Fifteen-year-old Matthew comes to your office for his annual examination. You last saw him a year ago, when his stepmother brought him in for his physical. For the first 10 minutes of that visit, the stepmother told you about Matthew's "attitude" toward--and "bad influence" on--the rest of the family. She reported that Matthew refused to talk to her or his father, alleged that he was spending all his time "instant messaging," and worried that he was watching pornography online.
Throughout that conversation, Matthew sat on the examination table in his boxer shorts, arms tightly folded, staring at the floor.
During the remaining 5 minutes left for the physical examination, Matthew refused to make eye contact and offered monosyllabic responses. Given the time limitations, you had asked Matthew whether he was using drugs, whether he had a girlfriend, and whether he was sexually active. His response was a firm "no." During the physical, Matthew refused to allow a genital examination.
As Matthew was leaving, you said: "Everything looks fine. Don't do drugs and stop drinking alcohol--they're bad for you. And always use a condom." You haven't heard from him again until today.
Having reviewed his chart, you brace yourself for another forced interaction with this teenager. You think, "I went into pediatrics to take care of babies, not to take care of obnoxious teenagers. What am I really supposed to talk about with this adolescent?"
Perhaps some aspects of this scenario sound familiar? Many pediatricians feel ill-equipped to meet the often complex needs of adolescents. Some physicians have a challenging time convincing teenagers to talk to them about anything. Others worry about opening a Pandora's box of issues that cannot fully be addressed. Given the time and reimbursement constraints facing primary care providers, the wish to avoid time-intensive patients is understandable.
Quality adolescent health care requires that the clinician address a myriad of social and emotional issues that can affect an adolescent's physical and mental well-being. This goes beyond simply ensuring that immunizations are current, listening for heart murmurs, and providing clearance for sports participation.
While time with patients is limited, pediatricians need to build a rapport that permits a glimpse into the adolescent's real concerns. In general, if a teen is treated with respect and addressed nonjudgmentally, he or she will learn to regard the physician as an ally.
Here I present a basic framework for obtaining the relevant psychosocial information that is important for maintaining a teenager's well-being.
The opening vignette underscores the importance of the following measures in establishing rapport with a teenager:
•When you enter the examination room, introduce yourself to the teenager first and shake hands before addressing the parent (if present).
•Take the history while the teenager is dressed and ask him to disrobe only for the examination.
•Face the adolescent and maintain eye contact as much as possible while listening to the parent. If the teenager perceives that he is the central person in the doctor- patient relationship, he will feel respected and will be more likely to trust you.
•When the parent has a laundry list of concerns, make sure to interject occasionally and politely ask the adolescent whether he shares those concerns, which can be addressed one-on-one with the teenager later in the visit.
With a new patient and family, I find it invaluable to discuss confidentiality up front. I usually say, "At this office, we encourage teens be honest with their doctor. It helps ensure that health concerns and questions are addressed. It also helps teens prepare for a rapidly approaching adulthood, when they will have to know how to discuss health concerns with their physician. Occasionally, we discuss sensitive issues such as sexuality and drugs and, for the most part, we agree to keep these conversations private. We expect teens to ask questions that will ultimately keep them healthy and safe."
I also discuss the contingencies of when confidentiality must be broken. Specifically, I explain that when there are issues that may put the teen's (or someone else's) life or health at risk, confidentiality must be broken and adults must be brought in who can help keep him/her safe. I tell the adolescent that I never break confidentiality without telling him first. The teen always has the option to decide how he would like the parent to find out.
THE "HEADDS" SCREENING TOOL
The "HEADDS" mnemonic reminds clinicians about the psychosocial factors that influence the physical and emotional well-being of teenagers. This is a helpful screening tool for identifying potential problems and risk factors.
•Try to get a general picture . . . Who lives with the patient? Does the family live in a house? Cramped quarters? Does the adolescent have any privacy?
•Do the parents live together? If not, is the out-of-house parent involved with the patient--and to what extent?
