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" The style and personality of the practitioner and his/her philosophy of medical care are considered to be most important in the medical care of adolescents. The practitioner should be mature and open-minded. He/she should be genuinely interested in teenagers as persons first, then in their problems, and also in their parents. He/she should not only like teenagers but must also feel at ease with them. He/she should be able to communicate well with his/her patients and their parents. The practitioner should help to enhance family communication while assuring confidentiality when requested around personal issues."
( Adapted from: Committee on Care of Adolescents in Private Practice of the Society for Adolescent Medicine).
GENERAL GUIDELINES FOR THE OFFICE VISIT
There are a few important guidelines in working with teens:
Liking the Adolescent - Important for the clinician working with adolescent to like adolescents. If the clinician has an aversion to adolescents and their problems, it is likely best to refer this age group to another colleague.
Involving the family - The family is a critical component in the care of an adolescent and it is important for the clinician to introduce himself or herself to the family. It is also important to spend time discussing the concerns of the parents. While more of the visit may be spent with the adolescent alone, it is important for the parents, in most cases, to be included at some point in the visit. This might be at the beginning, end or both depending on the age of the adolescent and the complexity of the problem. At the end of the visit, the clinician should summarize the findings and plan with the teen and if the parents or guardians are involved, summarize issues that can or must be discussed with family members. Although the adolescent may be the primary patient, the parents cannot be overlooked. Parents' input and insight are crucial, for in a real sense the family is the patient.
It is also important to consider that the definition of a family has changed and there may be many possible family constellations including blended families, stepfamilies, adoptive families and foster families. Family cultural and ethnic backgrounds are also critical to helping to understand the teen and their family.
Establishing rapport - It is important but not always easy to establish rapport with an adolescent during the first visit or several visits. Helpful suggestions include:
- Introducing yourself to the teen and parents or guardians.
- Chatting for brief period about the teens outside activities including hobbies or school.
- Letting the teen talk for awhile on topics or areas they feel like talking about.
- Treating the adolescent's comments seriously
- Moving from less threatening health subjects such as review of systems to more difficult topics such as sexuality and drugs.
- Exploring the issues that concern the teen - not only those concerns of the parents.
Ensuring confidentiality - It is critical to insure a sense of confidentiality with the teen. In this regard the health care practitioner should be familiar with those laws and regulations that cover consent and confidentiality among minors in their particular country, state, province or other locality. The limits of confidentiality should also be discussed. Parents should also be aware of these confidentiality guidelines.
Acting as an advocate - Since the adolescent may have had encounters with some adults who have been non-supportive, this is an opportunity for the clinician to stress the teen's positive attributes, characteristics and abilities. This is not the same as supporting high-risk behaviors.
Listening and displaying interest - Listening closely to the teen can be a key to developing rapport. This can include being cautious in giving advice when asked, trying to understand the teen's perspective and staying focused on what the teen is telling you. Demonstrating concern and interest is also helpful in establishing rapport.
Discovering the hidden agenda - It is very common for an adolescent to present with a complaint that does not represent the major issues that the teen is concerned about. It is also common that parents may present concerns that are not the major issue for the teen. For example, a teen may come in complaining of a headache or acne, but is really concerned about being pregnant or having a sexually transmitted infection. It is critical for the clinician to be aware of these other issues that may be more threatening to the teen's health then their chief complaint. A review of the HEADSS assessment below can help elicit this information.
Using a developmentally oriented approach - While it is important to cover areas of sex, family, peer group, and drug use, the clinician must keep in mind the developmental state of the adolescent. A 12 year old pre-pubertal male would not be asked the same questions in the same manner as would be asked a 18 year old fully mature male.
Information gathering - There are several methods that might be used to elicit both health information and psychosocial information. Traditionally this is through one and one interviews. Another method is a health assessment form. Examples for adolescents from the AMA Guidelines for Adolescent Preventive Services (GAPS) are at http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/adolescent-health/guidelines-adolescent-preventive-services.shtml . There has been a growing interest in using computerized techniques to help assess health status in both teens and adults. In some studies, this may even be preferred by many teens. One approach that was developed at Childrens Hospital of Los Angeles is to obtain psychosocial information using the HEADSS interview. This includes the topics of Home, Education, Activities, Drugs, Sex (activity, orientation, and sexual abuse), and Suicide. This includes questions such as:
Home Where is the teen living? Who lives with the teen? How is the teen getting along with parents and siblings?
Education Is the teen in school? What classes is he or she doing well in? What goals does the teen have when he or she finishes school? If the teen is older out of school, the practitioner should ask about employment.
