Approaching the Adolescent

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chapter 17 Approaching the Adolescent

Alexa L. Bagnell

It’s now or never

’Cause I ain’t gonna live forever

I just wanna live while I’m alive.

Adolescence is a time of many changes: physical, emotional, social, and cognitive. Each time they look in the mirror, adolescents see someone different. For most teenagers, these are exciting years, filled with new activities and responsibilities, and most enjoy the experience. They experiment, take more risks, engage in romantic relationships, and begin to display autonomy and independence from their parents, spending progressively more time with their peers. For some, this evolution can lead to difficulties. Many report significant stress and pressure. Therefore, learning to manage stress becomes a very important life skill. For any teen, the goal should be to develop into a physically and psychologically healthy young adult, who takes charge of his or her own health care.

Interviewing adolescents calls for a different approach from that used for younger children and their parents. To begin taking responsibility for their own health, adolescents need to meet privately with their doctor (without the presence of their parents or caregivers) to discuss personal health issues. This is an important sign of respect for the adolescent’s individuality and for the confidentiality of the doctor-patient relationship. (See Key Point, page 260.)

Brain Development

The frontal lobe, required for decision making, planning, emotion, and impulse control, is poorly developed in children and youth. Between ages 12 and 24 years, the brain’s synaptic system undergoes significant pruning of neural connections in the frontal lobes. The predominant theory of brain development in teens is “Use it or lose it.” Their experiences during this time determine which connections remain and which die off by adulthood.

Risk taking is a normal element of teen development. Teens are exposed to many more risk-taking models and opportunities than in the past (e.g., Internet, substances, media). This vulnerable stage of brain development, coupled with underdeveloped powers of decision making and impulse control, leads to a higher risk of poorer health outcomes in adolescents.

Puberty

Boys generally experience puberty between ages 10 and 17 years, girls between ages 9 and 14 years. The wide individual variation in the time of the onset and completion of the physical changes of puberty can cause angst for teens who undergo early or late puberty compared with their peers. Early puberty is sometimes advantageous to boys in terms of confidence and physical abilities; however, it can be disadvantageous for both sexes when they are uncomfortable with the changes in their bodies and with being noticeably different from their peers. Early puberty has also been associated with a tendency to join older peer groups and with exposure to higher risk behaviors, such as earlier sexual experiences or experimentation with substance use to “fit in.” Late puberty can also pose challenges with peer relationships and the development of self-confidence.

Body image becomes more significant in puberty and, for some youth, this can lead to unhealthy behaviors, including changes in physical activity and poor eating habits. Screening for health risk behaviors and education concerning good nutrition and regular activity is important for teen health. Puberty is also the stage in which teen sleep patterns begin to change. Youth become “night owls,” often staying up late; this is thought to be related to a change in timing of melatonin release in the brain during puberty. The difficulty for teens is that school starting times generally remain the same, so they often get less sleep during the week and try to catch up on the weekend. Teens should get 9 to 10 hours of sleep per night and, ideally, should stay on the same sleep schedule throughout weekdays and weekends. Good sleep hygiene is an important topic to discuss with teens and their parents because sleep deprivation can affect school, social relationships, physical health, and mental health.

Teen Health

For most adolescents, the teen years are a period of relatively good health, with low morbidity and mortality rates. Yearly check-ups should still be encouraged because it provides you with the opportunity to promote healthy choices and to take steps toward the prevention of illnesses and accidents, including the opportunity to identify at-risk youth. Accidents, suicide, and homicide are the three leading causes of death, accounting for about 75% of deaths in this age group. Whenever you see an adolescent for any problem, you have a golden opportunity to do a brief risk screen and provide appropriate health promotion education. The top two reasons for adolescent visits to teen health centers are for concerns about sexual health and mental health.

