Communication in Pediatric Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

ABSTRACT

Communication is central to pediatric care. Conversation analytic (CA) studies of recorded naturally occurring pediatric interactions contribute distinctive understandings; however, to date there has been no detailed review of CA’s unique contributions. We searched Medline, PsychINFO, Sciencedirect, Google Scholar, and the EM/CA Wiki database, identifying 74 empirical articles across diverse areas of pediatrics. Our state-of-the-art review highlights CA of clinician and caregiver conversations about a child patient, in addition to those involving the child. The findings have the potential to enhance clinical practice by illuminating how healthcare tasks are practically accomplished and enrich our knowledge of children’s participation in consultations by revealing the mechanisms that constrain and enable their involvement. We call for better synthesis of findings with broader CA literature (e.g., nonclinical child interactions, adult triadic clinical encounters, and fundamental knowledge of social interaction). We appeal for increased support for scholarly work in non-Western settings, and emphasize scope for applied initiatives. The data reported are in multiple languages.

Overview and background

Communication skills in pediatrics are a core clinical competency. Central to delivering essential clinical tasks and enabling/constraining children’s contributions, communication practices have been the focus of a substantial body of research. Our focus is a growing subset of that research: close and rigorous conversation analysis (CA) of recorded naturally occurring pediatric encounters, considered here as a coherent body of work for the first time. This review summarizes key contributions CA has made to the understanding of pediatric healthcare, to broader knowledge of the organization of social interaction, and in helping to identify areas for future research. We begin with a broad overview of non-CA research into pediatric communication and then specify the unique contribution that CA provides.

The importance of communication in pediatrics

In the service of managing the health, development, and wellbeing of infants, children, and young people, communication is key to accomplishing clinical tasks, achieving positive clinical outcomes, and optimizing patient wellbeing (De Winter et al., 1999). Consequently, it has been subject to interrogation via a range of methodological approaches. Studies seeking patient, caregiver, and clinician views via self-report methods (e.g., interviews) have generated understandings of the perceived impact of communication, ranging from positive clinical relationships, to improved diagnostic accuracy, with participants offering post hoc descriptions of good clinician communication from effective listening to appropriately tailoring information (Dryden & Greenshields, 2020). Absent from this literature is detailed examination of the actual encounters themselves in situ, to enhance our understanding of communicative practices and how they are deployed to accomplish clinical tasks.

The triadic dynamic is a hallmark of such pediatric encounters, and the associated tensions are well recognized (e.g., De Clercq et al., 2017). Clinicians, caregivers, and child patients each have their own rights and responsibilities, which can sometimes conflict. As representatives of the institution, clinicians deliver care, expertise, and access to treatments and services within the constraints of time and shared decision-making priorities, and with a duty to protect the best interests of the child (Coughlin, 2018). Caregivers act as surrogate and legal decision makers for child patients who, depending on jurisdiction, are generally not able to independently exercise decisional capacity before 18 years of age. Caregivers may report about the child’s medical history and symptomatology, and administer drug treatments and/or therapies. In cases of long-term illness, they may become highly expert in their child’s condition. Surrogate decision making tends to be relatively more straightforward in early childhood, when communication is necessarily dyadic due to the infant’s/child’s limited capacity. However, discussions and decision making can become progressively more complex as a child’s competence is increasingly displayed and recognized (Coughlin, 2018).

One of the most sustained foci of communication research in pediatrics, which does examine actual interactions, is children’s contributions to consultations (Cahill & Papageorgiou, 2007). Quantitative calculations suggest that children’s verbal utterances have consistently occupied 4% to 14% of the total consultation time over the last 50 years, a finding argued to be at odds with increasing recognition of children’s rights enshrined in law through the United Nations Convention on the Rights of the Child (United Nations, 1989; Van Woerden et al., 2023). However, an exclusive focus on verbal utterances is only part of the picture; it renders nonlexical and nonverbal elements of participation invisible, resources crucial in the complex achievement of social interaction (Goodwin & Goodwin, 2005).

The distinct contribution of conversation analysis

CA offers a distinctive contribution to analysing actual social encounters by focusing on how interaction works, revealing how participants do what they do and understand each other. As such, CA is used to systematically describe the complex mechanisms by which crucial clinical tasks are achieved and, simultaneously, the practices by which each member’s contribution and identities are interactionally accomplished. CA is built on the notion that children’s minority status and their agency and competency are intrinsically bound by intergenerational relations, realized in relation to others, especially adults (Brady et al., 2015; Mayall, 2015). The identities and competencies of the clinician, caregiver, and child are not assumed to be intrinsic to each individual but, rather, something that can be facilitated and enabled, or hindered and constrained, through the progress of social interaction (Brady et al., 2015; Hutchby & Moran-Ellis, 1998; Mayall, 2015). Consequently, these studies have the potential to deploy a competency rather than deficit model, identifying how each speaker operates as a skilled interactant.

Building on this, CA supports an alternative framework of participation wherein participation is reconceptualized as a socially organized phenomenon. As such, it is dynamically demonstrated, ratified, and managed by both speakers and hearers as they coordinate their behavior to achieve the activities at hand (Goodwin & Goodwin, 2005). CA provides detailed and nuanced descriptions of the verbal and nonverbal resources (such as prosody, volume, and gaze) by which this is accomplished. Despite a growing body of CA work generating crucial insights into the mechanics of pediatric practice, there has been no attempt to summarize what is known and identify priorities for future research. Our review will highlight the complex social organization of pediatric interactions described in CA studies, grouped into two sections.

