Providing excellent care for adolescents includes creating a safe space for confidential discussions. The clinically excellent pediatrician is able to help support the teen to share sensitive concerns with parents and caregivers.
For the past 18 years, I’ve been working as a primary care pediatrician and clinical preceptor for residents and medical students in a practice serving primarily low-income urban youth and families.
The daily stress of adolescence
Adolescents of all socio-economic backgrounds face considerable stress in their daily lives. Many have experienced major traumatic events and other adverse childhood experiences (ACEs), like physical, verbal or sexual abuse, parental substance use, witnessing interpersonal violence at home, parental incarceration, and others.
The annual visit may be the only place where adolescents are given time to talk with a trusting adult, like their pediatric healthcare provider. The annual well visit for adolescent patients provides an important opportunity to help teens deal with psychosocial challenges at home or school.
Visits should start with setting an agenda, including meeting alone with the adolescent to provide time and space for a confidential discussion. Providers should articulate with youth and parents ahead of time when disclosed issues need to be shared (e.g., risk of harm to self or others).
A trusting relationship can save a life
In the clinical scenario below from Clinical excellence in pediatrics, based on a trusting and supportive relationship, the adolescent felt comfortable to share her feelings of guilt, self-blame, and suicidal ideation with her mother in the presence of the pediatrician.
Given the limited time we have with patients during annual visits, pediatricians may miss the opportunity to uncover important feelings, behaviors and concerns of adolescents.
Janine was a 13-year-old female brought to her pediatrician by her mother for an annual checkup. The mother had not planned to address behavioral concerns during the visit. The pediatrician, however, asked to privately interview the child. After talking with the daughter, the pediatrician obtained consent from the daughter to bring the mother in the room and talk about these peer pressure and anger issues she had brought up.
After having gained confidence by talking privately with the pediatrician, the daughter then revealed in the mother’s presence that she had wanted to kill herself for the last 6 months as a result of self-blame for her father’s recent fatal car accident. The mother and daughter had been having a lot of problems for over a year; consequently the mother expresses gratitude for the daughter’s ability to confide in the doctor about what was bothering her. Although ongoing work was required for this family, the pediatrician visit was a major step forward in addressing and managing the daughter’s behavioral issues.
Creating a non-judgmental space
I’ve had numerous clinical encounters where teens are initially hesitant to disclose concerns due to fear about how they’ll be perceived. While creating space for patient-physician confidentiality is critical in adolescent visits, it’s probably even more important to help teens see the value of sharing their concerns with their parents.
Using a caring, empathetic and non-judgmental approach, pediatricians can help adolescents share concerns with parents and other adult caregivers.
While this can take time and careful planning, the above patient story illustrates our intended goal of helping teens begin to process feelings and experiences and help them begin to heal.
A family-centered approach
In the above patient story, we can also imagine the pain the patient’s mother has been facing with the recent death of her husband.
The pediatric visit could potentially be the first time her mother has talked with someone since the accident and she may need mental health support or bereavement counseling herself.
The pediatric annual well visit should also be seen as an opportunity to assess the needs and wellbeing of our patients’ parents and caregivers.
Providing excellent clinical care for children and adolescents requires a family-centered approach and one that considers how family and community stressors impact our patients’ physical and emotional health.