Mental illness

Major psychiatric illnesses often begin in adolescence, but many teens do not receive the help they need. About one in five teens will suffer from a psychiatric illness during adolescence. Major depression, schizophrenia, bipolar disorder, social anxiety disorder, panic disorder, eating disorders, and addictions all have their peaks of onset during the teen years. Suicide is the second leading cause of death in this age group in Canada (third in the United States) and is often related to underlying mental illness, such as depression. Stigma continues to be a problem for youth seeking help for psychiatric disorder. Fear, blame and misunderstanding contribute to stigma around mental illness. Many teens do not realize they need help or that effective treatment is available.

Youth should be screened at each visit with routine mental health questions. This can include a brief discussion about the importance of seeking help if symptoms develop, particularly in those who have a family history of mental illness. (See Key Point, page 262, for screening questions.)

Sexual health

Despite plenty of current discussion of sexual health, many youth still lack clear and concise information on which to base their decision making. Many seek information from friends, at school, or from the Internet. Youth may be diffident about approaching their parents and concerned with how they will react. They may also worry that if they ask their doctor, their parents will find out. Almost all youth will be thinking about this issue, and many are already engaged in sexual activity without having accurate health information. Physicians are a trusted source of such information, and every visit provides the opportunity to ask the key questions and provide facts. (See Key Point, page 262, for screening questions.)

Accidents

Accidents are the leading cause of death in adolescents. Most are caused by motor vehicle collisions. Many of these are preventable by the responsible use of motor vehicles (following speed limits, not driving when impaired); safety measures (seat belts, not using cell phones or texting while driving); and understanding the risks of substance use prior to or while driving. Increased risk of motor vehicle accidents has also been documented in adolescents with attention deficit/hyperactivity disorder (ADHD) and teens with insufficient sleep and fatigue, a common problem among teenagers. (See Key Point, page 261, for screening questions.)

Starting the Interview

Interviewing adolescents can be one of the most satisfying experiences of clinical pediatrics, providing that you follow a few clear guidelines. To begin, setting the stage for interviewing an adolescent is important. For previous patients now entering adolescence, let them (and their parents) know that at future visits you will start to spend some time with them on their own. For new adolescent patients, or for those who return to your office as teenagers after a lapse of several years, you can inform the youth and the parents that you will be spending part of the time with the teen alone. This is an important step in teaching adolescents to manage their own health care.

What if the parent refuses to leave the room? In some cases, a parent may refuse to leave the room, not allowing the teen to be interviewed alone. It will not benefit rapport or trust to push a parent out of the room unwillingly. There could be many reasons for this behavior. The best approach is to review the basic interview structure for future visits and explain that it is important for the adolescent to begin to develop autonomy in taking care of his or her own health. Addressing any issues the parent may have can also help increase their comfort with separating from their teenaged child. At the end of the interview, spend a few minutes asking the parent about their concerns. This may help facilitate seeing the teen alone at the next visit.

What if teens tell you something they do not want their parents to know? Confidentiality is vitally important. Concern about confidentiality of information can lead teens to avoid seeking appropriate medical care or not informing their physician about important health-related behaviors. If possible, at the start of the interview, point out that some issues may come up that will be kept confidential from parents. However, explain to them that if there are any concerns regarding the safety of the teen or the safety of others, confidentiality will not be maintained.

A general statement such as, “Everything we talk about in here is confidential, which means I keep it private and do not share it with other people (such as your parents or teacher) except those involved in your health care treatment team. There are some limits to this confidentiality. If I have any concern of risk of harm to you or someone else, I would let you know that I would need to break confidentiality, and then I would have to tell your parents and others if needed, to make sure you are safe.” Having both the adolescent and parents hear this at the beginning is important and helpful. Discussing this at the end of the interview can result in parents grilling the teen later about issues that they may not be sharing with them.

Working with the family and particularly the parents, while respecting confidentiality of the youth, is one of the challenges in taking care of this age group. As in any interview, the most important issue is building trust and rapport.