First, consideration is given to conversations about a child patient who is not participating, because he or she is either not present or not an active participant. These studies describe features of sensitive and sometimes difficult diagnostic and treatment decision-making discussions. They also illuminate how caregivers can be supported to deliver crucial therapeutic and clinical care. Second, consideration is given to interactions between clinicians and caregivers involving the child, describing tangible practices by which children assert or are invited to demonstrate the role of competent child patient (Stivers, 2012). By doing so, we consider the impact of CA on pediatric healthcare practice—particularly the management of social, moral, and technical dilemmas arising within delivery of clinical tasks—and consider the resources through which participants negotiate participation. We also highlight priorities for future research that will deepen understanding of communication in pediatric care with significant repercussions for children’s wellbeing and social identity, for healthcare more broadly, and for the field of CA.

Methodology

For transparency, we are a team of CA scholars who have conducted research on different types of pediatric encounters in the United Kingdom, Australia, and China. Working from this position, we present a narrative summary of CA research on pediatric care that occurs across different settings and languages, but that has been reported in English-language publications. We conducted a systematic search of Medline, PsychINFO, Sciencedirect, Google Scholar, and the EM/CA Wiki database¹ to maximize opportunities to retrieve conversation analytic studies that are not always captured in mainstream searches (Parry & Land, 2013) and to widen the criteria to book chapters. We set parameters from database inception until June 30, 2022, using the search terms “conversation analysis,” “pediatri*,” “paediatr*,” (or “paediatric/pediatric” for Sciencedirect and EM/CA Wiki, where wildcards are not supported), “child,” and “adolescent.” Additionally, we drew on knowledge from the review team, our own collaborations, searched reference lists of included papers, author profiles and publication lists, and contacted authors by e-mail.

Our iterative approach evoked new, narrower searches to expand our collection when we came across studies in novel settings. Two authors (LJ and SE, checked by NW) independently screened titles; abstracts; and, if necessary, full texts (where available) for inclusion. Conflicts were resolved in discussion with all authors. We included research articles and book chapters reporting close CA of recorded naturally occurring interactions (see criteria provided by Parry & Land, 2013; we excluded studies adopting video ethnography). Studies involved patients under 18 years old and/or their families, with clinicians in clinical and community settings for matters relating to their physical health, wellbeing, and development. This includes pediatric primary care, specialist services for palliative care, oncology, pain, allergy, vaccination appointments, health visiting, dentistry, pharmacy, and allied professions (e.g., speech and language therapy). We excluded children’s interactions in mental health settings, a literature base of comparable size to that covered in this review, which is addressed elsewhere (Lamerichs et al., 2019). To maintain homogeneity in search results, we restricted our criteria to post-birth contexts in which the infant/child is the primary patient, excluding studies of prenatal encounters, maternity appointments, and birth, and studies of interaction between healthcare professionals exclusively. Finally, we excluded results in which full texts could not be sourced and graduate theses that lack the elements of quality control embedded in the peer review process.

In total, 63 articles were included, in addition to 10 articles reporting quantitative analysis informed by CA studies included in our review (totaling 73 empirical articles, see Table 1). Data extraction led by LJ and supported by SE and NW identified author and reference details, country, clinical setting, description of participants, amount and nature of data (audio/video; face-to-face/telephone), and allocated theme.

As a first-of-its-kind review of CA in pediatrics, we sought to organize the findings in a manner that reflected the overall scope and diversity of the field across clinical specialties. We grouped studies into two broad themes according to their analytic foci: those that investigate the caregiver’s role in pediatric encounters and the practical problems and dilemmas faced by patients and clinicians, and those that focus on the child patient, offering detailed interactional insights that enhance the conceptual framework of children’s participation. Recognizing the pervasiveness of findings from studies in Western contexts (69/73 articles from the United States/Europe/Australasia, 54 of which are English-speaking countries), resulting at least in part through our English-language focus, we attempted to counter the risk of universally applying findings from Western contexts by intentionally identifying and amplifying literature from non-English speaking countries, particularly non-Western contexts. Our review showcases CA’s contribution to clinical practice and our broader understandings of the organization of social interaction.

Current state-of-the-art

Our review is organized into two main sections. First, we overview CA research highlighting caregiver (e.g., parent or grandparent) involvement in pediatric discussions about a child, focusing on caregiver participation in decision making and treatment delivery. Second, we overview research examining interactions involving a child—that is, studies that investigate the child as a participant in the interaction, illuminating the verbal and nonverbal resources by which adults and children coordinate their behavior in relation to each other, display engagement, and manage participation in pediatric healthcare encounters.

Caregiver involvement in pediatric care

This section focuses on two prominent areas of enquiry related to caregiver involvement: (1) decision making, illustrated with examples from decision making about treatment in pediatric acute primary care visits and life-sustaining treatment in neonatal intensive care; and (2) the delivery of treatment and care, supported by examples from pediatric speech and language support and medication management. We examine conflict and collaboration, how clinical tasks are accomplished, and how institutional identities are produced and resisted within these interactions.