•Have there been recent changes in the family dynamic--a new sibling, the death of a close grandparent, a parental separation or divorce? Is a family member sick? If so, how is this affecting the patient?
•How many siblings live at home and where in the birth order is the patient? In some large families, the responsibilities for younger children may fall on the oldest child. This level of responsibility may seem appropriate or it may overwhelm the teen.
These questions are best asked when the parent is present so that objective information (that can be discussed with the teen alone) can be obtained.
Many busy practitioners hesitate to explore issues about education because they believe that this is outside their domain. I would argue that avoiding a discussion about school performance prevents a real understanding of any underlying issues facing the teen. School is the adolescent's primary job, and almost all teens want to succeed. When things are going poorly in school, I see this as a manifestation of some other process that is inhibiting success. Such processes frequently include ADHD, learning disabilities, depression, anxiety, bullying, or school phobia.
It can be immensely helpful to ask the teen how well school is going while the parent is in the room. Teens often report that everything is "fine"; parents may counter that the adolescent has been skipping classes or is earning poor grades.
Some other key issues to inquire about:
•Have there been any changes (for better or worse) in the teen's academic progress during the past year?
•If the teen is doing poorly, find out why. Does he have difficulty paying attention in class or during homework time? Do homework assignments take forever to complete? Positive answers suggest the possibility of ADHD.
•Have teachers mentioned any problems with the student's ability to learn, digest, and understand information? Positive answers suggest possible learning disabilities. In this situation, the student might benefit from psychoeducational testing and/or the development of an individualized education plan.
•Is the student skipping classes? Has he joined a new peer group? Do the parents suspect any drug or alcohol use? Any significant mood changes recently? Could there be an underlying mood disorder (depression, anxiety) that prevents the student from focusing?
•Is the student having trouble waking up to get to school on time? Is he falling asleep in class? Are homework assignments incomplete because the student sleeps for hours each afternoon or early evening? The duration and quality of sleep can profoundly influence an adolescent's academic performance and should be addressed whenever academic concerns arise.
•What are the student's life plans and goals? Younger teenagers may simply want to be a "pro basketball player," a developmentally appropriate goal. By high school, there should be some discussions about the teen's post-high school plans. If the student is planning on going to college, is he pursuing the academics and activities necessary to meet this goal?
Be on the lookout for the adolescent with strong cognitive abilities who is faltering academically. An evaluation for mood disorders, substance abuse, ADHD, or learning disabilities is usually warranted.
After-school activities (or lack thereof) can profoundly affect an adolescent's physical well-being. I generally obtain this history without the parent in the room because the teen usually answers more honestly. If the history suggests participation in an activity that could be detrimental to the patient's health, this may warrant a private or a 3-way discussion with the parent.
Other key points to ask about:
•What activities does the teen participate in after school? Most adolescents need to be involved with some activity in addition to academics. Watching TV or Internet chatting all afternoon does not count as a healthy activity. The American Academy of Pediatrics recommends no more than 1 to 2 hours each day of "screen time."
•Simple "chilling" and "hanging out" generally spell trouble. With whom does the adolescent spend time? Is he home alone with a girlfriend or out on the street with peers? If an adolescent spends afternoons alone every day, some investigation of possible mood disorder or social issues is warranted.
The adolescent who naps for 2 to 3 hours every afternoon may require an evaluation for depression, substance use, or sleep cycle disorders.
Overactivity also needs to be identified. Teenagers (like everyone else) need time to relax and have fun. Some teens (or their parents) may require a friendly "prescription" from the doctor instructing them to incorporate this into their busy schedules.
Drugs and Drinking
There is no one "right" way to approach the topic, but the following tactics can be helpful:
•Start with a generalized conversation and open-ended questions: eg, "Many of my teenage patients tell me their friends sometimes try drugs and alcohol. What kinds of things have your friends talked about trying?"
