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Approaching Difficult
Subjects with Teens
Daryl A. Lynch, MD, FAAP, FSAHM
Professor, University of Missouri—Kansas City School of
Medicine
Chief, Section of Adolescent Medicine
Vice Chair of Ambulatory Medicine
Department of Pediatrics
Children’s Mercy Hospitals and Clinics
Objective
 By the end of the presentation,
participants will be able to:
Identify
Why confidentiality is essential to
adolescent clinical care
Understand
The laws regarding minors’ access to
reproductive health services
Describe
How a teen can receive confidential
services at CMH or the community
Rationale for Confidentiality
Confidentiality in Adolescent
Healthcare
Clinically
Essential
Developmentally
Expected
Supported
by Expert
Consensus
Developmentally Expected
 Confidentiality is developmentally
expected:
 Emotional need for increasing
autonomy
 Increasing intellectual capacity to give
informed consent
 Opportunity to take responsibility for
health
Case Discussion
 Michelle is a 15-year-old woman who has
come to your clinic with her mother
complaining of an ear infection. When being
weighed Michelle asks if she can get a
pregnancy test without her mother knowing
it.
How do you
proceed?
Adolescent-Friendly Health
Services Include:
 Establishing a comfortable, confidential,
safe space maintained by office staff and
providers.
 Communicating respectfully and
appropriately.
 Screening for high-risk behavior.
 Awareness of how:
 ability, age, culture, gender identity,
sexual orientation, religion,
socioeconomic status, can affect an
adolescent’s reproductive health.
Adolescent Friendly Services:
 Adolescent-specific
 Multi- and
interdisciplinary
 Accessible
 Financially
affordable
 Adolescent-focused
materials on display
 Peer educator
component
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Adequate space
Confidential
Flexible scheduling
Comprehensive
services
 Continuity of care
 Help transitioning
into the adult
medical care system
Preparing for Clinical
Visits
Discuss Confidentiality in
Advance
 Inform parents about confidentiality
policy before the visit.
 Consider sending a letter home:
 Detail reasons for wanting to meet alone with
teen (responsibility)
 Discuss billing issues
 Display materials such as posters
or brochures discussing
importance of doctor/patient
confidentiality.
A Message for our older patients here in the
Dialysis Center…
Our discussions with you are private. We hope
that you feel free to talk openly with us about
yourself and your health. Information is not
shared with other people unless we are
concerned that someone is in danger.
Develop Referral Network
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Social worker
Nutritionist
Psychologist or counselor
Abortion, adoption, and prenatal
care services
 CMH Teen Clinic
 STD clinics
 Planned Parenthood
The Clinical Interview
(Including the
“parentectomy”)
Comprehensive HEEADSSS
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H: Home
E: Education/Employment
E: Exercise/Eating
A: Activities
D: Drugs
S: Suicidality/Depression
S: Sexuality
S: Safety
*Additional questions:
 Strengths, Spirituality
Utilizing HEEADSSS
 Time limitations make model
difficult
 Can use written questionnaire in
waiting room
 Provider should follow up on
answers drawing concern
Other Clinical Interview Tools
 GAPS: AMA Guidelines for Adolescent
Preventive Services
 Bright Futures: Collaboration between
AAP and Bureau of Maternal Child Health
Care
 Trigger Questionnaire: Developed by
Office of Managed Care in the New York
State Department of Health
 ACOG Tool Kit: Designed by the ACOG
Committee on Adolescent Health Care to
help every office care for adolescent
patients
Drug and Alcohol Use
Drugs and Alcohol
 Does anyone you hang out with smoke,
drink, or use drugs? Do you?
 How frequently and how much?
 Do you smoke or chew tobacco?
 Do you use anabolic steroids?
 Do you drink alcohol?
 What kind: beer, wine, hard liquor?
 Any blackouts? Ever pass out? Vomit?
Drugs and Alcohol
 Do you use any other drugs?
 Marijuana, inhalants, cocaine, crack, heroin,
pills, LSD, ecstasy, crystal meth, other
drugs?
 Ever do anything you have regretted while
high?
 Context of use: socially, alone, how often?
 Attitudes toward cutting back and/or quitting?
 Ever received drug treatment or counseling?
 How is your drug use supported?
 Have you ever had any arrests?
CRAFFT Questions: Identify
Problem Use
 Have you ever ridden in a Car driven by someone
who was high or had been using alcohol or drugs?
 Do you ever use alcohol or drugs to Relax, feel
better about yourself, or fit in?
 Do you ever use drugs or alcohol when you are
Alone?
 Do you Forget things while using drugs or alcohol?
 Do your family or Friends ever tell you that you
should cut down on your drinking or drug use?
 Have you ever gotten into Trouble while using
drugs or alcohol?
