Talking with Teens

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Information about Talking with Teens
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Published on March 13, 2009

Author: measbhc

Source: authorstream.com

“Talking with Teens, Minor's Rights, and How To Squeeze the Dirt out of them”. : “Talking with Teens, Minor's Rights, and How To Squeeze the Dirt out of them”. Jonathan Fanburg, MD, MPH Maine Assembly of School Health 11/7/08 Disclosure : Disclosure I have no financial relationships to anything I will be discussing today. What I am going to talk about : What I am going to talk about Risks taking and interviewing Minor’s rights Why teens like (or don’t like) you How to keep up with the clock Key Interview Basics : Key Interview Basics The Beginning The Middle The End Key Interview Basics(the take home slide) : Key Interview Basics(the take home slide) 1. The Beginning (the greeting) Talk to adolescent Outline visit Define confidentiality Get agendas (x2) Size up cognition - Open ended questions 2. The Middle (the interview) HEADS assessment – size up development Non-judgemental, empathy, poker faced, Open ended becomes directed questions Demonstrate cleanliness 3. The End (the treatment) Teachable moments Building resilience Teen Mortality : Teen Mortality 10-14 year old Accidents Malignancy Suicide Congenital Conditions 5. Homicide 15-19 year old Accident Homicide Suicide Malignancy Heart Disease Teen Morbidity : Teen Morbidity Unintentional injuries Intentional injuries Substance Use Sexual Behaviors Psychiatric illness Overweight Suzy : Suzy 13 year old comes to the school nurses office for the first time. Key Interview Basics(the take home slide) : Key Interview Basics(the take home slide) 1. The Beginning (the greeting) Talk to adolescent Outline visit Define confidentiality Get agendas (x2) Size up development - Open ended questions 2. The Middle (the interview) HEADS assessment Non-judgemental, empathy, poker faced, Open ended becomes directed questions 3. The End (the treatment) If your are digging for dirt, know where to dig. : H – home E – education A – activity D – diet D – drugs S – sex S - suicide If your are digging for dirt, know where to dig. Tell me about your dietary health? Are you careful with how you eat? VS Is weight something you wish to work with? If your are digging for dirt, know where to dig. : If your are digging for dirt, know where to dig. H – home E – education A – activity D – diet D – drugs S – sex S - suicide What Do Teens Want us to Talk about?(want us to initiate conversation) : What Do Teens Want us to Talk about?(want us to initiate conversation) Drugs, STI’s, Smoking What Do We Talk About? Eating, Weight, Exercise ME School Stats - % who received Intervention 2006-07 Nutrition 81%, Exercise 25% Sexual Activity 29%, Etoh 28%, Smoking 31% (AAP NCE, 10/09.) Confidentiality? : Confidentiality? Why? Stating Confidentiality policy increases odds of disclosure. (Ford. JAMA 1997;278:1029) What? When? MCMH Providers See TeenagersAbout Sensitive Issues! : MCMH Providers See TeenagersAbout Sensitive Issues! 1 year sampling of data (2003) AGES 10 - 18 1595 Different teenagers seen at MCMH 170 Chlamydia/gonorrhea DNA probes sent (7 were positive (4.1%)). More if included molecular amplification tests. Source: Cliff Vaux, LSS Computer, July 2003. MCMH Providers See TeenagersAbout Sensitive Issues! : MCMH Providers See TeenagersAbout Sensitive Issues! AGES 10 - 18 143 Pregnancy tests done (8 were positive (5.6%)). 126 Patients seen over 306 visits with depression or anxiety. Source: Cliff Vaux, LSS Computer, July 2003. (Include state teen preg rate) Do I provide confidential health care to all teens? : Do I provide confidential health care to all teens? Depends Depends Depends Depends Depends on the Issue Depends on the Age Depends on the Circumstances Case #1 : Case #1 18 year old female wants Birth Control Case #1 : Case #1 18 year old female wants Birth Control You provide care. Confidentiality is outlined by HIPPA guidelines. Case #2 : Case #2 18 year old female wants Birth Control She comes with her mother. Case #2 : Case #2 18 year old female wants Birth Control She comes with her mother. Set the stage Eye contact with patient. Outline the visit. Get the agenda(s). Size up the patient (development, cognition) Interview her