Caregiver participation in decision making

The most sustained area of CA investigation of caregiver involvement relates to prescribing decisions around antibiotic medication in pediatric acute primary care visits, which has received significant attention, given the global public health concerns around antibiotic resistance. This research has demonstrated how caregivers orient to their rights to actively participate in treatment decision making and influence prescribing outcomes. The caregiver influence can be asserted early in the consultation (e.g., during problem presentation, history taking, or diagnosis delivery) or much later (e.g., during treatment negotiation). In the United States, caregivers use alternative practices to present their child’s problem, embodying their different stances. For instance, when presenting their problem with a “symptom only” practice, they display themselves as primarily seeking medical evaluation from physicians; in contrast, when using a “candidate diagnosis” practice, they display themselves as seeking confirmation of the diagnosis and indexing a relevance of a proper course of treatment (most often antibiotics; Stivers, 2002). Fragment 1 provides an example.

Fragment 1:Lake Mead Vacation (Stivers, 2002, pp. 308–309)

The candidate diagnosis, “I was thinking she had like uh sinus infection” (Line 10)—together with other reported recurrent communication practices, such as resistance to viral diagnosis—has been found to increase clinicians’ perception of parental expectations for antibiotics and increase likelihoods of inappropriate prescribing (Mangione-Smith et al., 2003; Stivers et al., 2003). Caregiver stance may take more overt formats during treatment discussions, such as resistance to non-antibiotic treatment recommendations or explicit requests for antibiotics. Similar practices have been observed across various cultural contexts (see Barnes & Woods, 2004; Cabral et al., 2019; Stivers, 2007; Wang, 2020). The following example illustrates an explicit request for antibiotics, which is more frequently used by Chinese caregivers than their counterparts in other contexts.

Fragment 2:Cough, fever (Wang, 2020, p. 3, simplified)

In this case, the child’s test results and symptoms indicate a nonsevere bacterial infection. Although the clinician clearly states that non-antibiotic prescription is sufficient for the patient (Lines 1–2, 4), the grandmother (GM) still makes an explicit request for antibiotic prescriptions (Line 7). Despite it being counter to her original stance, the physician ends up prescribing it. Statistical analyses show that caregivers’ use of overt advocacy for antibiotics increases the likelihood of doctors prescribing them by over nine times (Wang, 2020).

Clinicians may design and deliver certain actions to preempt or counter potential caregiver resistance to a no-problem diagnosis or non-antibiotic treatment recommendations. One communication strategy clinicians in the United States have been documented to deploy is to positively recommend non-antibiotic treatment to (Stivers, 2005). Affirmative formats (such as offering cough medicine containing decongestant for a cold) are most common, and parents are much less likely to resist these proposals within a consultation compared to clinician recommendations against a medication, such as antibiotics.

CA studies on antibiotic treatment recommendations represent a significant proportion of CA studies in pediatrics that have significantly shaped and enhanced broader theoretical understandings of the organization of social interaction, particularly requests, resistance, and decision making (Land et al., 2017); wider debates around matters of agency, knowledge, and decision making (Enfield, 2011); and have important implications for communication-based interventions (see Applications). In this way, CA in pediatrics has described and elucidated general practices that enhance understanding of human interaction. What is striking in our examination of studies of decision making in pediatrics is the absence of focus on children as members of the multiparty interaction in these studies. Even when examples illustrate resistance articulated by the child patient, this is subsumed into overarching claims about parental resistance (Stivers, 2005). There is scope for more focused analytic attention on children’s participation within these discussions.

We now shift our attention to studies of discussions around life-sustaining treatment to illustrate ways in which the child’s role as patient is explicitly oriented to during difficult clinical decisions regarding infants guided by a “best interest” standard (De Clercq et al., 2017;). Shaw et al. (2016) demonstrated how this principle becomes interactionally relevant when doctors justify recommendations about life-sustaining treatment based on the child’s best interest. The following fragment, taken from a conversation that took place in a neonatal intensive care unit in the United Kingdom, provides an example.

Fragment 3:F1R4 (Shaw et al., 2016, p. 1225)

In this fragment, the mother complains about a lack of options for her child’s care (Lines 2–3). In response, the doctor pushes back by contrasting optionality with reference to the child’s best interest (accomplished here with “the right thing for the baby,” Lines 7–9). Such references to a child’s best interest were common when doctors were making strong recommendations rather than providing options about treatment. Caregivers did not usually align with this, instead asking questions that challenged the doctor’s recommendation or formulating challenging turns about the upshot of what doctors have been saying.

References to a child’s best interest were less common when doctors made recommendations by listing and then discussing different options with caregivers. The type of recommendation was not necessarily related to the likelihood of survival, with both strong recommendations and option listing being used when the chance of a child’s survival was poor. When doctors presented options, this typically resulted in strong alignment between the parties (Marlow et al., 2021; Shaw et al., 2016). This is consistent with findings from CA research on health visiting that showed that new mothers were more likely to accept advice from health visitors when it was fitted to their own perspective (Heritage & Sefi, 1992). Other research also has shown that indirect initiation of discussions about future difficult matters creates opportunities for families to consider the future, but without mandating such discussions (Ekberg et al., 2020). CA research in pediatrics thereby contributes to our broader analytic capital across clinical specialties by illuminating practices involved in advice giving, presentation of treatment options, managing joint decision making, and circumventing conflict including high-stakes and incredibly sensitive situations such as end-of-life care.