Activities What does the teen do after school? What does the teen do to have fun and with whom? Does the teen participate in any sports activities? Community or Church activities? What are the teen's hobbies? This may be an opportunity to explore issues of seat belt safety or bicycle helmet safety.
It is useful to reassure confidentiality again before questions about drugs and sexuality.
Drugs What types of drugs are used by the teen's peers or family members use? What types of drugs does the teen use and what amount and frequency and is there intravenous use? This includes both alcohol and tobacco. It can be useful to begin questioning with a less invasive approach such as: "I know that drugs are fairly common on school campuses. What drugs are common on your campus?" and "It is not uncommon for some teens to try some of these drugs. Have any of your friends tried them? and "How do you handle the situation when your friends are using drugs? Do you ever try?
Sexuality Is the teen dating and what are the degree and types of sexual experience? Is the teen involved with another individual in a sexual relationship? Does the teen prefer sex with the same, opposite, or both sex (es)? Has the teen had sexual intercourse? This is also to find out how many partners the teen may have and also a history of both sexually transmitted infections and contraceptive use.
An approach might be to ask something like: "Laurie, I mentioned that I might be asking some questions that were personal but very important to your health. Again, this is information that I will be keeping confidential. The area I want to discuss has to do with relationships. Are you going out with anyone right now?" and something like: " As you know, there are many teens who are sexually active. By that I mean that they have had sexual intercourse. There are also many teens who have chosen not to have sexual intercourse. How have you handled this part of your relationship with Bill or with other boys you have dated?
Suicide Has the teen had any prior suicide attempts? Does the teen have any current suicidal ideation?
Sexual Abuse or Physical Abuse These can be critical areas to ask about particularly in adolescents with any significant problems in the areas listed above such as family dysfunction, change in school grades, lack of friends, substance abuse, early onset of sexual activity, history of suicide attempts or runaway behavior.
Interview tips: Help interview tips with adolescents include:
- Shaking hands with the adolescent first.
- Avoiding lecturing and admonishing.
- Focusing on the initial history taking on the presenting complaints/problems.
- Having a positive attitude towards the adolescent
- Avoiding judgmental responses - taking a neutral stance
- Avoiding medical jargon
- Being attentive, genuine and empathic
- Identifying who has the problem (i.e., is this problem the teen's concern or the parents').
- Avoiding writing during the interview, especially during sensitive questions.
- Criticizing the activity, not the adolescent and highlighting the positive.
Physical examination : The physical examination may provide another opportunity to teach the adolescent about their changing body. Reassurance about normal findings may also be helpful. Sometimes the true chief complaint is disclosed during the examination.
Closure: When the history and physical assessment are complete, the clinician should give the teen a brief summary of the proposed diagnosis and treatment. Issues that should be discussed with the family should also be addressed at this time. Also at this time resources should be discussed and a follow-up appointment made as needed. The adolescent should also have time to ask final questions.
The space that adolescents are seen for their care can also be helpful in their overall care.
Space: Adolescents prefer not to be treated as children and the more private their space and waiting area the better. Materials in the waiting area and clinical offices appropriate for their age group is helpful. The examination table should not face the door and curtain should be available for privacy. If possible the desk in the office should be oriented so that the health-care provider sits beside the desk, not behind it.
Appointments : Time can be a problem with the adolescent visit particularly for the first visit. More time should be allotted for this visit to allow for discussing their past medical and psychosocial history. If the clinician is pressed for time, doing the history at the first visit and the physical examination on another day is a reasonable approach.
Billing : In regions where teens may be required to pay for their visit or the parents will receive a bill, arrangements should be discussed early. Confidentiality can become a problem in certain billing situations and may require special arrangements. The adolescent must realize that an insurance payment may result in parents finding out about visits and the diagnosis; however, a neutral diagnosis can be used in most situations.
Availability of educational materials : It is helpful to place books, pamphlets, hot line numbers and reliable web site information in the waiting room or office on topics such as puberty, sexually transmitted diseases, sexuality, and contraception.
Note taking: The practitioner should take as few notes as possible during the interview.
Often parents come to the health care professional with requests for help with parenting their teens. Helpful suggestions include:
Guidelines for parenting
- Listening to the teenager
- Treating his or her comments seriously and avoid minimizing a problem.
- Being flexible
- Avoiding power struggles
- Showing interest in the teen and their activities
- Spending time together both working together and having fun together
- Showing trust in the adolescent
- Avoiding comparison with other teenagers
- Avoiding lecturing or moralizing
- Avoiding overreacting, especially reaching conclusions based only on appearance, dress, or language.