Copyright © Children's Hospital Boston. All rights reserved
Depression and
Suicidality
Depression/Suicidality
 What is your usual mood: happy, sad, both?
 What do you do to cope with or relieve
stress?
 Have you ever received counseling and/or
therapy?
 Have you ever been in a psychiatric hospital?
 What was the reason?
 How long did you stay?
 Have you ever thought of hurting yourself?
 Have you ever tried to hurt or kill yourself?
 Whom did you tell?
Sexuality
Sexual Orientation
Sexual
Attraction
Sexual Behavior
Paradigm of
Sexuality
Biological
Sex
Gender Identity
Sexual/Reproductive
Health History
 Number of lifetime
sexual partners
Sexual orientation

Number
of
partners
in
Gender identity
last 3–6 months
Age at first
 History of STIs
intercourse
 Sexual satisfaction
Vaginal, oral, anal sex
 History of survival
history
sex, sexual
Contraceptive history victimization,
unwanted or coerced
Pregnancy history
sex
Timing of
childbearing plans
 Menstrual history
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Sexual Behavior Questions
Don’t
 Ask “Are you sexually
active?”
 Use gendered-biased
pronouns when referring
to sexual partners
 Use judgmental language
 Use slang unless patient
offers it first
Do
 Assure confidentiality
 Explain why you are
asking sensitive questions
 Ask patient to describe
specific sexual behaviors
 Add “second tier”
questions to assess
comfort with behaviors
Including Sexual Minority
Youth
 Actual prevalence of gay, lesbian, bisexual
(GLB), transgender, and questioning is
unknown
 Try to make educational materials and
other materials (posters, pictures, etc.)
have appeal to sexual minority youth
Assessing Sexual Orientation
 Are you romantically interested in
boys, girls, both or neither?
 Are you comfortable with your
feelings?
 For younger teens: when you imagine
yourself in a relationship in the future
is it with a boy, a girl, or both?
Discussing Sexual and Romantic
Relationships
 Have you ever had a crush on a boy
or girl? What was that like?
 Have you ever had a romantic
relationship with someone?
 How would you describe it?
 Tell me how far your relationships
have gone physically
Assessing Sexual
Behavior
 How old were you when you first had
sex? (Include anal, oral, and vaginal.)
 What was the date of your last
intercourse?
 Did you use condoms with last sex? If
not, what are the barriers that keep you
from doing that? NO WHY’s!
 How many sexual partners have you
had?
Sexual Health
 Have you ever had any STIs?
 Do you know that most infections cause
no symptoms?
 Have you ever been tested for an STI?
 Have you ever been pregnant or gotten
anyone pregnant? What were the
outcomes?
 Do you have any concerns about fertility?
 When (if ever) would you like to have
children?
Sexual and Physical Abuse
 Have you ever been forced to have sex or
been touched in a way against your will?
 By whom and is this still going on?
 Who did you tell?
 How does it affect your day-to-day life?
 In what ways does that experience affect
your sexual relationships now?
 Has anyone ever hurt you on a repeated
basis? At home, in school, or in your
neighborhood?
Interpersonal Violence
includes
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Child abuse
Battering
Domestic violence
Partner violence
School, peer, community violence
Sexual harassment
Sexual abuse
Sexual assault
Hate crime
Strengths*
 Assess healthy behaviors and
resiliency throughout the
interview
 Identify past difficulties that
have been overcome
 Provide positive feedback and
balance to the interview
Please Complete Your
Evaluations Now
Provider Resources
 www.prch.org—Physicians for Reproductive Choice and
Health
 www.aap.org—The American Academy of Pediatrics
 www.acog.org—The American College of Obstetricians and
Gynecologists
 www.adolescenthealth.org—The Society for Adolescent
Health and Medicine
 http://www.aclu.org/reproductiverights—The Reproductive
Freedom Project of the American Civil Liberties Union
 www.advocatesforyouth.org—Advocates for Youth
 www.guttmacher.org—Guttmacher Institute
 www.cahl.org—Center for Adolescent Health and the Law
 www.gynob.emory.edu/centers/jfc—The Jane Fonda Center
of Emory University
 www.siecus.org—The Sexuality Information and Education
Council of the United States
 www.arhp.org—The Association of Reproductive Health
Professionals
Provider Resources
 PRCH’s Minors’ Access to Confidential Reproductive
Healthcare Cards and Emergency Contraception: A
Practitioner’s Guide
 ARHP’s Reproductive Health Model Curriculum
 AMA Guidelines for Adolescent Preventive Services
(GAPS)
 The American College of Obstetricians and
Gynecologists:
 Confidentiality in Adolescent Health Care
 Primary and Preventive Health Care for Female Adolescents
 Tool Kit for Teen Care—available at:
 www.acog.org/bookstore/Tool_Kit_for_Teen_Care_P348C84.cfm
 For emergency contraception: www.not-2-late.com