profession

Conversation skills key when treating truculent teens

How, as a clinician, do you connect with a troubled or combative adolescent?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Feb. 11, 2013.

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Scenario A high-school-age adolescent accompanied by her mother comes into your office with an attitude that says, “I am not listening to anything you tell me.”

ReplyYour next clinic patient, allocated to a 15-minute urgent visit slot, is a 16-year-old girl with a possible diagnosis of “excessive anxiety.”

Before the appointment, the mother, also your patient, calls to tell you that her daughter has been acting out recently — coming home late, not answering phone calls and being rude and defensive when asked where she has been. You also know that the girl's parents are going through a divorce.

You are now in your office, and the patient is sitting across from you. She looks mad. Mom looks anxious. You ask the girl, “How are you? Is everything OK?”

Mom immediately interjects, “Everything is not OK! We are all stressed out. My daughter won't speak to me. My husband is a jerk! My daughter, I think, is having sex with strangers and smoking pot way too much. I am a mess. You know our story. Please help us!”

You look at the girl — your patient. You ask her if it is all right for her mother to leave the office so you can speak to her alone. You tell the mother that if anything medically concerning comes up that she should know, you will tell her immediately. And again, you ask both the mother and the girl if this OK. They both agree. Mom steps out. You promise the girl that everything she tells you is confidential, except if she wants to hurt herself or someone else, or if someone is hurting her, sexually or physically.

She says, “Whatever.”

Medical confidentiality concerns

Here's some background you should know: Federal and state statutes about medical confidentiality vary and are often vague, and subject to the doctor's discretion regarding disclosure of medical information regarding mental health and reproductive care, as a Guttmacher Institute web resource shows.

Beginning in the 1970s, the U.S. Supreme Court, along with state legislatures, allowed minors to make their own health care decisions. In many families, perfect harmony does not exist, and these laws were enacted not to undermine parents' authority, but to support a child when the notification of a parent would block the teen's access to needed medical care.

In these cases, the patient's right to privacy overrides the parent's right to know. The Mature Minor Doctrine provides doctors with rough guidelines for determining when to provide medical treatment based on the teen's consent.

If there is imminent medical danger to the child or others (actively drinking and driving, refusing treatment for diabetes), the parents or legal guardian should be notified.

Patient assessment interview

Now, turning back to the patient, you should work through the HEADSS assessment interview for Home, Education/employment, peer group Activities, Drugs, Sexuality and Suicide/depression.

Generally, it goes like this: Home: Where does she live? Who lives at home? Does she have her own room? Does she feel safe? Are there weapons in the home? Education: Where does she go to school? What grade is she in? What grades does she get? How many days of school has she missed in the past six months? Activities: Sports, clubs, work? Drugs: Is she using drugs or alcohol? Sexuality: Who is she attracted to — men, women or both? Is she sexually active? What is she using to prevent pregnancy and STDs? Finally, suicide: Is she depressed? Having thoughts of self-harm or thoughts of harm to others? Any history of physical or sexual abuse?

A synopsis of the interview may be as follows.

You ask the patient, “How is everything at home?”

“OK, I guess.”

“Are you sad?”

“Yes.”

“Do you want to run away, hurt yourself?”

“No.”

“Are you using drugs, or alcohol, or nicotine?”

“Just weed.”

“Is someone hurting you?”

“No — not really. Not at home, anyway. Just at school.”

“What do you mean?”

“Kids at school are just — well, they just don't get it. They have perfect lives and perfect homes, and mine just sucks. And they don't get it. So they don't include me in anything. They ignore me and just stare at me. My old friends have all just moved on. I feel so alone.”

“What can I do to help you?”

“Nothing.”

“Really? There is nothing I can do? I have known you since you have been born, since you were a little girl. I think I can help you.”

“How? Can you make my parents stop fighting? You know, doc … I don't want to stay out late every night. I hate waking up with guys I don't know. I feel awful when my younger siblings look at me like I am some kind of a freak. Can you get me counseling or something?”

And there you have it. You are in. Most teens are willing to be helped. If you follow the guidelines about confidentiality and then work through the format of HEADSS or a similar interviewing technique, you will obtain a thorough history. Adolescents will learn to trust you. Interesting and important is the fact that their families will, too. In this case, perhaps you find the patient a counselor in her high school teen health center, and help her move away from some high-risk behavior, including frequent sexual contacts and use of marijuana.

But let's take a different patient and situation. Suppose the interview goes like this:

You ask the patient, “How is everything at home?”

No response.

You try again. “It seems like you are upset. I have known you since you were a baby, and I am very concerned about you. How can I help you?”

She says nothing and is weeping.

You look at her arms and notice that she has lacerations on both of her wrists, erythematous and inflamed. She quickly pulls her sleeves down.

“I notice that you have cuts on your wrists. I am very worried about these. Can you tell me what happened?”

She gets up to leave.

You say, “I need you to stay here for just a few minutes.”

You then call your social worker, your nurse or even 911 to contact mental health professionals to help with this patient. It is important to ask for help when you need it or feel like you aren't getting through to the patient.

In this actual case, the social worker quickly responded and began talking to the patient. I left to contact the family. The patient was gently escorted to the emergency department for assessment of her self-harm behavior and ultimate psychiatric admission.

Was the patient mad at me? Maybe initially, but not ultimately. Will she ever thank me for helping her? Maybe. Probably not. But that was not my goal. My goal as the physician was to provide care for her and keep her safe.

Cora Collette Breuner, MD, MPH, professor of adolescent medicine, Seattle Children's Hospital, University of Washington

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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External links

Guttmacher Institute, “Overview of Minors Consent Laws” (link)

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