- Avoiding phrases such as: "The trouble with you is...." or "How could you do this to me?" or "Is that all? I thought it was something important." Or "in my day" or "That's a dumb thing to say"
- Stressing positive attributes of the adolescent.
- Respecting each other's privacy
- Keeping a sense of humor
- Resolving conflicts together. Decisions that occur in the home about the adolescent should involve the adolescent's input and may involve the whole family.
House Rules: House rules may help a family work together better. These include the expectations for behaviors for the family to live together as a group. It is helpful to have these rules worked out with input from the whole family and for them to be written down. The rules should be fair and consistent with associated consequences if the rule is broken. Teens may be eager to participate in the establishment of such rules when they find out that they might include a rule such as "no one will enter someone else's room without knocking first." Rules are mainly needed for teen or family member behaviors that are a problem and there should be a maximum of 5 - 10 rules. Some examples include:
- Dinner will be at about 6 PM and everyone is expected to be home and ready to eat at that time.
- Family members are expected to speak courteously to each other.
- Before opening someone's door, knock and wait for an answer.
Other parenting issues include:
As teen's peers become an increasingly important influence and the teen seeks more independence, parents must adapt to change in relationship with their teen.
Experimentation by teens: Important for parents to remember that while teens may experiment with many types of behaviors, most teens accept their parent's basic values. Parents can set firm, fair and explicit limits around teens behavior.
Parents must not overreact to rejection of one or both parents by the teen for a time period.
A dolescents are at maximal growth velocity and change and may be more vulnerable to social risks such as drugs, risks of parts of sexuality, domestic violence, and poverty.
Modern family issues such as less intact families and less extended families add additional challenges.
The violent messages added through the media add to the challenges.
Invulnerability: Adolescents feelings of invulnerability also add to the risks that teens place themselves.
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Suggest a few helpful concepts during the first visit with an adolescent and their family.
Some helpful concepts during the first visit include:
- Assuring confidentiality
- Involving the family unless there are particular contraindications
- Using good listening techniques
- Being aware of the hidden agenda
- Interviewing the adolescent with a developmentally oriented approach
- Including a psychosocial history in the history taking
- Making sure the adolescent understands the diagnosis and treatment plan.
- Liking the Adolescent
What changes could the clinician make to a clinical setting to make it more "adolescent friendly"
Suggestions might include:
- Having appropriate materials in the waiting room and offices for teens
- Setting up special times for teens to come to the clinic
- Making sure the exam table does not face the door and have privacy curtains available
- Allowing more time for the first visit
- Discussing billing arrangements with teen and parents if billing and confidentiality issues arise
What items are critical to ask in the psychosocial history of a 16-year-old adolescent?
- Home situation
- Educational/school issues
- Activities and hobbies the teen is involved in
- Drug use including alcohol, cigarettes and other drug use
- Sexuality issues including relationships, types of sexual activity, sexual orientation, contraception, STIs.
- Suicidality and mental health assessment
- Sexual or physical abuse particularly in teens with higher risk profile or problems
You are about to examine a 12-year-old girl who has complaints about breast lumps? Who should be in the examination room?
Certainly a male examiner should have a female chaperone in the exam room. It might be important to ask the teen if she prefers to have her mother present. Some younger teens prefer to a parent present while others do not. It would be less appropriate to have a parent present for an older adolescent.
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You are scheduled to see a sixteen-year-old adolescent female named Leslie who has recently been complaining of headaches and abdominal pain. She is in the waiting room with her mother.
How would you first approach seeing this combination of adolescent and her mother?
There are probably a couple of ways to approach this teen and her mother. It would be important to introduce yourself to both the mother and the teen. The first approach might be to see the daughter first and take the appropriate history and then have the mother come in to see what her concerns might be and how she interacts with her daughter. Then one could see the daughter without the mother for the physical examination. An alternative approach might be to see them together to see how they interact and after obtaining some of the mom's concerns and a short family history one could excuse the mother and interview the adolescent. In either case, at the end of the examination, it would be important to sum up the information for the teen and then bring in the mother to convey information that is not confidential.
You see the teen and the mom together first and the mom does not let the teen really answer or give much information. The mother is concerned that the teen may have some kind of tumor. She mentions that the teen has been extremely difficult in recent months and does not listen to her or her husband about when to be home and how much she should be studying. She states that she seems to spend a lot of time with some guy named Tom who she does not really like. You thank the mom for her concerns, that they are important and you will discuss these with her daughter. You also explain that you will be spending some time interviewing and examining the teen alone. You explain the importance of spending time with the adolescent alone as she is a developing adult.
What information would be particularly important to obtain from this adolescent as part of the history?
