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I see no more than you, but I have trained myself to notice what I see.”

– Sir Arthur Conan Doyle1

Medical encounters can be frightening for children, who, when afraid, may resist cooperating, inhibiting assessment and treatment. When trust is established, children cooperate, making it easier to obtain accurate and complete diagnostic information and perform a physical examination or procedure. Understanding and effectively managing a child’s emotional state during medical encounters are essential to building trust, eliciting cooperation, and creating a positive experience for the child and their family.2–5 While negative medical experiences can be emotionally traumatic for children, leading to apprehension of medical treatment and personnel,6–15 positive medical experiences favorably influence future medical encounters for children and their families.16–20

This chapter defines and examines the elements of establishing trust with children and describes a methodology for managing a child’s emotional state during medical encounters.


This methodology involves a cyclical practice of observation, assessment, and engagement based on perceiving, accurately interpreting, and appropriately responding to a child’s verbal and nonverbal cues. This process facilitates management of the child’s emotional state and formation of trust.2,3 Here, clinical observation is used to gather, analyze, and interpret data from the child’s cues, leading to assessment of their emotional state and positioning on the Fear-to-Trust Axis (Fig. 8-1).21 The provider then employs a set of engagement methods to alleviate fear and establish trust, while continuously observing and adapting to the child’s responses (Fig. 8-2). This process is not formulaic; it is iterative, individualized, and—importantly—inductive. Verbal and nonverbal data from the provider–child–parent interaction are used to inform and guide the interaction toward trust. Formulaic approaches inconsistently engage children and establish trust because they employ the same methods irrespective of the child’s cues (e.g., blowing bubbles to engage every 2-year-old).


Observing and assessing.


Engaging and monitoring.

This methodology parallels how we might approach a dog, something we all know how to do intuitively. We would not approach a dog without assessing its “emotional state,” for fear of being bitten or attacked. Our approach might follow a specific methodology:

  1. We observe the dog’s initial cues and response to our presence, noting facial expressions (is the dog baring its teeth? Are its ears tense and elevated or relaxed?) and posture and gestures (is its fur standing on end or flat? Is its tail wagging? Is it growling?).

  2. We might begin interacting with the dog from a distance, adjusting our posture, gestures, and eye contact so as not to startle or threaten it.

  3. We may use distinct speech, as if talking to a child, which contains ...

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