alone briefly (HEADS) She tells you she is sexually active already. Case #2 : Case #2 18 year old female wants Birth Control She comes with her mother. Interview her alone briefly. She tells you she is sexually active already. STD Testing, PAP if indicated ** Provide care. Confidentiality is outlined by HIPPA guidelines. Case #2a : Case #2a 18 year old female wants Birth Control Mother Calls for test results. Can’t give them out without the patient’s explicit consent. HIPPA Best to get permission as to what to do every time a test is being obtained. Case #3 : Case #3 17 year old female with abdomen pain. Her mother comes along. Visit outline and confidentiality You interview her alone and she says she wants Birth Control. Case #3 : Case #3 17 year old female wants Birth Control Interviewed alone, SA, needs testing. Do HIPPA Guidelines apply? Can you give out birth control without parental consent? “Minors’ Rights to Confidential Health Care in Maine” (2002)www.prch.orghttp://www.prch.org/assets/library/6_maine.pdf : “Minors’ Rights to Confidential Health Care in Maine” (2002)www.prch.orghttp://www.prch.org/assets/library/6_maine.pdf Physicians for Reproductive Choice and Health Maine Chapter AAP Maine Medical Association Center for Adolescent and Young Adult Health, MCMH ACLU of Maine Family Planning Association of Maine HIPPA for Teens : HIPPA for Teens If a state has a law addressing teen health, it supercedes federal HIPPA laws. Hence, DEPENDS ON THE ISSUE. Maine Laws for Teens : Maine Laws for Teens STD's/HIV Pregnancy Contraception Emotional Health Drugs/Alcohol Maine Law : Maine Law Sexually Transmitted Diseases Testing and Treatment Includes HIV New HIV consent laws 2002 law, changed 2007 HEADS Questions: “Have you started dating yet?” “Have you started having sex yet?” “Have you started kissing or touching personal parts?” “Do you date girls, guys, or both?” “Have you ever been touched in spots where you didn’t Want to be touched, or had sex when you didn’t want to?” Watch For PAUSES in Responses Maine Law : Maine Law Sexually Transmitted Diseases Pregnancy Testing / Abortion For abortion, need counseling from a provider, nurse, clergy, or other need consent from an adult family member need consent from a judge. Maine Law : Maine Law Sexually Transmitted Diseases Pregnancy Testing / Abortion Contraception oral, injectible, implantable, patch, emergency contraception So long as the provider believes the minor would “suffer probable health hazards” if she does not receive these services. Maine Law : Maine Law Sexually Transmitted Diseases Pregnancy Testing / Abortion Contraception Emotional / Psychological Health Although not explicit, it includes anxiety and depression including treatments. If actively suicidal or homicidal, obligation to disclose exists. HEADS Questions: “On a 1-10 scale of happy to sad, what are you?” How high? How low? “Do you ever feel like hurting yourself?” Maine Law : Maine Law Sexually Transmitted Diseases Pregnancy Testing / Abortion Contraception Emotional / Psychological Health Drug / Alcohol Abuse HEADS Questions: “Have you tried cigarettes before?” “When was the last time you used pot?” “When was the last time you used etoh?” “What is the hardest drug you have tried?” (Use peer as marker of risk.) CRAFT : CRAFT C – driven in a CAR R – use drugs/etoh to RELAX A – use drugs/alcohol ALONE F – FORGET things while using drug/etoh F – do FRIENDS tell you to cut down T – ever been in TROUBLE (>2 gives Sens 76%, Spec 94%, PPV 83%) (John Knight, Children’s Hospital) Case #3a : Case #3a 17 year old female seeks care for ear infection Case #3a :  Case #3a 17 year old female seeks care for ear infection Don’t evaluate or treat her unless it is an emergency. LAWSUIT Case #3a : 17 year old female seeks care for ear infection EXCEPTIONS: CAN SEEK ALL CARE 1. Living separate from parents and financially independent > 60 days. 2. Has ever been married or in military. 