Medical history - This would information about what concerns the teen has and in particular a about her headaches and abdominal pain.
- She discusses that the headaches are not very severe and that she has had occasional headaches when she is stressed for about 5 years. They are more frequent when she has school exams or she is fighting with her parents over her friends. She has no associated neurologic symptoms and the headaches usually resolve with ibuprofen or over a couple of hours. There has been no increase in severity
- The abdominal pain also has been very mild and is associated with stress. They are not related to eating or bowel movements and there are no other associated gastrointestinal complaints. The pain is midline without radiation. The teen states she is not very concerned about the pain.
Sexual history : After reassuring the teen that information about her sexuality will be confidential, you ask about her relationship with Tom and other individuals. She discloses that Tom is her first boyfriend and that they have been having sexual intercourse for six months. He uses condoms occasionally. She states that she thinks she cannot get pregnant because her periods have always been irregular, but she has been more concerned recently because she has stopped having periods for over two months. She uses no other contraception. She has no history of any vaginal discharge or genital lesions or history of STIs. She has not had sex in at least two weeks.
Menstrual history : She had her first menses at age 12.5. They have always been somewhat irregular and occur about once every two months. Her last menses was over two months ago. She occasionally has cramps with her menses.
Home situation: She lives with her mother, father and one brother. They usually get along but recently when she has been going out with Tom she has felt her parents have been very angry with her for going out and distrustful of where she is and what she is doing. She does not talk much with her father.
Drug history: She denies any drugs except for an occasional beer on the weekends and trying marijuana a few times.
Mental health: She states that she is usually fairly happy but she is concerned about the possibility of pregnancy and she is worried that if her parents found out they "would kill me". She mentions that the headaches and abdominal pain got worse when she started worrying about being pregnant. She has no suicidal ideation and has never been physically or sexually abused by anyone.
You perform a physical examination. Her vital signs are normal. Her general examination is unremarkable. Her abdominal examination shows no organomegaly and no tenderness. Her neurologic examination is also normal. You explain the importance of a pelvic examination and what is involved. A pelvic examination shows no genital lesions, no vaginal discharge, normal cervix and no adnexal or uterine tenderness. You also perform a Pap smear, gonorrhea and chlamydia test.
What might you wish to discuss with the teen at this point?
Possibility of pregnancy - This might be a good time to review with the teen issues of the possibility of pregnancy and how she might approach this if she had a positive pregnancy test. This would include would she involve her parents, if not why not; had she thought about options if she were pregnant; and possibilities of contraception if she were not pregnant at that point. You let her know that you will be ordering a pregnancy test at this point and will review those findings first with her only.
Summary of her physical findings: You reassure the teen that her history and exam do not suggest any serious problems in regards to her headaches and abdominal symptoms. It is quite possible that they are related to the stress that she is under recently.
As she has not had a blood test in at least ten years you order a CBC and urine pregnancy test.
The pregnancy test is negative and the CBC is ordered. You discuss with the teen the results of the pregnancy test and while she is reassured that she is not pregnant, you point out that she still could become pregnant. You also point out that while the condoms are a great idea to protect for STIs, she should be considering alternatives for additional protection against pregnancy. She has previously thought about oral contraceptives, wants to start and wants to know if she can do this without discussing this with her mother.
Can you prescribe oral contraceptives to this adolescent without her mother's knowledge or consent?
The answer to this question depends on the laws and regulations in your own region or country. In many areas, regulations allow minors to consent for prevention of pregnancy including contraception. It is important to know the regulations for the area that you practice in. In fact in many areas, not only do minors have the right to consent but that is associated with the right to confidentiality and privacy over this information, so one would not have the right to disclose this information to a parent.
You discuss the options with the teen, you discuss the possibility of talking with the mother with you acting as a mediator with the mom. However, she still refuses to have the mom involved with her decision. You review contraceptive options and she chooses the birth control pill. You prescribe her an oral contraceptive pill.
What are important issues to discuss with the teen and the mother together?
Review of the results of her history and examination. At this point you review with the mom and the teen that her history and examination suggest tension headaches and not a tumor and that both the headaches and her abdominal pains probably relate to stress from both school. They also may relate to some of the tension regarding the disagreements that they have over her relationship with Tom.
Discussion with mom and teen about relationship with Tom: It would be important to explore Mom's concerns about the relationship. It would also be important at this point to assess how dysfunctional you think the relationship is between Leslie and her parents and whether you could intervene yourself with one or several follow-ups or whether at this point a referral to a counselor would be appropriate.