Conflict between caregivers and clinicians has been documented in CA studies of treatment recommendations for pediatric epilepsy (Stivers & Timmermans, 2020), for children with asthma (Koole et al., 2020), and in discussions about childhood vaccination (e.g., Hofstetter et al., 2017). Notably, the decision-making activities in which conflict and resistance are observed in each of these settings—and the types of subsequent responses documented—differ across these clinical specialties, emphasizing the importance of expanding research across domains of pediatric care. In the next section we consider the domain of treating and managing a child’s condition, and the communicative practices deployed in the service of engaging caregivers in this process.

Caregiver involvement in treating and managing a child’s condition

Although practical aspects of healthcare are usually initiated by clinicians, some or even most healthcare tasks ultimately may be performed by caregivers outside professional settings (Sullivan-Bolyai et al., 2003). Clinicians may therefore seek to equip caregivers with skills they need to perform care activities. In this section we present studies that describe communicative practices through which clinicians achieve this. For example, speech and language therapists guide caregivers’ use of therapeutic practices, so they can reuse these with their children outside formal therapy sessions (Ronkainen et al., 2014). The following fragment, taken from a speech and language therapy session in Finland, provides an example. It involves the father (FAR) leading a therapeutic activity with his child (CHI), under the supervision of the speech language therapist (SLT).

Fragment 4:(Ronkainen et al., 2014, pp. 180–181, simplified)

The father asks his child to name an object. The child’s response, “missa” (“cat,” Line 2), is lexically correct but contains a phonological error. After the child produces the word correctly (Line 9), the therapist provides explicit positive feedback to the father (addressed in Line 11 through gaze and with the pronoun “you”). This type of feedback was found to be common, which reveals both the caregiver and the child can be targets for support in therapy sessions (Ronkainen et al., 2014). This support can be critical to ensure caregivers effectively deliver interventions outside healthcare (Gardner, 2005). There is also evidence that this support can operate in the opposite direction, with caregivers supporting therapists as they attempt to deliver particular components of therapeutic activities (Ekberg et al., 2019).

Unlike the previous section, the studies reviewed here focus on collaboration rather than episodes of conflict. They examine moments when caregivers are being explicitly supported to develop their capacity in therapeutic tasks. Clinicians can also direct talk toward caregivers to evaluate a child’s involvement in an assessment or therapeutic activity (Ekberg et al., 2018). Similar to the practice of “online commentary” prominent in pediatric primary care visits “that describes or evaluates what the physician is seeing, feeling or hearing during the physical examination of the patient” (Heritage & Stivers, 1999, p. 1501), one of the functions of this type of online communication is to briefly address the caregiver with positive evaluations after a child has made a correct response following multiple absent or incorrect responses (e.g., “she’s starting to add that little sound on the end which is good”). By doing so, clinicians actively engage caregivers in the therapeutic process before returning to a child-directed activity. These studies offer positive and teachable practices to support service delivery and have informed subsequent studies in hearing loss settings.

Collaborative interactions between clinicians and caregivers have also been observed in the context of managing children’s medication. Although patients and caregivers can become progressively knowledgeable about medication, particularly with long-term conditions (Pilnick, 1998), lack of confidence can remain. For example, caregivers can report uncertainty about delivering home-based care for children with life-limiting conditions, prompting clinicians to provide reassurance (Sansone et al., 2022). The expertise of patients and caregivers is thus open to continual negotiation and renegotiation in and through their interactions with clinicians in ways that have implications beyond pediatric settings (Pilnick, 1998). As the research shows, caregivers can become increasingly involved in the delivery of care over time (Ronkainen et al., 2014), and CA offers positive and teachable therapeutic and clinical practices to support delivery of services.

Summary

In this section we described research that predominantly focuses on interactions between clinicians and caregivers. There are compelling clinical and scholarly reasons for this analytic focus: Clinical conversations often take place without the child present, or the child, although present, does not demonstrate capacity to participate. These studies revealed important insights into handling clinical tensions and dilemmas and supporting caregivers to deliver care to their children. We also identified ways these studies enhance our understanding of the organization of interaction (such as our knowledge on advice giving and recommending practices). Notably, some studies we discussed do involve children who display capacity to participate, such as in decision-making discussions around antibiotic treatment, or when therapists temporarily suspend interaction with the child to accomplish important clinical tasks with the caregiver. Overall, these studies do not foreground participation as an analytic concept. In the section that follows, we turn our attention to CA studies that adopt this focus, and consider the triadic dynamic produced by child patient, caregiver, and clinician.

Children’s participation in pediatric care

We now turn to studies in which the child is the starting point for enquiry and consider the way CA studies contribute nuanced and detailed characterization of participation beyond exclusively verbal utterances. In the first section, we consider resources by which children’s competence is enabled and constrained, and in the second, we highlight the culturally and contextually bound nature of these findings.

