The therapeutic relationship in child health care is typically triadic, involving the health professionals, the young patient and his/her parents or legal representative. 

Meaningful child participation in health care decision-making involves doing away with practices based on the assumptions that a parent or doctor automatically “knows best” (based on age, life experience and professional expertise). It requires for a shift towards a shared decision-making model which respects 1) the views and the emerging capacity of the child patient, 2) the parental authority and 3) the knowledge and the expertise of the health care professionals.  Under this new paradigm, adults and children work together to reach decisions. 

As emphasised throughout the Guide, a good decision must take account of, consider and balance what the child wants, what is needed to secure the child’s health and wellbeing (including their survival, healthy life and development), what the other stakeholders (parents and health professionals) want and what is genuinely in the best interests of each child.

 From theory to practice

While it is increasingly recognized that child participation is desirable, that children can understand and act competently and that direct communication between health professional and child yields benefits, in practice, adults still often tend not to involve (or to disregard) children in decisions regarding their health.

It has been observed, for example, that in paediatric consultations, the health care professional will often involve children by asking them questions, in view of obtaining information, but will then turn to the parent(s) when providing explanations about a diagnosis and children are unlikely to participate in other parts of the discussion, such as treatment planning and discussion, and this regardless of the child’s age.  Moreover, if a health professional is talking with a child and a parent interrupts, the consultation is likely to revert to an adult–adult conversation. As a result, adults often dominate and control these consultations.  

Professionals sometimes justify this by invoking factors such as a lack of time or bad organization or other. It may however also point to other reasons, such as a difficulty to share decision-making power, not knowing the patient well enough, wanting to protect the child or a lack of adapted communication skills.  

A lot can still be done, from the part of health care professionals, to ensure that children are enabled to participate meaningfully and actively in decisions regarding their health. Health professionals of all levels need to receive regular training and supervision, about how to support children’s (and their families’) individual participation needs, capacities, preferences, and expectations, and to help them better respond to those needs and develop their communication skills for children of all ages and all developmental stages. The next section looks at how health professionals can support child participation throughout the decision-making process.