Introduction

Adolescence is a complex developmental phase with cognitive, physical, and psychosocial milestones ( Table 2.1 ). As a young person navigates this journey, they may engage in risk-taking behaviors as they explore their identity. Studies have shown that adolescents are more likely to seek out appropriate health care when they are able to access confidential care as needed. Screening for reproductive health, substance use, and mental health concerns in a developmentally appropriate way is key as you care for patients transitioning from early adolescence to young adulthood. The importance of giving adolescents the time and space to understand what kinds of health risk behaviors they are engaging in has become even more critical, as the top three causes of mortality among adolescents are firearm-related injuries, motor vehicle crashes, and drug overdose and poisoning. Depression has also became more pervasive among youth, with recent data indicating nearly half of high school students report clinically significant hopelessness and sadness. It should be noted, however, that the types of information that are considered confidential vary significantly across the United States. ^, Understanding the laws that apply locally is essential.

TABLE 2.1

Tasks of Adolescence

Social goals	Transition from dependence on parents to independent identity and mature relationships with peers
Cognitive goals	Shift from concrete and egocentric thinking to abstract thought and ability to take perspectives other than one’s own
Physical goals	Undergo pubertal changes and develop a realistic sense of self and one’s body image

 

Part 1: Setting the stage

Setting expectations at the beginning of the visit is key in ensuring that both the adolescent and their family understand the limits of confidentiality, including the types of situations in which confidentiality must be breached. ^, This messaging is ideally delivered in a way that underscores the importance of “alone time” in a developmentally appropriate way, while acknowledging the supportive and positive relationships that parents and guardians can have in a young person’s life.

Part of setting the stage is also acknowledging any bias you may have as a provider. It is essential to ask these questions of all teens and to not avoid asking these questions because of assumptions based on the patient’s religious, socioeconomic, or cultural background.

For adolescents with intellectual disability, it is important to gauge their level of independence and ability to consent for confidential care. It is key not to assume that patients with intellectual or physical disabilities are not engaging in the same risk-taking behaviors as their peers. If they have the capacity to consent to confidential services, they should be given the same time alone with their health care provider. Additionally, as patients with intellectual and physical disability are at higher risk for experiencing sexual abuse, ^, these conversations are even more critical.

If interpreter services are needed, be sure to review confidentiality expectations for all persons involved in the interview.

As an example, stating:

“For today’s visit, we’ll all meet together and then I’ll have you [parent/guardian] wait in the waiting room while I meet with [PATIENT’S NAME] alone. When you [PATIENT] and I meet alone, I’ll be checking in with you about topics that affect teens, unless I have concerns about your safety, for instance, you hurting yourself, you hurting someone else, or someone else hurting you, then what we discuss will remain confidential. If any of those safety concerns come up, I will let you [parent/guardian] know. It is also up to you [PATIENT] who is in the room for your examination, which we can figure out later.”

Rarely, there may be parents/guardians who are uncomfortable or apprehensive about leaving the room for the confidential interview. If this happens, you can begin by asking what their concerns are. Often, by reviewing the limits of confidentiality, many parents/guardians will be reassured that they will be informed if there are any significant concerns. For some, highlighting the importance of allowing their adolescent to practice speaking with a physician on their own as part of managing their health care, which will one day be their responsibility, can help to facilitate alone time with the teen.

For example, stating:

“I hear your concerns and can understand this can be a difficult transition. Giving the space for your child to speak with the doctor alone allows them to practice having their own relationship with their health care provider and being responsible for their own health needs/health care. Also, in [YOUR STATE], adolescents have certain rights to confidential health care. I encourage you to have these conversations, as we both want your teen to be as healthy and safe as possible. Again, to reassure you, if I have any concerns about your child’s safety, I will let you know.”

The same conversation can be helpful for the adolescent who does not want their parent/guardian to leave. If ultimately, the parent/guardian remains in the room, you can review the topics that would be addressed to see if the teen is willing to discuss any of them with their parent/guardian present and then document the context of how the history was obtained in your note.

For example:

“Typically, I would check in with you [PATIENT] about substance use, things like birth control, and how your mood is. Are there any topics you’d like to discuss today?”

In this case, it is helpful to let the teen drive the conversations, as they can dictate the amount of information that is disclosed, and you can counsel about the health information topics relevant to them. As part of the discussion with the adolescent around confidential information sharing, it is important that they understand where their information goes within the electronic health record (EHR) and who has access to it. For example, changing pronouns in the EHR to affirm their gender identity may be visible to any provider who opens their chart and could be inadvertently disclosed to their parents. Encouraging teens to have their own portal account can help them to take on more ownership of their health care and facilitates confidential communication with their health care team. It is essential to educate yourself about what types of health information are shared within your EHR to patients and families so you can best counsel your patients and protect their confidentiality rights.

Part 2: How to ask the questions

Now that you have set the stage and are meeting with the adolescent by themselves, many providers wonder where to begin. The first step before obtaining this important information is ensuring you have accurate contact information for the teen in case you need to communicate with them directly after the visit. For many teens, if permitted within the EHR, messaging through the patient portal can be a convenient mode of communication.

Many frameworks exist to help you normalize what can be sensitive topics and structure the conversation ( Fig. 2.1 and Table 2.2 ).

HEADSSS is a similar psychosocial screening tool but with the structure shown above.

TABLE 2.2

Example of SHADESS Structure

Domain	Example Questions
Strengths	What is your favorite part or quality about yourself? What would your best friend say they like best about you?
School	Where do you go to school? What grade are you in? How were your grades last year? What do you plan to do after you finish high school?
Home	Who all lives with you at home? How do you get along with folks at home? Do you feel safe at home?
Activities	What activities or hobbies are you into right now? What activities do you do in your free time?
Drugs	Any vaping, marijuana, alcohol, or other drug use? If the patient answers yes, then you can ask the following questions: How have you used _______? (for example, with marijuana, it can be used in multiple different forms, e.g., vaping, smoking blunts, edibles) How long have you been using ______? How often do you use _______? What do you like about using _______? Have you noticed any downsides to using _____?
Emotions/eating and depression	Do you have any concerns about body image or your eating habits? What is one word you would use to describe your mood? Have you ever felt really down or sad? If so, have you ever felt so down or sad that you had thoughts of hurting yourself? If so, have you ever hurt yourself?
Sexuality	Are you attracted to guys, girls, both or neither? Have you ever had sex, which includes oral, anal, or vaginal sex? If the patient answers yes, then you can ask the following questions: How old were you when you first had sex? How many sexual partners have you had in your whole life? Have you ever been on birth control? Have you ever had to take emergency contraception? Have you ever been pregnant? What do you use to protect yourself against sexually transmitted infections? If the patient has been in a relationship, screening for intimate partner violence is important : Has anyone ever made you do something sexual that you were not comfortable with? Have you ever felt afraid of your partner?
Safety	Do you feel safe at home? Do you feel safe in your neighborhood? Do you or anyone you know carry a weapon (e.g., gun, knife, etc.)? Have you ever been touched in a way that you did not want? Have you ever seen people at home hurt each other?

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Normal puberty
2. Pediatric gynecologic examination
3. Abnormal puberty
4. The normal menstrual cycle

Stay updated, free articles. Join our Telegram channel

Join