The Adolescent Interview

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The adolescent interview can present a number of special challenges, as well as its own special delights.

Adolescents, aged 13 to 22 years, make up 15% of the U.S. population. Too old to be considered children but too young to be considered adults, adolescents may avoid health care because they do not feel comfortable either at the pediatrician's office or at an internist's office. On the other hand, mortality rates are almost five times higher among 15- to 24-year-olds than among 5- to 14-year-olds, and adolescents experience considerable morbidity. Perhaps 20% of adolescents have a chronic health condition, and many suffer consequences of engaging in adult behaviors: sexual activity, drug and alcohol use, driving, paid employment, and competitive sports. Adolescents' limited life experience and their psychologic stage (described as ''adolescent egocentrism'') magnify the risks of these exposures. The rapid physical changes in a teenager's body come at a time when the psychologic process of forming a body image is at its strongest; the mismatch between the actual and the desired physique can be a serious source of distress for a teenager. Major mental illness, from depression to schizophrenia, can manifest in this age range as well.

Until ages 11 to 12 years, the pediatric history is usually obtained from the child and parent together. Both sources continue to be important, but it is essential to give an adolescent private time with the doctor. In fact, laws in most states entitle adolescents to confidential care for sexually transmitted diseases, pregnancy, and drug use.

Early in the visit, it is vital to establish the ground rules about confidentiality with both the parent and the teenager, as well as to support the parent's role in their son's or daughter's health care. For instance, the clinician may say something like, ''For someone your son's age, it's very important for him to have a private visit with his doctor, just as it would be for you with your doctor. I will keep what he and I talk about confidential unless something comes up that is acutely life-threatening. While it's crucial that I keep what he tells me confidential, I also encourage my teenaged patients to share with their parents what they have told me.''

The HEADS mnemonic is a useful tool for remembering the main topics for the private adolescent interview. Beginning with more neutral questions about home, education, and activities can promote the teenager's comfort, and the teenager can see how you respond to disclosures. For ''Home,'' you might ask the following questions:

How are things at home?'

What are your responsibilities?''

What are the rules that you have to follow?''

Do you have brothers or sisters? How do you get along? What sort ofthings do you argue about?''

If the situation warrants it, you might need to ask, ''Do you feel safe at home?''

For ''Education,'' you can ask the following questions:

How is school going?'' What grade are you in?'' What school do you go to?'' What subjects are you taking?'' What do you like best? least?'' What are your future plans?'' Do you feel safe at school?''

If indicated, you might need to ask the following questions:

Have you been involved in any fights?''

Have you ever been suspended? What was that about?''

''A'' can stand for ''activities'' or ''alcohol.'' Some questions about activities are as follows:

Are you involved in any clubs or sports?''

What do you do after school?''

What do you like to do with your friends?''

Are your friends mostly girls? mostly boys? both?''

Asking about alcohol use broaches a potentially sensitive subject, and there are many ways to introduce it; for instance:

' 'Do any of your friends use alcohol? Have you ever tried it?''

''Lots of kids your age are curious about drinking. How about you?''

' 'You mentioned that you like to go to clubs with your friends. Are any of you served alcohol there?

If the teenager does report drinking, then you need to explore how much, how often, and whether there have been negative consequences: for example, losing consciousness, a ''driving while intoxicated'' (DWI) offense, or a suspension from school.

''D'' stands for ''drugs'' or ''depression.'' Drug use can be asked about in the same way as alcohol. Remember that nicotine and other chemicals in tobacco are drugs. Screening for depression merits special emphasis. Suicide is one of the top three causes of death among teenagers, and at least 50% of teenagers who complete suicide had visited a physician in the preceding 2 weeks. Therefore, at every visit with a teenager, ask something like:

How has your mood been?''

' 'Do you ever find yourself feeling down and sad for more than a few hours?''

If the teenager admits to a depressed mood, then you need to probe further: How would you describe your mood?''

Thoughts of suicide on the part of a teenager are a clear-cut indication to violate confidentiality. You must involve the parent or another responsible adult in getting the adolescent prompt mental health care.

The ''S'' stands for ''safety'' and ''sex.'' Safety refers not only to personal safety practices, such as using a seat belt or wearing a bike helmet, but also to the risk of violence in interpersonal relations: at home, with an intimate partner, at school, or in the community.