Confidentiality is a crucial part of the treatment of adolescents. It should be discussed with the teen and parents at the beginning of the interview.

Building trust and rapport

Adolescents are looking for the same thing as patients of all other ages in that initial contact: they want to be listened to, including during all subsequent visits. They want to know that you are genuinely interested in learning about them and in finding out who they are. Put down your pen, sit down, and have a brief conversation. This is particularly important at the start of every initial interview. Take a few minutes to develop rapport. For example, identify one of the teen’s particular interests, and ask questions about it. This might involve music, sports, drama, books, movies, computers, television, or video games. Faking your interest will not work because the youth will see right through it. If you have never heard of whatever they are talking about, be honest, with statements such as, “Wow, I have never heard of that—tell me how that works.” This admission may make you look far from “cool,” but honesty and genuine interest carry great value in the teen-doctor relationship.

The information you learn can help reconnect with the teen at subsequent visits, so make a brief note of those interests to remind yourself at the next visit.

Sometimes the visit starts with parents expressing concern or frustration with their teen. This is guaranteed to increase the teenager’s discomfort and promote his or her withdrawal from the interview. If parents have just made negative statements about the youth, it may be helpful to gently interrupt them (one of the rare occasions when this is a good idea) and to say to them, “Excuse me, I realize _______ (insert name of teen) has some problems you are worried/upset about, but before we get to that, why don’t you tell me three things that are terrific about him/her and things that he/she does well?” (Teens will often brighten with this shift in focus and be more forthcoming in the subsequent interview after parents have left the room.) If parents have reported negatively about the youth, you can ask the teen directly, possibly in front of the parents but definitely later when alone with the teen, “So what do you think about what your parents said?” This allows the teen to talk and lets the teen know that you are interested in what he or she has to say.

Interviewing adolescents

The teen interview focuses primarily on the patient’s psychosocial environment and potential health-risk behaviors. Physical exams are still a core component, but the focus of an exam is determined by both the presenting complaint and health-risk behaviors identified. Adolescent interviewing is a physician educator’s dream come true. Most youth are open with physicians if they feel safe and if their doctor asks the right questions. Try to listen with an open mind and remain neutral when information is disclosed. Express empathy around feelings that the teen is sharing. “You sound angry about what your friend said,” or “You seem very sad about your recent breakup.” This provides the teen feedback that you are listening and care about him or her, and that this is a safe place to express feelings. Statements such as, “What were you thinking?” and “You’ll get over it,” are generally not going to lead to open and honest communication.

What if the teen refuses to talk to you? Adolescents are sometimes forced to attend appointments because of parental worries that they do not share or do not want to hear or talk about…again. By not talking, the adolescents are letting their parents know that they are unhappy and expressing their displeasure by becoming uncommunicative, saying nonverbally, “You can make me come to the appointment, but you can’t make me talk.” Teens may also be fearful of seeing a doctor and concerned that something is wrong, or they may feel uncomfortable about being examined. Withdrawal and not interacting can also be signs of mental health issues. The teen may not believe the doctor can help or does not feel that help is needed. These situations call for a calm approach and a careful inquiry into the reason for the visit. If parents are angry and upset, then spending some time with the teen and parents separately early in the interview is a good idea. Tell the adolescent that you are interested in him or her and in what he or she has to say. Review confidentiality and how it works. Try different approaches to connect with the teen, such as suggesting ways that the teen might be feeling and indicating whether any of those ways fit. You can mention concerns that the parent has and ask whether the teen is also worried about the same thing, or you might comment on some article of clothing or activity of interest as a way of engaging the teen.

Sometimes having the teen write or draw can start the process. Give the teen some time to feel comfortable and talk, but if the teen still does not feel like talking, respect this. Let the teen know that you are available and would be glad to see him or her again. Meet with the parents briefly and suggest another appointment. Sometimes an adolescent may be more comfortable with a same-sex physician. If this is an issue and this option is available, this can be offered.