How children’s competence is enabled and constrained

As noted in the overview, studies that calculate the proportion of the consultation occupied by children’s verbal utterances consistently quantify their contributions to pediatric healthcare encounters to be relatively small. In our review, 21 studies expounded on this. We begin with seminal research on practices for inviting children’s participation in Western pediatric care, expanding this by considering the implications of these practices in contexts in which children demonstrate reduced capacity and drawing close attention to the centrality of embodied actions in the management of children’s contributions.

Stivers’s (2001, 2012) analysis of pediatric primary care consultations in the United States identified systematic ways children are selected—or not selected—to present the problem in a pediatric care encounter. She described practices by which clinicians select the caregiver and constrain children’s participation via gaze, gesture, and using the child’s name (e.g., “What’s goin’ on with Mae?”), and cases in which clinicians are ambiguous in their selection (e.g., “What can we do for you today?”). To specifically select the child as next speaker, clinicians may unambiguously refer to him or her by name (e.g., “Okay, Jolyn, what’s up”), or tacitly refer to the child as the person who has something wrong (e.g., “What’s wrong with you?”).

Building on Stivers’s research, Clemente (2008) led a series of studies that exposed the importance of epistemic positioning in how child patient accounts are promoted in outpatient pediatric pain consultations in the United States. As shown in the following fragment, this can be accomplished by prefacing enquiries about symptoms with claims about the child patient’s epistemic status.

Fragment 5:Case 64 on-pain (Clemente et al., 2008, p. 1422)

By asserting, “I think you’re the guy who’s been sufferin’ with th’ headaches” (Lines 4–5), the doctor downgrades her own epistemic access and establishes the child as the primary informant. The caregiver meanwhile is specifically tasked with waiting to provide additional information. This prefaces the doctor’s explicit invitation to the child to present his symptoms (Lines 15–16). Clemente’s work illustrates the interactional nature of knowledge, and the way that assumptions about children’s access to and rights to report on experiences and symptoms are constructed through social relations in healthcare settings.

Importantly, Stivers (2001) showed that, although clinicians most frequently select children to present the problem, caregivers are most likely to respond. The value of CA is in its capacity to illustrate that this finding may not be as controlling as might be assumed. Caregivers in Stivers’s data oriented to children’s right to answer; their responses tended to follow multiple missing child responses and additional prompts by caregivers to encourage a response from the child. Stivers’s analysis demonstrates the mechanisms by which speakership is carefully negotiated interactionally, within which adults orient to children’s rights and capacity to respond.

In addition, children display their competency to control their role as informant about their own healthcare in their management of caregiver assistance. For example, Clemente’s (2009) examination of pediatric outpatient consultations in the United States demonstrated how children solicit corroborations or answers from caregivers and complete the caregiver’s answer to reinforce that they are the primary respondents. In this way, children solicit help to answer questions without losing the opportunity to present their own symptom account (Clemente, 2009).

Relatedly, Jenkins et al. (2020) revealed how in British pediatric allergy consultations, children instigate talk without being invited or selected as a speaker, positioning themselves as legitimate contributors and providing additionally clinically relevant information. For example, in one consultation a child resolves a mystery regarding the ineffectiveness of a second bottle of medicine compared to the first bottle by self-selecting to propose that maybe dad (not present) has reduced the dosage. In addition to demonstrating his capacity to contribute verbally, the child demonstrates his detailed understanding of the talk in progress, and thus, his participation as a hearer, an aspect of participation not captured in analyses that focus on and measure verbal utterances exclusively (Goodwin & Goodwin, 2005).

These fine-grained analyses of children’s participation reveal the complexities of participation as it is negotiated on a moment-by-moment basis. This is particularly valuable as clinical service delivery evolves, demonstrated in studies of video-conferenced pediatric speech and language therapy in Australia, where therapists adapt their practices to engage child and caregiver when play-based manipulation of jointly accessible objects is restricted (Ekberg et al., 2019). CA details how children’s participation is interactionally negotiated and illustrates children’s practices for displaying competence and exerting agency in ways that realize their “right to say what they think should happen when adults are making decisions that affect them and to have their opinions taken into account” (United Nations, 1989).

CA research has also revealed practices for engaging children’s participation in instances in which children may not communicate extensively through verbal conduct, due to their age, language skills, or neurodiversity. Ekberg et al. (2022) examined practices for engaging children during adult talk in Australian pediatric palliative care settings. They explored tag questions directed to children by clinicians and adult family members, following a declarative claim ostensibly in the child’s epistemic domain, such as, “We had a little bump. Didn’t we Cohen.” (Ekberg et al., 2022). Notably, this practice is used both with children who verbally contribute to the conversation and with those who do not demonstrate capacity for verbal communication. Nonetheless, this practice incorporates children into the conversation as active members, positioning them as legitimate parties to the encounter and ratifying their participation even when they are not verbally contributing.

Low communicative competence is also at stake in consultations with patients who are recent migrants to a country. Caronia et al.’s (2020) examination of encounters with unaccompanied minors in the Italian healthcare system illustrated ways doctors facilitate child patients’ active participation via yes/no interrogatives that require minimal responses and embodied gestures indicating the location of an injury or medical intervention. This study builds on research already considered by highlighting intricate and subtle ways clinicians can design their talk to suit individual patients and their circumstances, with particular emphasis on maximizing opportunities for patients to demonstrate competency in participation. This exemplifies the way CA can adopt a competence rather than deficit approach to examining participants’ engagement in consultations.

