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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 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 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 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 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 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