By Julia Joseph DiCaprio, MD, MPH, FAAP, MNAAP Board Member and Chief of Pediatrics at HCMC…
Tennessee Williams wrote the following about adolescence in his short story “The Resemblance Between a Violin Case and a Coffin”, “But between childhood and adulthood there is a broken terrain which is possibly even wilder than childhood was. The wilderness is interior. The vines and brambles seem to have been left behind but actually they are not so noticeable from the outside. Those few years of dangerous passage are an ascent into unknown hills. They take the breath sometimes and bewilder the vision.” Adolescence can be a difficult period and many find talking with teens challenging. Nevertheless, there are tools that can help health care providers communicate with teens to understand the context in which they live, and determine if they are engaging in any risk behaviors or are at risk for a negative health outcome.
An important first step in communicating with teens is explaining confidentiality to them and their parent/guardian. Research has found that physician assurances of confidentiality decreased adolescents’ anxiety and increased the teen’s general trust; increased trust regarding discussion of specific sensitive topics; increased perception of the physician as someone the teens could talk to; and, increased comfort with the physician. The teens were also more likely to disclose information and seek health care after an assurance of confidentiality.
Self-report surveys are key to assessing the health of the youth. It has been shown that most middle school and high school students completed these questionnaires honestly. These surveys should be administered at every preventive health visit or if the concern about a problem behavior arises. The American Academy of Pediatrics works with the Maternal and Child Health Bureau’s Bright Futures on implementing health supervision guidelines that include such self-report tools. Bright Futures includes developmentally appropriate previsit and supplemental questionnaires to be completed by the teen. There are separate questionnaires for parent/guardians and all the surveys include questions about various aspects of health including mental, dental and sexual.
Bright Futures also has psychological and behavioral assessment tools. For example, the Pediatric Symptom Checklist (PSC) is, according to Bright Futures, “a psychological screen designed to facilitate the recognition of cognitive, emotional, and behavioral problems so that appropriate interventions can be initiated as early as possible.” The PSC score can range from 0-70 and scores 28 or higher indicate potential psychological problems that need further discussion and evaluation.
There is also the Patient Health Questionnaires (PHQ) for depressive disorder screening. A positive score on either of the questions on the PHQ-2 should be followed by further testing with the PHQ-9 or other some other detailed assessment for depression performed. The PHQ-2 score can range from 0-6 and a score of 3 or greater has a sensitivity of 83% and a specificity of 92% for a major depressive disorder. The PHQ-9 score ranges from 0-27 with depression severity ranging from mild to severe for scores 5 or greater. The PHQ-9 can also be used to monitor a patient’s depression.
The Car, Relax, Alone, Forget, Friends, Trouble or CRAFFT screening questionnaire allows assessment of substance use by an adolescent in addition to uncovering the circumstances of the use. For example, if a youth discloses any substance use on the questionnaire, they are then asked more questions to determine when and for what reasons they use alcohol and drugs, and if they have had any adverse consequences from the use. This and other similar screening questionnaires are part of the medical record and can be scanned in and made a part of an electronic health record (EHR).
Providers use other tools to understand the context in which a teen exists such as the published, organized approaches for health screening. For example, HEADSS is an approach in which a youth is asked about the areas of Home, Education, Activities/Employment, Drugs, Suicidality, and Sex. HEADSS questions can be asked quickly and the answers entered directly into any medical record, including an EHR. Because adolescents engage easily with computers, using the EHR in the exam room can facilitate discussions with a teen and is not a barrier to communication.
In summary, getting to know an adolescent and assessing for risk behaviors in a busy clinic is challenging. Nevertheless, there are tools that can make this work easier. They include assurances of confidentiality, self-report questionnaires, and organized health screening questions.