3. Has been emancipated by courts. Case #3a Safe Case #4 : Case #4 13 year old female wants Birth Control. Seen alone. Sexually active with another 13 year old. Case #4 : Case #4 13 year old female wants Birth Control. Seen alone. Sexually active with another 13 year old. Tests POSITIVE for chlamydia. Demands Confidentiality Maine Law : Maine Law Where Maine law allows a patient to consent for care, they also allow confidentiality. *** Teen must be capable of consent in order to obtain confidentiality. *** DEPENDS ON AGE (not chronological), but DEVELOPMENTAL AGE TeenDevelopment 101 : TeenDevelopment 101 Early Adolescence (10-13) Self centered Struggle with autonomy and separation from parents Preoccupied with body image – compare self to peers – the body “norm” keeps changing Very concrete thinkers Look to outside house for role models I.e. have to be able to consent in very clear, concise, black and white terms. Neinstein. Adolesc Health Care: A Practical Guide. 2002. DEVELOPMENTAL AGE : DEVELOPMENTAL AGE Mid Adolescence (14-16) Strongly attached to peer group Trying out different images (pants, looks, ect) Appeal to opposite sex (sexual experimentation, view partner as sex object) Risk takers, impulse driven Invincible Trying to prove autonomy – Let Teen Arrive at Right Conclusions on Own. Neinstein. Adolesc Health Care: A Practical Guide. 2002. DEVELOPMENTAL AGE : DEVELOPMENTAL AGE Late Adolescence (17-19) Adult level of abstract reasoning, yet idealist. Respond to more traditional adult approaches. Relationships are 1:1 with intimacy and caring. Satisfied with body image, work on personality Neinstein. Adolesc Health Care: A Practical Guide. 2002. Case #4 : Case #4 13 year old female wants OCP’s. Seen alone. Sexually active with another 13 year old. Tests POSITIVE for chlamydia. Demands Confidentiality She is rational, capable of making mature decisions You decide to treat confidentially Case #4a : Case #4a 13 year old female wants OCP’s. Tests POSITIVE for chlamydia. Demands Confidentiality. Doesn’t want to be treated. Maine Law : Maine Law Exceptions to Confidentiality Law “If failure to inform parent would seriously jeopardize the health of the teen or would limit the provider’s ability to provide medical care,” the provider may break confidentiality. Other Times: Suspected child abuse or neglect. When the minor makes threats against self or other. Teens treated inpatient for greater than 16hrs require parental notification. Submitting bills to insurance company DEPENDS on the CIRCUMSTANCES Risk of Inappropriately Breaking ConfidentialitySystem Flaws : Risk of Inappropriately Breaking ConfidentialitySystem Flaws Parent calls for test results Office does reminder calls for patient visits Parent needs copy of medical records Records are transferred and new provider discloses information Teens can be seen confidentially for 5 topics (contraception, pregnancy, sexually transmitted diseases, drugs, and emotional issues).2. They must be capable of consent.3. They must make rational non-harmful decisions for treatment.4. Confidentiality must be broken if abuse, suicide, homicide, or extended hospitalizations. : Teens can be seen confidentially for 5 topics (contraception, pregnancy, sexually transmitted diseases, drugs, and emotional issues).2. They must be capable of consent.3. They must make rational non-harmful decisions for treatment.4. Confidentiality must be broken if abuse, suicide, homicide, or extended hospitalizations. Confidentiality Pearls Key Interview Basics(the take home slide) : Key Interview Basics(the take home slide) 1. The Beginning (the greeting) Talk to adolescent Outline visit Define confidentiality Get agendas (x2) Size up cognition - Open ended questions 2. The Middle (the interview) HEADS assessment – size up development Non-judgemental, empathy, poker faced, Open ended becomes directed questions Demonstrate cleanliness 3. The End (the treatment) Teachable moments Building resilience Teen Friendly Clinic? : Teen Friendly Clinic? Adolescents are not just small adults, nor are they Big Kids. Slide 52: Décor MUSIC Age Appropriate Posters Educational Brochures Staff Appearance Patient Typing Slide 53: OFFICE STAFF Patience Friendly Smiles Confident Complimentary Non-Judgmental Reassuring WATCH NON-SPOKEN BODY LANGUAGE Teen Advocate Accommodating Teen Friendly Clinic : Teen Friendly Clinic Very Self Conscious Think Short Term - want quick visit - - want quick fix - Easy Access (telephone, location, check in, return calls) Valued as a patient (Communicate respect, empathy, interest) Confidentiality statement clearly stated, and kept. Clean environment and provider Straight talk Treated as an adult Interview Technique : Interview Technique “So!