Nonetheless CA research also highlights how promoting child participation potentially requires more time and effort according to the child’s skills. Solomon et al. (2016) analyzed recordings in the United States involving healthcare professionals, caregivers, and elementary-aged children diagnosed with autism spectrum disorder (ASD), which is associated with socio-communicative and behavioral challenges. Analysis of these interactions identifies difficulties and disruption to progressivity in opening sequences when compared to equivalent interactions with typically developing children.

Fragment 6:Opening 4: Child with ASD (Solomon et al., 2016, p. 383)

The doctor and mother repeat Jacob’s name several times (Lines 24–31) to gain Jacob’s recipiency (Line 32), which facilitates the reciprocal greeting sequence (Lines 34–6). Solomon et al. (2016) showed that sequences that are usually seamless and accomplished without significant delay with typically developing children may be difficult to accomplish with children with ASD and require more interactional work. Although the child is treated as having and clearly displays competency to participate, there are difficulties in achieving the child’s participation (for important broader discussions on disability and inclusivity in clinical settings, see Dooley and Webb, 2024). This challenges the taken-for-granted notion that children can be gradually attributed more interactional competence with age, a matter to which CA could offer a valuable contribution in future research. Solomon et al. (2016) highlighted that children’s participation is one of several, sometimes competing interactional and clinical objectives. As such, CA findings from pediatric settings have potential to more explicitly contribute to the characterization of practices that could serve analysts working on different types of data, and to inform wider debates, for example, on the nature of participation (Goodwin & Goodwin, 2005) in situations in which different levels of competency and epistemic status are enacted.

A significant resource for participation across the research reviewed thus far is nonverbal conduct, in negotiating the distribution of speakers and displaying attentiveness using gaze and tapping (Clemente, 2009; Jenkins et al., 2020; Stivers, 2012), in maximizing intersubjectivity in contexts of limited shared language (Caronia et al., 2020), and in the delivery of therapeutic services (Ekberg et al., 2019). Important and recent work focusing specifically on how embodied touch is deployed in the service of accomplishing clinical procedures reveals parallels between how children’s verbal and embodied participation are managed in consultations. Guo et al. (2020) analyzed pediatric dentistry in mainland China, where manipulation of the body is sometimes necessary to manage the child’s behavior and facilitate certain dental procedures, particularly when the child experiences fear or pain. In the following fragment, the child (Lim) is attending for tooth extraction. She holds her hands over her eyes while the dentist interacts with a colleague regarding the location of a dental drape. She does not have visual access to the dentist preparing to disinfect her mouth; the mother and dentist collaboratively use verbal instruction and touch to prompt Lim to open her mouth:

Fragment 7:#83Lim – video clip 1 (Guo et al., 2020, p. 8)

The mother produces a vocal gesture “aa:” which instructs Lim to open her mouth. This vocal invitation is immediately accompanied by the dentist’s gentle tapping of Lim’s chin, which prompts her to extend her lower jaw downward. Although it is Lim who actually moves her jaw, the action is distributed between multiple actors. Elsewhere in the same consultation, the mother physically takes over the task of opening the child’s mouth. The authors showed that there is a continuum between direct embodied actions in which the adult moves the child’s body, and adults’ physical conduct that communicates that some kind of motion is required in ways that mirror the distinction we draw between interaction about and involving the child. By detailing the social actions that touch performs, Guo et al. (2020) emphasize the fluctuating nature of agency and the way it is collaboratively constructed by child, caregiver, and clinicians. Importantly, they show how embodied actions relate to participant roles, agency, and relationships; who has rights to manipulate the child’s body; and how institutional clinical goals are accomplished in ways that contribute to broader discussions on multimodal features of interaction.

We have introduced a notion of participation, supported by CA, that enhances quantifications of children’s verbal utterances via illustrations of nonverbal resources deployed by children and adults to display understanding of and participation in the talk in progress. CA studies also provide details of where, when, and how speakers’ verbal contributions are asserted, enabled, and constrained. This shifts the focus from types of participants (and how much they contribute) toward how participants collaboratively accomplish situated activities (Goodwin & Goodwin, 2005). However, as we advocate in the next section, caution is advised when considering the universality of these findings.

Contextualizing child competence and participation

The research on children’s participation reviewed thus far demonstrates how CA studies can identify ways of promoting the involvement of child patients in healthcare. Notwithstanding the strength of these insights, caution should be exercised about the universality of these findings. We have chosen to amplify a relatively standalone study of healthcare interactions beyond Western biomedicine that has received relatively little attention. This comparative analysis of primary care and traditional Mapuche medicine in Southern Chile highlighted the culturally and contextually bound nature of healthcare and the potential for embedded analytic assumptions within Western studies to be accepted as universally relevant by identifying starkly different diagnostic practices that are used with children. Guzmán (2014) demonstrated that clinicians in primary care encounters sought a reason for the consultation from caregivers, establishing a complaint-driven focus organized around the goal of gathering information. In contrast, Mapuche medicine involved the healer as the primary teller in the diagnostic process; rather than elicit symptom accounts, healers verbalized experiences and sensations that the ailing person ostensibly experiences and described the problems affecting the child. This is exemplified in Fragment 9.