•As the adolescent answers, start bringing the conversation closer to home. "It must be a challenge for you to be at a party where your friends are drinking and getting drunk. How do you deal with it when they offer you (or pressure you with) something to drink?"
•Congratulate the teen who continually insists that he has never indulged in any of these substances for making good, mature decisions for his health.
•If the teen admits to trying various substances, be careful not to sound judgmental. Explore the benefits (and consequences) the teen gets from the substance use, how it makes him feel the next day, how often he is using the substance.
•When you identify a substance use problem, encourage a follow-up appointment. Let the teen know that you can see why he is attracted to the substance, but that you have concerns for his safety.
•Suspected habitual substance use by a teenager who will not follow up with you constitutes a safety issue that requires breaking confidentiality.
Sex and Sexuality
Addressing sexual development can help prevent unplanned pregnancies, sexually transmitted infections, and HIV/AIDS. Data consistently indicate that adolescents frequently begin sexual experimentation during middle school. Providers who wait until high school before discussing sex with teenagers may be doing their patients a great disservice.
Teenagers can usually tell if their physician is uncomfortable talking about sex and they typically withhold information if they suspect that the disclosure of sexual activity will lead to a judgmental reaction. If the practitioner has strong moral, ethical, or personal objections about talking with teenagers about sex, referral to a colleague more comfortable with the topic is appropriate.
A few personal pointers on talking about sex:
•Try to talk about the patient's friends' sexual experimentation before asking the patient about personal experiences.
•Consider the possibility that the patient may have same-gender attractions or experiences. Many adolescents who are unsure of their sexual orientation tend to avoid labels such as "gay," "lesbian," or "bisexual." A good way to broach this topic with a male teenager might be: "I see lots of teenagers, and we frequently talk about sex. Some like girls, some like guys, some like both, and some are just not sure. When you think about dating or having sex, do you think about guys, girls, or both?"
•Patients frequently use slang to describe genitalia or different kinds of sexual activity. If you are unsure, ask for clarification.
•Teens hate lectures. Rather than lecturing on safer sex, involve the teen in a discussion on how he would approach various situations. For example, ask a female patient how she would negotiate not having sex with a partner who did not have a condom. Ask a teenage boy how he might behave if he was about to have intercourse and his girlfriend changed her mind.
Suicidality and Mental Health
The following approach can help you quickly assess the patient's mood and mental health status:
•Explain that many teenagers deal with strong emotions during adolescence that can sometimes make them feel "out of control."
•Ask about mood-related symptoms. Does the teen feel "down" more often than his friends do? How many days a week is he happy? Sad? Inquire about persistent irritability--a presenting symptom of depression in teens.
•Ask about fatigue and/or inability to fall asleep. Does the patient wake early in the morning, unable to get back to sleep? Has his appetite changed recently?
•Does the teen feel worthless or guilt-ridden? Has there been any change in the teen's ability to enjoy activities as before?
•Have there been changes in relationships with friends, family, teachers? Does the patient care about the future?
•If the patient admits to any of these things, you must ask about thoughts of hurting or killing himself or anyone else. An affirmative response requires emergency psychiatric consultation.
As a physician who specializes in taking care of teenagers, I have learned that a comprehensive psychosocial evaluation cannot be done in a 20- or 30-minute annual visit. However, by touching on some of these issues, one can at least start to identify real problems facing a teen and, perhaps, provide some intervention in the form of follow-up appointments or (when indicated) referral. The hope is that by talking about these sensitive issues, the adolescent comes to regard you as a trustworthy resource. *
FOR MORE INFORMATION:
• Neinstein LS, ed. Adolescent Health Care: A Practical Guide. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:59-78.
• Pratt H. Office counseling for the adolescent. In: Primary Care: Clinics in Office Practice. Philadelphia: WB Saunders & Co; 2006;32:349-371.
• Reif C, Warford A. Office practice of adolescent medicine. In: Primary Care: Clinics in Office Practice. Philadelphia: WB Saunders & Co; 2006;33:269-284.