…you STILL won’t talk, eh?” Interview Technique : Interview Technique Lazare et al Define relationship – confidentiality, disclosure, who’s doctor you are, order of interview. Stating Confidentiality policy increases odds of disclosure. (Ford. JAMA 1997;278:1029) Communicate professional expertise – dress, demeanor, confidence – unforgiving teens Communicate interest, respect, support, and empathy – don’t dismiss issues, don’t make teen jokes as a group, don’t talk in 3rd person Recognize barriers – hostile patient, own issues Recognize patient’s perspective – of symptoms, diagnosis, and treatment Lazare. The Medical Interview. 1995. Interview Technique : Interview Technique Bi-directional interviewing Open ended questions, supportive statements, non-judgmental, attentive, asking patient opinion (Lazare. The Medical Interview. 1995) Fewer lawsuits (Schubiner, J Adol Health. 17:37-41; 1995.) More likely to get information disclosure of sensitive information (Wissow, Pediatrics. 93:289-95 1994.) Slide 58: ? ? The Teen Perspective : The Teen Perspective Ginzburg Teen Focus Groups (Source: Ginsburg KR. Pediatrics. 1997, 100; 6: 922-30.) Ginsburg Conclusions : Ginsburg Conclusions Provider characteristics are more important than site/system characteristics Teens worry about disease transmission more than respect Respect is measured by straight talk, long waiting room period, recognition of illness/discomfort, recognition of patient modesty Teens want explanations of what is going on Confidentiality must be demonstrated (Source: Ginsburg KR. Pediatrics. 1997, 100; 6: 922-30.) Ginsburg Conclusions : Care more about provider empathy than age Females prefer female provider. Males prefer male interviewer, female examiner. Recommendations Wash hands/open sterile packaging in front of teenager. Demonstrate competence by hanging diplomas up. Post signs stating why some patients are seen out of order. (Most teens don’t understand concept of triage.) Proof: Adolescents who are satisfied with their provider are more likely to keep appointments consistently and follow through with treatment regiments. (Litt. J Adol Health. 1984;4:196-200) (Source: Ginsburg KR. Pediatrics. 1997, 100; 6: 922-30.) Ginsburg Conclusions Key Interview Basics(the take home slide) : Key Interview Basics(the take home slide) 1. The Beginning (the greeting) 2. The Middle (the interview) 3. The End (the treatment) – time efficient Teachable moments Building resilience Slide 64: FOCUS History taking Use risk based algorithms for questions Positive comments for good behavior. 3 types of answers: Perfect responses – Resilience building Many agenda issues – pick 1-2, revisit for rest Problems – address problem, postpone rest Build Resilience – Circle of Strengths : Build Resilience – Circle of Strengths (Circle of Belonging, Brentro, 1998) Key Interview Basics(the take home slide) : Key Interview Basics(the take home slide) 1. The Beginning (the greeting) Talk to adolescent Outline visit Define confidentiality Get agendas (x2) Size up cognition - Open ended questions 2. The Middle (the interview) HEADS assessment – size up development Non-judgemental, empathy, poker faced, Open ended becomes directed questions Demonstrate cleanliness 3. The End (the treatment) Teachable moments Building resilience The End : The End Slide 69: Maine Laws Related to Sex in Teenagers 1. Sexual Assault/Abuse/Rape in Maine Title 17-A, Chapter 11 (254) Sexual abuse of a minor if Child is 14 or 15 years old and perpetrator is 5 years older. Child is 16 or 17 year old students and Perpetrator is >=21 years old school teacher/official/employee 2. (253) Gross sexual assault if Child is < 14 years old. Child is < 18 years old student and Perpetrator is a teacher/official/employee. Same for foster care/group home/ect. 3. (255-A) Unlawful sexual contact if Child is < 14 years old and Perpetrator is 3 years older. Child is < 18 years old student and Perpetrator is teacher/official/employee. Same for foster care/group home/ect. 4. (260) Unlawful sexual touching Child is < 14 years old and Perpetrator is 5 years older. Child is < 18 years old and Perpetrator is teacher/official/employee . Reportable: Title 22, Chapter 1071 rape, gross sexual misconduct, incest or sexual abuse (4012) abuse and neglect must be reported within 48 hours

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