A common mnemonic used for key areas to ask the teen about is HEADSS, which is organized to start with fairly neutral topics and progress to more sensitive issues. These topics include:

• Education (and Employment)

• Suicide (and mental health)

(HEADSS developed by Cohen, E, MacKenzie, R.G., Yates, G.L. HEADSS, a psychosocial risk assessment instruction. Journal of Adolescent Health 12: 539–544, 1991.)

It is not easy to cover all of these areas in a brief interview, and basic screening questions can be used to target risk areas. Start with general questions, and then lead into more sensitive issues. It is not true that talking about a topic or asking questions around it will make teens think about doing it (this comes up in sexual education, asking about suicide, or drug use). In fact, if you do not ask about these topics, teens often will not tell you what they are thinking or doing. It also helps to briefly summarize if there are issues that you will be discussing with his or her parents at the end of meeting with the teen, and ask if there is any information that the teen does not want to be shared. This avoids any surprises and gives the teen a chance to have input before meeting together.

Teen Interview *:

1. Listen openly and avoid judgmental statements.

2. Express empathy.

3. Address key areas using HEADSS mnemonic.

4. Praise the teen on good health choices.

5. Provide appropriate education.

^* If you don’t ask, teens will often not tell you. Asking the questions does not lead to teens thinking about doing something they would not have done otherwise.

Home

Ideally, the home environment should provide the adolescent with stability and basic needs, love, acceptance, discipline, and moral values. Structured family time remains important for adolescents, and there is strong empirical support for better health and well-being and reduced risk-taking behavior in teens whose families eat at least one meal (usually dinner) together most days. But for some teens, there are difficulties and stressors in their home. These questions will help give a picture of their home life.

• “Who lives in your home?”

• “How do you get along with members of your family?”

• “What do your parents do for work?”

• “How often do you eat together as a family and what are mealtimes like?”

• “Have there been any recent stressful events in your home?”

• “How are you disciplined?”

• “Is there any violence or aggression in your home?”

Activities

Peers become increasingly important during adolescence. Youth also begin to have more autonomy from their family. Ask about their activities outside of home and school. This will give you a better picture of their life and identifies areas of concern. Engaging in regular exercise is a good health practice that begins in childhood, but the trend is for youth (particularly female) to become less active in their teen years. Questions about activities help identify areas of concern, particularly with peers.

• “What do you do after school?”

• “Who are your closest friends?”

• “What do you enjoy doing the most with friends?”

• “Have you ever been bullied?”

• “How do you stay in touch with and communicate with friends/peers?”

• “What do you do for exercise in a week?”

• “Do you drive a car?”

• “Do you wear a seat belt?”

• “Have you had any problems with the police?”

Drugs

More than half of adolescents have used alcohol or marijuana. Most teens have tried smoking cigarettes. Substance abuse and addictions are a leading cause of health problems in adulthood and are linked to significant morbidity and mortality in adolescence. Drug and alcohol use often stem from behaviors within an adolescent’s family or peer group, or both. Most teens will not volunteer this information unless you question them directly, and they tend to underreport substance use. Drugs used, frequency, and problems associated with substance use are key questions.

• “Do any of your friends smoke cigarettes or use substances?”

• “What about in your home and in the family history?”

• “Have you ever smoked cigarettes?”

• “Do you use alcohol or other drugs?”

• “What do you use, how much, and how often?”

• “Have you ever had any troubles or done anything you regret while using alcohol or other drugs?”

• “How do you pay for cigarettes, alcohol, or other drugs?”

• “Have you ever driven a motor vehicle after drinking or using other drugs or been a passenger driven by someone who had been drinking or using other drugs?”

