision Making in Chronic Disease and Its Barriers and Facilitators. The Journal of pediatrics, 2016.PMID 26817588
6. [6]Coyne I, O'Mathúna DP, Gibson F, et al. Interventions for promoting participation in shared decision-making for children with cancer. Cochrane Database of Systematic Reviews, 2016.PMID 27898175
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9. [9]Hess EP, Homme JL, Kharbanda AB, Tzimenatos L Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head Trauma: A Cluster Randomized Trial. JAMA network open, 2018.PMID 30646167
10. [10]Quaye AA, Coyne I, Söderbäck M, et al. Children's active participation in decision-making processes during hospitalisation: An observational study. Journal of clinical nursing, 2019.PMID 31430412
11. [11]Skains RM, Kuppermann N, Homme JL, Kharbanda AB What is the effect of a decision aid in potentially vulnerable parents? Insights from the head CT choice randomized trial. Health expectations, 2020.PMID 31758633
12. [12]Giambra BK, Haas SM, Britto MT, Lipstein EA Exploration of Parent-Provider Communication During Clinic Visits for Children With Chronic Conditions. Journal of pediatric health care, 2018.PMID 28866436