Talking With Adolescents
Monica Sifuentes, MD
This is a first-time visit for a 15-year-old girl who is accompanied by her mother. The mother is concerned because her daughter’s grades have been dropping since beginning high school, and she appears fatigued and irritable. The mother reports no new activities or recent changes in the home situation and no new stressors in the family. Both parents are employed, the girl has most of the same friends she has always had, and her siblings currently are doing well academically. The girl is healthy and has never been hospitalized. After the mother leaves the room, the girl is interviewed alone.
1. When interviewing adolescents, what is the significance of identifying their stage of development?
2. What are important areas to cover in the adolescent interview?
3. What issues of confidentiality and competence need to be discussed with adolescents before conducting the interview?
4. When should information be disclosed to others, despite issues of confidentiality?
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.
Box 4.1. Keys to Successful Interviews With Adolescents
•Listen attentively, with minimal interruptions.
•Use open-ended, nonjudgmental questions; start with general observations of concern and follow up with specific questions.
•Define medical terms clearly.
•Invite the adolescent to ask questions.
•Help empower the teenager to address health issues.
•Reinforce the teenager’s own positive support systems.
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.
|Table 4.1. Developmental Milestones During Adolescence|
Concrete, egocentric thought processes
± Abstract thought processes emerge
Abstract thought processes well formed
Parental supervision prominent
± Parental supervision
Limited or no parental supervision
± Risk-taking behavior with feelings of invulnerability
± Risk-taking behavior
Risk-taking behavior diminishes; vocational objectives formalized
± Peer pressure
Peer pressure prominent
Impact of peer pressure decreasing
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.
Box 4.2. What to Ask
•With whom does the adolescent live?
•Have there been any recent changes in the living situation?
•How are things between parents/other adults living in the home?
•Are the parents or guardians employed?
•How does the adolescent get along with the parents and siblings?
•Does the adolescent feel safe at home? In the neighborhood?
•Is there a firearm in the adolescent’s home? If so, what does the adolescent
•know about firearm safety?
E: Employment and education
•Is the adolescent currently in school?
•What does the adolescent enjoy about school? Dislike?
•How is the adolescent performing academically?
•Has the adolescent ever been truant or expelled from school?
•Are the adolescent’s friends attending school?
•Is the adolescent currently employed? How many hours does the
•adolescent work each week?
•What are the adolescent’s future education/employment/vocational goals?
•What does the adolescent do in his or her spare time?
•How much time is spent on technology (the computer, cell phone,
•other electronic devices) during the day and at night?
•What does the adolescent do for fun? Is the adolescent ever bored?
•With whom does the adolescent spend most of his or her time?
•Do any of the adolescent’s friends smoke tobacco, use electronic cigarettes, vape, or use illicit drugs or alcohol?
•Is the adolescent currently using, or has he or she ever used, tobacco, electronic cigarettes, or vaporizer?
•Is the adolescent currently using, or has he or she ever used, any illicit drugs? What about steroids? Alcohol?
•Does the adolescent ever feel pressured by friends to use drugs or alcohol?
•What is the adolescent’s sexual orientation and/or gender identity or expression?
•Is the adolescent currently in a relationship?
•Is the adolescent sexually active?
•If so, what was the age of the adolescent’s first sexual experience?
•What types of sexual experiences has he or she had?
•How many sexual partners has the adolescent had in his or her lifetime?
•Does the adolescent have a history of sexually transmitted infections?
•Does the adolescent (or the partner) use condoms or another method of protection?
•Does the adolescent (or the partner) use any methods of contraception?
•Does the adolescent have a history of sexual or physical abuse?
•Is the adolescent bored all the time? Ever sad or tearful? Tired and unmotivated?
•Has the adolescent ever felt that life is not worth living or ever thought of or tried to hurt their self? More importantly, does the adolescent have a suicide plan or access to a firearm?