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For Teens and Parents
American Social Health Association web site for teens
Health information for teens and parents
Information for teens from Planned Parenthood Federation of America
Go Ask Alice ! is the health question and answer Internet site produced by Alice!, Columbia University's Health Education Program —a division of the Columbia University Health Service .
Web site dedicated to providing parents with comprehensive and responsible guidance
National Womens Health Information Center from Office of Womens Health
For Health Professionals
Society for Adolescent Medicine site: go to links and then categories
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Books on Parenting
Steinberg L, Levine A. You and Your Adolescent. A parent's guide for ages 10 to 20. Harper Perennial, HarperCollins Publishers, New York , NY , 1997.
Fairchild B, Hayward N. Now that you know: A parent's guide to understanding their gay and lesbian children. Hardcourt Brace, 1998.
Ponton L. The Sex Lives of Teenagers , Dutton, 2000.
Slap GB, Jablow MM. Teenage Health Care. The first comprehensive family guide for the preteen to young adult years. Pocket Books, New York , NY 1994.
Books for Teens:
Canfield J, Hansen MV, Kirberger K. Chicken Soup for the Teenage Soul. 101 Stories of Life, Love and Learning. Health Communications, Inc., Deerfield Beach , Fl, 1997.
McCoy K, Wibbelsman C. Life Happens. A teenager's Guide to Friends, Failure, Sexuality, Love, Rejection, Addiction, Peer Pressure, Families, Loss, Depression, Change and other Challenges of Living. A Perigee Book, 1996.
Columbia University 's Health Education Program. The “Go Ask Alice ” Book of Answers: A Guide to Good Physical, Sexual and Emotional Health. An Owl Book, Henry Holt and Company, New York , 1998.
McCoy Kathy, Wibbelsman Chuck: Teenage body book Perigee, 1999
Madaras Lynda: Whats happening to my body? Book for Boys: The New Growing Up Guide for Parents and Sons , 3 rd Edition, Pocket Books, 2000.
Madaras Lynda: Whats happening to my body? Book for Girls: The New Growing Up Guide for Parents and Daughters , 3 rd Edition, Pocket Books, 2000.
References and Additional Readings :
Braverman PK, Strasburger VC. Office-based adolescent health care: Issues and solutions. Adolescent Medicine: State of the Art Reviews. Hanley & Belfus, Inc. Philadelphia , PA , 1997; 8(1): 1-14.
Bright Futures: Guidelines for Health, Supervision of Infants, Children and Adolescents. M. Green M (ed), Arlington VA : National Center for Education in Maternal and Child Health, 1994.
Coupey SM. Interviewing adolescents. Pediatr Clin North Amer 1997; 44 (6): 1349-64.
English A. Treating adolescents. Legal and ethical considerations. Med Clin North Am 1990; 74:1097-1107.
English A. Changing health care environments and adolescent health care: Legal and policy challenges. Adolescent Medicine: State of the Art Reviews. Hanley & Belfus, Inc. Philadelphia , PA , 1997; 8(3): 375-384.
Elster A, Kuznets N. AMA Guidelines for Adolescent Preventive Services (GAPS), Recommendations and Rationale. Baltimore, Williams & Wilkins, 1994.
Frazar GE. A private practitioner's approach to adolescent problems. In Adolescent Medicine: State of the Art Reviews. Hanley & Belfus, Inc. Philadelphia , PA , 1998; 9(2): 229.
Johnson RL, Tanner NM. Approaching the adolescent patient. In: Hofmann AD, Greydanus DE , eds. Adolescent medicine, 2nd ed., Norwalk Connecticut : Appleton & Lange, 1989.
Klein JD, Slap GB, Elster AB, Schonberg SK. Access to health care for adolescents: A position paper of the Society for Adolescent Medicine. J Adolesc Health Care 1992; 13: 162.
MacKenzie RG. Approach to the adolescent in the clinical setting. Med Clin North Am 1990; 74: 1085.
Neinstein LS: Adolescent Health: A Practical Guide, 4 th Edition, Chapter 3: Woods ER, Neinstein LS: Office Visit, Interview Techniques and Recommendations to Parents. Lippicott Williams and Wilkins, Philadelphia , 2002.
Patterson G, Forgatch M. Parents and adolescents: living together. Part 1: the basics. Eugene , Oregon : Castalia Publishing, 1987.
Rainey DY, Brandon DP, Krowchuk DP. Confidential billing accounts for adolescents in private practice. J Adolesc Health 2000; 26 (6): 389.
Ryan C., Futterman D. Lesbian and gay youth: Care and counseling. State of the Art Reviews: Adolescent Medicine. Hanley & Belfus, Inc., Philadelphia , PA , 1997; 8(2): 259.