Sexuality

Adolescence is when most youth begin engaging in sexual relationships. The majority have had sexual intercourse by the end of high school. Youth often report having engaged in sexual activity while under the influence of alcohol or drugs, or due to coercion. The rates of sexually transmitted diseases and teen pregnancy remain high in adolescents, despite an increase in options for contraception and protection against sexually transmitted infections. At least 1 in 10 adolescents has questioned his or her sexuality or sexual orientation, or both, and your questions need to be open to this possibility and provide a safe setting for teens to discuss these issues. Asking questions and providing accurate information around sexual health choices and practices is important. Do not assume that adolescents have already heard this information at school or at home.

• “Have you ever had sex?”

• “Have you had sex with boys, girls, or both?”

• “How many partners have you had?”

• “Have you ever been forced to have sex?”

• “How do you protect yourself from getting sexually transmitted diseases?

• “How do you prevent pregnancy?”

• “Do you have any concerns about your sexual health?”

• “Do you have any questions about sex?”

Screening Questions for Sexual Health:

“Are you in a romantic relationship?”

“Are you currently or have you been sexually active?”

“How many sexual partners have you had?”

“Have your partners been boys, girls, or both?”

“What do you use for contraception and protection from STDs?”

“Have you ever felt pressured or forced into a sexual encounter?”

“Have you had any sexual health problems or concerns?”

Suicide (and mental health)

Mental illness often has its onset in adolescence. Depression is one of the most common mental illnesses in teens (about 10% of teens suffer from depression), yet adolescents rarely present with complaints of depressed mood. Typical adolescent mood lability and angst can often mask symptoms of depression and other mental health disorders; conversely, mental health disorders can be missed by attributing symptoms to adolescence. Depression can present in the form of irritability, withdrawal from activities and friends, poor sleep and concentration, deterioration in school performance, and difficulty coping (using alcohol or other drugs, or both). Suicide is a leading cause of death in this age group and frequently linked to untreated mental illness. Previous suicide attempts, substance abuse, and family history of suicide are predictors of suicide.

Dieting can also become a concern in adolescence as youth struggle with pubertal changes and use dangerous strategies to lose or control weight. Eating disorders often begin in adolescence, and your questions should screen for these issues. It is important to ask questions about mental health and suicide in this age group.

• “What is your mood like most days?”

• “What do you do when you are feeling down or are having a bad day?”

• “Describe your sleep routine (time you go to bed, how long it takes to fall asleep, what time you wake up, how rested you feel, energy level during the day).”

• “Have there been any changes in your appetite or weight?”

• “Do you think you are too fat, too thin, or just right?”

• “Have you felt sad, down, or angry more days than not in the past few weeks?”

• “Does anyone in your family have mental health problems or a history of suicide?”

• “Have you ever thought about ending your life or have you ever tried to harm yourself?”

Interview with Parents

For many parents, the adolescent years are entered with dread and foreboding. Rumor has it that children no longer listen to parents, the home becomes a battleground, and there is nothing parents can do except “ride it out.” It is important to emphasize that family and parents still remain a very important part of a teen’s life, and that these years can be very enjoyable and wonderful for parents as their child develops into a young independent adult. Some adolescents pose more parenting challenges than others depending on the individuals, health issues, and family dynamics involved. Parents benefit from having an understanding of normal teen developmental tasks, such as questioning values and testing authority, spending more time with friends, exploration, and developing autonomy from parents. Parents have a very important role in these stages to encourage and support these developmental steps while maintaining safety, clear limits, and reasonable expectations for their teenager. Family time together should be prioritized and there is significant literature to support the protective factor of eating meals together as a family at least several days per week. Parental modeling of healthy decision making, openness to communication, acceptance, and trust will help in fostering this relationship through this time.

History. John is 16 years old and in his second to last year of high school. His parents bring him to see you because his grades have declined this year. He was formerly an A and B student, but he is now barely passing. He goes out with his friends a lot on the weekends, and when he is home he does not want to spend time with his family. His parents are concerned and have received reports from the school that he is skipping classes.