Fragment 8:Fernando (Guzmán, 2014, p. 263) (HEAL – healer)

After identifying the patient, the healer tells Fernando to let her feel his pulse. While getting in position to take Fernando’s pulse, the healer asks about the wellbeing of Fernando’s mother (Line 6), who has been consulting the healer for over a year. A long silence follows, during which the healer is recognizably engaged in focused attention on the child’s body. In stark contrast to the typical organization of primary care encounters, no reason for the consultation is solicited from either the child patient or his caregivers; the evidentiary grounds of the healer’s knowledge are established following this focused attention, whereupon she declares that the patient is suffering from depression (Lines 10–11). The studies we examined before assumed that caregivers/children are the source of symptom experience knowledge; they focus on who is selected to present. Guzmán (2014) powerfully demonstrated that these assumptions are culturally bound; yet this is rarely, if ever, noted in Western CA studies. Guzmán’s work provokes CA scholars to critically interrogate the epistemological positions embedded in assumptions around children’s participation, and to resist universalizing and perpetuating Western assumptions and Anglocentric worldviews.

Systematic comparisons have also been made within a single cultural context. Such analysis can reveal exclusionary differences in practices for providing opportunities for children to demonstrate competence, revealing mechanisms through which some children are systemically marginalized in clinical encounters. Extending existing CA understandings of speaker selection practices in the United States in a large quantitative study, Stivers and Majid (2007) showed that Black children and Latino children of low-education caregivers were less likely to be selected to answer questions than their same-aged White peers, irrespective of education. Stivers and Majid’s (2007) work distinctly shows how race and socio-economic status are socially constructed inequitably through interaction via different attributions of competence. In this way, the detailed micro-analysis of interactions characteristic of CA studies inform understandings of how social injustice in healthcare is established and maintained. This study is standalone in its objective of highlighting the pervasive relevance of race in clinical interactions. It is a provocation to leverage tools from CA to deconstruct race and racism in the service of tackling deeply entrenched matters of inequity and marginalization in pediatric settings, and to challenge a White worldview in which race is deemed irrelevant.

Summary

Pediatric healthcare is characterized by a triadic dynamic, in which child patients, caregivers, and clinicians have unique roles to play. This state-of-the-art review has considered CA research that examines how this triadic dynamic is manifested in two ways: one in which interactions are about the child and the other in which interactions involve the child. Research examining moments when children are not involved in interactions about them highlights how this can be due to caregivers’ roles as surrogate decision makers and as people who deliver care outside clinical settings. However, even in these discussions, we see the pervasive relevance of the child as a participant. Research explicitly examining the involvement of children helps us understand how a child’s competence is not fixed to some developmental trajectory, but can be displayed, enabled, or constrained through his or her interaction with caregivers and clinicians. Together, the research reviewed provides insights into how crucial clinical tasks are accomplished in pediatric care, alongside children’s situated and negotiated roles within these interactions.

Applications

The CA research considered in this review addresses matters of central concern to practitioners, such as how to execute certain clinical tasks, manage resistance to diagnoses, facilitate children’s participation, and support caregiver involvement in therapies and treatment decisions. Given this focus, and the concrete descriptions of communication practices resulting from the analysis, CA studies are well placed to inform clinical practice through knowledge translation initiatives such as interventions and guidance. To date, very little is available in the published literature about CA informed interventions in pediatrics. One notable exception draws on the work on antibiotic prescription described above.

Kronman et al. (2020) described a communication-based learning program aiming to reduce outpatient antibiotic prescribing in U.S. primary care. Within a randomized controlled trial, primary care practices received a training program comprising online intervention modules combining a CA-based tutorial on best practice communication strategies with prescribing feedback and webinars on inappropriate antibiotic prescription. The intervention succeeded in achieving a statistically significant reduction in antibiotic prescription. Importantly, this study required cross-disciplinary methodological, logistical, and financial support and commitment.

The findings of other CA studies contribute to pediatric care through informing best practice in relation to involving caregivers in decisions about critically ill patients and caregiver vaccination discussions while also underpinning clinician training, as in resources to support conversations with families of children with life-limiting conditions (e.g., National Institute for Health and Care Research, 2021). These types of application demonstrate the powerful potential of this research and provoke CA scholars to optimize opportunities to make methodological insights and applications available to colleagues and clinicians. However, they also highlight that translating CA findings into practice is unlikely to be a neutral enterprise. Antibiotic research adopts an emic or “insider” approach in which current public health paradigms on antibiotic resistance are treated as incontrovertible and are privileged; as with vaccination discussions, caregiver/child agendas opposing the clinical agenda are not supported.

Issues for reflection

This review identifies, across a range of countries and diverse pediatric specialties, significant CA insights clustering into two themes.

• First, clinician interactions with caregivers about a child patient. These studies describe the accomplishment of institutional tasks such as decision making, treatment recommendations, and involving caregivers in delivering care. They examine challenges and conflicts that arise when decisions are resisted, and how caregivers can be supported to deliver care.

