CHAPTER 4

Talking With Adolescents

Monica Sifuentes, MD

Adolescence is a time of unique change from a cognitive, physical, and neurobiological standpoint. Unlike other periods in life in which individuals have at least some knowledge or experience to guide them, adolescence can be characterized by feelings of physical awkwardness, emotional turmoil, and social isolation. In addition, the teenage years are dreaded by most parents, who often feel ill-equipped to handle the unpredictability of their children’s responses to puberty and daily social interactions. Rather than directly approach their adolescent, some parents choose to engage in quiet observation. They fully intend to support their children but wait to be approached. Thus, many adolescents do not have the active guidance or timely advice of parents during the teenage years and prefer to spend their time alone or in the company of friends or acquaintances. Fortunately, most adolescents pass through this period uneventfully. In fact, many individuals go through this period gladly and appreciate finally being permitted to drive a car, gain employment, or start dating.

The physician should approach interviews with adolescents differently from interviews with younger children, because with adolescents information comes directly from the teenager rather than a parent (Box 4.1). Unlike an interview with a younger pediatric patient, the adolescent interview should focus on several psychosocial issues that may be uncomfortable to discuss in the presence of a parent. Thus, each teenager should be interviewed alone. The goal of the interview is to help adolescents become more comfortable discussing issues related to physical and mental health with the physician, give adolescents the opportunity to become more responsible for their health care, and discover any psychosocial issues that might interfere with a relatively smooth passage through adolescence.

Adapted with permission from Sacks D, Westwood M. An approach to interviewing adolescents. Paediatr Child Health. 2003;8(9):554–556.

Stages of Adolescence

Adolescents are stereotypically labeled as difficult, complex, and time-consuming patients with complicated concerns that result in nonmedical diagnoses. In addition, they can be accompanied by overbearing, demanding parents, or sometimes no parent.

The quality and quantity of information obtained from the adolescent during the medical and psychosocial interview can be greatly enhanced by taking developmental milestones into consideration. Adolescence can be divided into 3 developmental stages: early, middle, and late (Table 4.1). For example, interest in discussing long-term educational goals varies depending on the age of the adolescent. Most 18-year-olds are prepared to discuss college plans, specific vocational interests, and employment opportunities. In contrast, 12-year-olds are still anchored in the concreteness of early adolescence and often are ill-prepared to discuss detailed plans for higher education. Current middle school experiences are much more important to this age group and therefore should be the focus of discussion. Peer pressure is most prominent during middle adolescence; thus, 16-year-olds with friends who smoke cigarettes and drink alcohol likely have tried or use the same illicit substances.

Reprinted with permission from March CA, Jay MS. Adolescents in the emergency department: an overview. Adolescent Medicine. 1993;4(1):1–10.

Knowledge of these developmental differences allows the interviewer to more effectively explain instructions and diagnoses to teenagers. For example, compared with 14-year-olds, 19-year-olds can better understand the effects of untreated or recurrent chlamydial cervicitis on long-term fertility. This is not to say that physicians should not discuss these possible consequences with a sexually active 14-year-old with chlamydia; rather, they should use more concrete descriptive wording and repeat the information at future visits. Age guidelines are not rigid, however, and each interview should be individualized to the particular adolescent and the circumstances surrounding the visit.

Issues of Confidentiality and Competence

A discussion about confidentiality is essential and can be approached in 1 of 2 ways. Each method has distinct advantages and disadvantages. To allow conversation to flow more naturally, interviewers should use the approach with which they themselves are most comfortable.

The first approach involves informing adolescents at the beginning of the interview that most issues discussed are held in strict confidence and will not be repeated to anyone. Exceptions are suicidal or homicidal behavior and a history of or ongoing sexual or physical abuse. In any of these instances, other professionals are told of the disclosed information, and parents or guardians ultimately are informed of the disclosure. The advantages of this approach are that discussion of such logistics at the beginning of the interview is less awkward, and the ground rules are clear from the start. This contributes to an atmosphere of trust and honesty. The disadvantage is possible inhibition by adolescents who are unsure about disclosing particular incidents (eg, those concerning sexual abuse) for fear of involving other professionals or family members. Interviewers should be nonjudgmental, reassuring, and empathetic to reduce the possibility of such an occurrence.

