Questions, trust are vital in teen medical history
Where do your skills rate when it comes to taking a medical history from an adolescent? If you work in a publicly funded family planning setting, those skills need to be at top level, for four in 10 teen-agers who are sexually active and in need of contraceptive services turn to Title Xfunded clinics.1
Take a tip from two experienced adolescent care providers, who recently shared their experiences at two national seminars: the Contraceptive Technology conference in Washington, DC, and San Francisco and the North American Society for Pediatric and Adolescent Gynecology’s annual meeting in New Orleans.
"An essential feature of the encounter with the adolescent is to work at developing a relationship with the adolescent," says Susan Coupey, MD, professor of pediatrics at the Albert Einstein College of Medicine at Yeshiva University and associate director of the division of adolescent medicine at Montefiore Medical Center, both in the Bronx, NY. "In order to do that, one has to ask a couple of open-ended questions and then really listen to the adolescent to develop an interest in some area of the adolescent’s life."
Melanie Gold, DO, assistant professor of pediatrics at the University of Pittsburgh’s school of medicine, uses the mnemonic device "HEEADSSS" — Home, Education/Employment, Exercise/Eating, Activities, Drugs/ Depression, Suicidality, Sexuality, Safety — to cover important points in the medical history.
Gold starts early in the interview with open-ended questions, then progressively narrows the focus. By working through the lines of dialogue, the provider builds an active relationship with the adolescent. "This building of communication is different from the old way," she says. "We called on patients to give information, then we gave instructions, then we became unhappy if they didn’t follow the instructions."
Confidentiality is key
Whether a teen comes in for an examination accompanied by parent or alone, providers need to stress upfront the information is confidential. If treatment is to be effective, teens must feel they can divulge information without fear of judgment or recrimination, whether they need a prescription for birth control pills or a test for chlamydia.
If a teen is accompanied by a parent, Coupey usually greets them both and invites them into the office to talk for a few moments. She then asks the parent to leave the office during the examination. She uses this approach: "Your daughter is 15 now, and I’m going to talk with the two of you a little bit and then I’ll ask you to leave, Mrs. X. I will examine her, and then we’ll speak again together about what is going on." By setting these parameters, the provider has acknowledged that the teen is old enough to have private time with the provider.
Coupey suggests that once providers are alone with the teen, they approach the issue of confidentiality this way: "Now that we are alone, I just want to tell you that I’m going to ask you some questions that are about some very private matters. I want you to know that I’m not going to share the information with your mother or your parents unless I think your life is in danger."
Follow this statement with a more explicit one: "The things we talk about I will not share with your parents unless I think your life is in danger, and in that case, I will let you know. I’m not going to do it behind your back."
Gold informs teens she will break confidentiality in three situations: when a teen is suicidal, homicidal, or being physically or sexually abused. "I tell kids that upfront, and I think that it reinforces that what we talk about really is confidential. I think it also makes it clear that there are times when we have to not hold with the confidence."
As you work through the questions, an adolescent may share information on problems that are outside your scope of treatment. A complaint of amenorrhea may lead to discovery of a possible eating disorder. Questions about missing a couple of birth control pills may turn up signs of drug abuse. What do you do?
Develop a cadre of mental health resources, Gold suggests. Identify several with different scopes of practice, especially those specializing in eating disorders, substance abuse treatment, and anger management. Even better, know those who can handle requests for urgent attention.
Adolescent morbidity and mortality are connected with behavioral issues, Coupey says. It is essential to explore several aspects of a teen’s life to assess his or her risk for developing health problems. "Explore their relationships with their peers and within their family, as well as their recreational pursuits, their sexuality, drug use, and particularly issues of mental health because mental health problems are very prevalent in adolescents," Coupey explains. "Learn how to ask adolescents questions to explore their mental health without insulting them."
Reference
1. Frost JJ. Family planning clinic services in the United States, 1994. Fam Plann Perspect 1996; 28:98.
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