• Second, clinical interactions involving children. A substantial number of studies reveal practices that enable or constrain children’s participation, whereas other studies highlight how children unilaterally initiate and manage their participation. Such discoveries provide a foundation for evidence-based interventions, particularly in difficult decisions surrounding end-of-life care and decisions surrounding antibiotic treatment and vaccination that relate closely to public health debates, with some evidence of how these can change clinical practice.

Here, we offer three reflections that relate to the reviewed studies. The first consideration, not unique to pediatric care, is the challenge of defining “good practice” within CA research. Given that interactional practices for delivering clinical care are culturally bound (Guzmán, 2014), CA scholars face quandaries relating to whether and how certain practices should be privileged over others. Communication scholars necessarily work with institutions, not least for reasons of collaborative access to data and implementation of interventions. Occasionally there may be consensus between clinicians, caregivers, and—uniquely to paediatics—child patients, on which practices should be targeted for intervention, such as the discriminatory and marginalizing practices described by Stivers and Majid (2007). Interventions in antibiotic prescription and vaccine administration raise more complex moral questions around children’s “best-interests,” advocating for population-based health recommendations, and handling localized interactional disagreements. These are conflicting paradigms with which CA scholars must inevitably engage.

A second consideration relates to how CA findings in pediatric care speak to broader CA work in healthcare, and to more fundamental concerns about participation and inclusion. CA in pediatric care provides demonstrable evidence of how children’s involvement is interactionally enacted or constrained, and reinforces the notion that children are not a homogenized and decontextualized group, but are social actors within contexts (Hutchby & Moran-Ellis, 1998; Lamerichs et al., 2019). As such, examining pediatric settings draws on and contributes to broader central concerns about the nature of membership and personhood within and outside of clinical settings, and how identities are constructed via interactional practices. Our review demonstrates how clinician, caregiver, and child patient identities, and their relative competencies and participation rights, are constructed and/or inhibited via interactional practices such as inviting or asserting the problem, proposing and resisting treatments, and supporting involvement in care.

Children’s competence and participation intersect closely with other matters, not least disability (see Dooley and Webb, 2024), race (Stivers & Majid, 2007), and mental health. In studies across these fields, the ex/inclusion children and adults face is constructed in terms of environmental, structural, and social obstacles (Tisdall, 2012). The CA studies we have described reveal the practices that function to accomplish this. We have seen how child patients—specifically, neonatal infants—are treated as incompetent to contribute. They embody the subject of dyadic conversations between caregivers and clinicians. When child patients are older and present, whether and how to include them is more complex. CA shows how children’s verbal and embodied competence as participants in discussions is asserted, facilitated, or inhibited. Adults can treat children who display the most limited capacity as relevant parties and contributors to discussions. However, children’s participation takes time and effort and has implications for accomplishing clinical activities.

Crucially, CA enables us to integrate a fuller understanding of the triadic dynamic with its complex and interactionally negotiated responsibilities and capacities. This existing knowledge is highly relevant to a cumulative body of CA findings on companions in other fields, not least adult contexts of dementia, disorders that involve loss of consciousness, end-of-life care, and communication impairments, in addition to adult–child talk and multiparty talk in mundane settings. However, discussions at these intersectional boundaries are underdeveloped, and we would greatly benefit from the analytic richness generated by better integration of these insights across contexts.

Finally, we draw attention to the potential for CA scholars to contribute to wider debates on ethical research on and with children. Existing networks and discussions around research involving children (ERIC, 2019) showcase a wealth of resources and publications addressing questions relevant to CA research with children. There is scope within CA studies to engage with debates around, and tensions within: recruiting participants and communicating CA to children; consideration of evolving capacity to understand and consent to how data is used as children age; longer-term rights to withdraw; co-design and participatory methods with children; and communicating findings with children. CA scholars can also contribute to discussions on good practice within the specific and growing multidisciplinary field of audio-visual methods with children (Robson, 2011). Greater reflexive discussion, transparency, and publication of the methodological and ethical protocols underpinning CA’s valuable technical and empirical findings could reciprocally enrich debates in both CA and ethical practice.

Future CA of pediatric care

We have seen, through CA research on pediatrics, the value and potency of having detailed understanding of how clinical tasks pertaining to children are accomplished, and how pitfalls and challenges arise and are handled. CA develops understanding of the triadic dynamic characterizing pediatric care conversations about or involving child patients. Ultimately, CA deepens theoretical conceptualizations of childhood; identifies tangible, applicable practices for effective implementation of clinical tasks; and delivers insights to tackle deep-rooted inequity. At the same time, the field is still emerging, with scope for supporting increased scholarly work in non-Western settings, and potential to amalgamate findings with CA studies on children in nonclinical settings and studies of triadic interactions with adult patients. Interactional analysis of clinical encounters concerning child patients holds promise for developing our understanding of human interaction and improving clinical practice.

Acknowledgments

The authors would like to thank scholars in the field for their collegiality in sharing their work with us, not all of which was possible to include within the scope of the article but which nonetheless contributes to the thriving and growing analysis of communication in paediatric care. Thanks also to two anonymous reviewers and the editorial team for insightful comments that improved earlier drafts.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/08351813.2024.2305046.

Notes

¹ http://emcawiki.net/EMCA_bibliography_database.