When meeting on his own with you, John is sullen and slightly irritated. He tells you there is nothing wrong and says that his parents “worry too much.” He denies any problems with his mood. You go through some screening questions. He reports that he does drink and uses marijuana “sometimes.” You ask him the CRAFFT substance use screening questions (see Box 17–1), and he scores a 3.

BOX 17–1 Crafft Substance Use Screen (Copyright 2009)

(From Knight JR, Sherritt L, Shrier LA, et al: Validity of the CRAFFT substance abuse screening tests among adolescent clinic patients. Arch Pediatr Adolesc Med 156:607–614, 2002.)

(Answering “Yes” to two or more questions below indicates a substance-related problem.)

Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

Do you ever use alcohol or drugs to RELAX, to feel better about yourself, or to “fit in”?

Do you ever use alcohol or drugs while you are ALONE?

Do you ever FORGET things you did while using alcohol or drugs?

Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?

Have you ever gotten into TROUBLE while you were using alcohol or drugs?

You discuss with John the risks of substance use and how this may affect him negatively (school, home, and safety). You suggest a referral for counseling and John refuses. You offer to see him again in a few weeks and he agrees. He asks if you will tell his parents about his substance use, and you discuss the importance of confidentiality with him.

Parents may have concerns about the health or safety of their teen. Encourage them to discuss this with their child, and set clear parameters for behaviors. Discourage parents from breaking the adolescent’s trust, such as reading a diary, text messages, or e-mails, unless this has already been discussed with the teen as part of the parents’ role, because of concerns about decision making or safety. Youth now live in a cyber world, with much of their social experience taking place through electronic media. Encourage parents to discuss with teens the use of electronic media and safety in terms of personal information that should not be accessible to others on the Internet or shared with people the youth has never met in person. One suggestion for parents who are concerned about what their teen is doing online and personal information they may be sharing is to give their child a 24-hour warning that they will be inspecting all sites accessed and personal information the teen has posted online. This provides the teen the chance to self inspect and delete any information, and then parents can say in the future they will not give the 24-hour warning before checking.

Summary

The adolescent interview can be overwhelming in the scope of the questions and health risk behaviors that may arise in a 15- to 30-minute appointment. It is important to identify areas of concern, but then focus initially on one or two behaviors or identified health areas for that visit. Try to find at least one health-related choice or behavior to praise during the appointment. Parent involvement and support are important and should be encouraged within the parameters of confidentiality and development.

The foundation of the doctor-patient relationship, established by building trust and rapport with the adolescent, will encourage the teenager to return for further follow-up. The follow-up appointment ideally should be given to the teen before leaving the office, and, if this is not possible, there should be a clear plan for when the office will contact the teen with the next appointment. Letting adolescents know what will and will not be shared with their parents and giving a valid reason for follow-up appointments while maintaining confidentiality will facilitate trust. Ultimately, if youths feel their physician is listening to them, is interested in them, and that they are not being judged, they are more likely to engage positively in their own health care.

HEADSS is organized to start with fairly neutral topics and progress to more sensitive issues in the adolescent interview:

• Education (and Employment)

• Suicide (and mental health)

Suggested readings

Ford C.A., Coleman W.L. Adolescent development and behavior: implications for the primary care physician. In: Levine M., Carey M., Crocker A., editors. Developmental Behavioral Pediatrics. 3rd ed. Philadelphia: WB Saunders; 1999:69-79.

King R.A. Adolescence. In: Martin A., Volkmar F.R., editors. Lewis’ child and adolescent psychiatry. A comprehensive textbook. 4th ed. Philadelphia: Lippincott; 2007:279-291.

National Center for Chronic Disease Prevention and Health Promotion. Information on adolescent health and health behaviors. http://www.cdc.gov/HealthyYouth/AdolescentHealth/index.htm.

National Institute of Mental Health. Information on child and adolescent mental illnesses. http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml.

Neinstein L.S., Gordon C., Katzman D., et al. Adolescent health care: A practical guide, 5th ed. Philadelphia: Lippincott, 2008.

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