The second, less popular approach to the discussion of confidentiality involves informing adolescents at the end of the interview or when and if an exception to maintaining confidentiality arises. Proponents of this approach argue that adolescents tend to respond more honestly to questions when they do not believe physicians will inform others, including their parents or legal guardians. As mandated reporters, however, physicians have a legal responsibility to report sexual and physical abuse; in cases of suicidal or homicidal behavior, it is in the patient’s best interest to inform other professionals of this disclosure. The disadvantage to this method is that these issues often arise at very emotional times during the interview, and it is difficult to interrupt the patient to discuss mandated reporting. If physicians wait until the end of the interview to inform adolescents about mandated reporting, however, patients may leave the office feeling deceived and may not return for future visits. For this reason, most health professionals prefer to inform adolescents at the onset of the interview about confidentiality with the hope that it contributes to the development of a trusting relationship.

An assessment of the adolescent’s ability to make health-related decisions is another important aspect of the interview. Competence is the ability both to understand the significance of information and to assess alternatives and consequences to sufficiently identify a preference. Various factors other than age must be considered, such as maturity level, intelligence, degree of independence, and presence of any chronic illness. This last factor is included because adolescents with chronic conditions may have already participated in decisions about their health care. Regardless, it can be difficult to assess competence from just 1 visit. It may not even be necessary to make an assessment emergently, except in certain cases, such as with an unplanned pregnancy.

Although it is imperative to interview adolescents alone, every attempt should be made to involve parents or guardians in physical and mental health decisions. Although specific state laws allow physicians to treat minors in emergent situations and in cases of suspected sexually transmitted infections without the consent of a parent or guardian, physicians should urge adolescents to inform their parents or guardians of any ongoing problems disclosed during the interview. The ultimate decision, however, rests with the adolescent. Physicians can assist adolescents in discussing delicate issues with their parents by role-playing with teenagers or by sitting in on the conversation between the adolescents and their parents when disclosing sensitive information. Health professionals should become familiar with the specific consent laws related to minors in the state in which they practice medicine to confirm the legal abilities of minors to consent to sensitive health care services.

Psychosocial Review of Systems

A major part of the adolescent interview involves obtaining a thorough psychosocial history, which typically can be completed in 20 to 30 minutes. The approach, which is known by the acronym HEADSS (home, employment and education, activities, drugs, sexuality, suicide/depression), allows interviewers to evaluate the critical areas in adolescents’ lives that may contribute to a less than optimal environment for normal growth and development (Box 4.2). Questions about sexuality, sexual orientation, and gender identity must be asked in a nondirected, open-ended, nonjudgmental fashion, giving adolescents time to respond. This information is imperative to adequately assess risks for conditions such as social isolation, unintended pregnancy, and sexually transmitted infections, including HIV. In addition, an inquiry about sexual, physical, and emotional/verbal abuse is indicated during this part of the interview.

Because most adolescents now have access to the internet 24/7 via their cell phone, home computer, or other electronic device, it is important to discuss screen time with them and their parents to obtain a more accurate picture of their online activities, connectedness with peers and family, and sleep hygiene practices. In addition to reviewing the amount of time spent on an electronic device each day, physicians also should inquire about texting, sexting, and whether the patient is a victim or perpetrator of cyberbullying.

Issues That Need Immediate Attention

Many issues discussed during the psychosocial interview can be a source of significant stress and anxiety for adolescents. Evidence of psychological or adaptive difficulties must be taken seriously and should be reassessed at future visits. Certain disclosures, however, demand immediate attention. Suicidal ideation, with or without a previous attempt, requires a more in-depth analysis of the gravity of the problem. Mental health professionals should be involved emergently in the clinical assessment of these precarious situations. Other issues that require immediate attention include possible danger to others and a history of or ongoing sexual or physical abuse. Depending on the specific circumstance, issues such as a possible or confirmed unplanned pregnancy, bullying, substance use, and sexual orientation may not necessarily require the emergent involvement of other providers initially; however, close follow up must be assured and arranged by the physician or other health professional regardless of consent by a parent or guardian.

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