Almost 50% of students in 9th through 12th grades have initiated sexual activity, 6% of them before age 13 (2005 Youth Risk Behavior Survey).* Half of the new cases of sexually transmitted diseases occur in people aged 15 to 24 years, and almost 1 million girls aged 15 to 19 years become pregnant each year.

There are many ways to introduce the topic of sexual activity. For instance, you can normalize the questions: ''I know that lots of people your age are thinking about having sex. How about you?'' It may also be very helpful to explain your ''need to know'': ''In order to understand what is causing your pain, I need to know something about your sexual experiences.'' However or whenever you bring it up, it is useful to be explicit: Something like ''Have you ever had sex?'' is more likely to tell you what you need to know than ''Are you sexually active?'' The teenager may answer no to the second question because he or she has not had sex in 2 weeks. It is also important to consider the possibility that your patient is having sex with someone of the same gender and to phrase your questions with as little heterosexual bias as possible.

It can be challenging to maintain your composure when a teenager discloses high-risk behavior to you. You need to help the teenager appreciate the risk that he or she is incurring at the same time that you support your relationship with your patient. One way to handle this is to invite the teenager to reflect on his or her own behavior:

' 'You decided to get a ride home with Jason after he put away several beers. How are you feeling about that decision now?''

''I think we were both worried that you might have gotten pregnant last weekend, when you had sex without a condom. How do you think you could have handled that situation differently?''

A large number of teenagers who are sexually promiscuous turn out to have been victims of incest or sexual abuse as children. In more than 80% of all cases of sexual abuse, the molester is not a stranger. All children should be told that their bodies are private and that no one has the right to touch them in a way that makes them feel uncomfortable. Children need to know that there are different types of touch: Good touches are hugs, kisses, and pats; confusing touch is tickling or rubbing; bad touch is hitting, hurting, spanking, or touching or fondling the ''private parts'' of their bodies. Listen carefully to a child who describes any type of sexual abuse. Children do not confabulate sexually explicit stories. If the clinical circumstances warrant, a child older than 3 years of age can be asked the following:

Has anyone touched your body in any way that made you feel uncomfortable or confused?''

A child who has been sexually or physically abused may exhibit behavior such as aggression, moodiness, irritability, withdrawal, regression, memory loss, insecurity, and clinging. In addition, the child may exhibit some of the following physical changes: torn or bloody clothing, bruises or other suspect injuries, difficulty in walking or sitting, loss of appetite, stomach problems, genital soreness or burning sensation, difficulty in urination, vaginal or penile discharge, excessive bathing, or a desire not to bathe at all. An older child in school may exhibit a drop in academic performance, prevarication, stealing, or even running away from home.

Adolescents and even younger children now spend a great deal of time exploring the Internet, which is both a boon and a source of concern. Ask the youngster about the family's rules about using the Internet. Specifically, ask the following:

How much time each day do you spend online?'' ' 'Do you have a page on MySpace or FaceBook or something similar?''

''Have you ever been a victim of' cyber-bullying'? Have you ever gone out with someone you met online?''

The American Academy of Pediatrics has published guidelines for youngsters and families to minimize the hazards of Internet use.{

*CDC Youth Behavior Surveillance—US, 2005. MMWR Surveill Summ 55(55-S), June 9, 2006. {See http://safetynet.aap.org (accessed June 27, 2008).

Table 24-2 Apgar Scale

Sign

Score

0

1

2

Color

Blue pale

Pink body with blue extremities

Completely pink

Heart rate

Absent

Below 100

Over 100

Reflex irritability*

No response

Grimace

Sneeze or cough

Muscle tone

Flaccid

Some flexion of the extremities

Good flexion of the extremities

Respiratory effort

Absent

Weak, irregular

Good, crying

The acronym APGAR is useful for remembering the examinations of the Apgar test: Appearance, or color; Pulse, or heart rate; Grimace, or reflex irritability; Activity, or muscle tone; Respiratory effort.

The acronym APGAR is useful for remembering the examinations of the Apgar test: Appearance, or color; Pulse, or heart rate; Grimace, or reflex irritability; Activity, or muscle tone; Respiratory effort.

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