What YP tell us about consultations

• ■ ‘Hello, I'm sitting here’: YP feel marginalised in consultations;10

• ■ YP want to be central in the consultation, with most of the conversation directed at them;

• ■ YP want parents to be actively involved, with bad news shared with both parents and YP at the same time;11

• ■ Consultations are often one sided, with lack of respect for the adolescent's point of view;

• ■ YP feel that they are not listened to, are patronised, lectured to and given unsolicited advice.12

Language

Language is a key issue when working with YP. The average young person has half the vocabulary of a 25- to 32-year-old, and some find it particularly hard to discuss emotions. Specific language develops within peer groups to give a sense of unity and identity, and at times, privacy. It is a mistake for health professionals to emulate youth language; this is as likely to alienate as to engage YP. Rather, professionals should act their normal selves, and enquire inquisitively about language they do not understand.

Our names are central to our identity: asking a young person how they wish to be addressed demonstrates interest in them. Likewise, how health professionals are addressed can influence the relationship they have with YP and their families. Prefixes such as doctor or professor are a two-edged sword; while they can be useful, they can also act to alienate YP by highlighting a power differential between the doctor and YP. YP describe this power imbalance as a contributor to poor communication.12

The critical first 2 minutes of a young person-centred consultation

• ■ Seat the YP in the prime position that facilitates communication most easily.

• ■ Introduce yourself first to the YP: My name is X, you can call me Y.

• ■ Ask them what they like to be called and who they have brought with them to the consultation.

• ■ Show interest in them and spend some time getting to know them before focusing on their medical problems (problem-free talk, see below).

• ■ Explain that you will routinely spend some time alone with the YP towards the end of the consultation.

• ■ Target questions first at the young person and then at the parents.

• ■ Ask the YP's permission to ask the parent for their opinions/observations.

Spend some time with the young person alone

Although it can be challenging to find the time, all consultations with YP should include time spent alone with the young person, even if only for a few minutes. It allows them a voice without their parents present and is an important part of transitioning the young person into adulthood and helping them become accustomed to consulting a doctor alone. Explain at the start that it is routine to spend some time alone with the young person towards the end of the consultation. Informing the family of this routine nature can help it feel less targeted and suspicious.

Offering YP time alone gives them the opportunity to discuss health concerns that they want to keep private. YP have concerns about confidentiality and frequently want to keep health concerns from their parents and their peers (57% and 69% of YP, respectively).13 One study showed that 25% of YP would not seek healthcare advice because their parents may find out, yet less than half of YP reported ever being told about confidentiality since seeking healthcare as a teenager.13 YP find disclosure of maltreatment difficult, and barriers include not knowing how to disclose and anxieties about being disbelieved.14 Seeing patients alone is vital if health professionals are to evaluate risk of maltreatment and give YP the opportunity to disclose abuse.

Spend some time with the parent alone

Parents often have concerns about YP being seen alone and they can be resistant to leaving the consultation room.15 This is often rooted in protectiveness and lack of preparation and you may need to offer the parents some time with you alone to help prepare the family to see this as an appropriate and helpful way of working with YP. If seeing parents alone, this should be done before seeing the young person alone to maximise YP confidentiality and trust; if done in reverse, the YP may have concerns that you are sharing their confidential information without them present in the room. Seeing parents alone allows them to discuss confidentially topics that either the YP may have banned them from talking about, such as bedwetting, or are too sensitive or private to talk about openly, such as previous abuse or parental difficulties.

Confidentiality

Assurance of confidentiality increases the adolescent's willingness to disclose sensitive topics such as sexuality, substance use and mental health, and to return for further healthcare.16 Vulnerable YP in particular are more likely to forgo seeing a health professional due to confidentiality concerns, particularly those who report health-risk behaviours, psychological distress and/or unsatisfactory communication with their parents.17 By defining clear indications of when confidentiality might be breached, with whom, and for what reasons, you will be empowering the young person to decide what they tell you. There is often a mismatch between how doctors and YP define both risk and reasons to break confidentiality; doctors may be thinking about sexual abuse and suicidal risk, while YP may interpret this as smoking, sex and drinking alcohol.

Explaining conditional confidentiality to YP

‘This conversation is private between you and me. This means I won’t tell your parents what we talk about unless you want me to. However, if you tell me something that worries me, I may need to share this with other people, such as another health professional or a social worker. I will tell you if I need to do this. The sort of thing I’m talking about is if you tell me that you have been sexually abused, or you are wanting to seriously harm yourself, or something serious like that, but not for other things, like drinking or smoking. Is that OK?'

Clinicians should not assume that the private conversation needs to remain confidential: YP at times withhold sensitive information from their parents because they do not know how to tell their parents. If they judge the clinician to be a skillful communicator, they may want him/her to act as a conduit to engage their parents to help resolve difficulties. By asking the YP what their parents know about the private conversation, the clinician is able to ascertain differences in knowledge and discuss strategies to manage this. Any clinician prescribing contraception is obliged to encourage the YP to discuss this with their parents, however they are neither obliged to talk directly to parents, nor enforce the discussion (Fraser Guidance).18

Parents may want to know what has been discussed in these private discussions, particularly if mental health, eating disorders or drug use have been disclosed.15 Parental understanding of confidentiality can be different to that of the young person and health professional17; at times they may assume that doctors will share all information gained from YP and so falsely infer that there are no problems if they are not informed about them. The key to managing these expectations is preparation and adequate parental education.19

What you need to know about confidentiality in YP

• ■ YP have a right to confidentiality, even if they are not competent.

• ■ YP should be informed if information is to be shared, with whom, and the decision justified.

• ■ YP need not be informed of disclosure if the clinician judges that it would further increase risk of harm.

• ■ Confidentiality should not be kept with disclosure of sexual abuse, significant suicidal thoughts or self-harm or homicidal intent.

Five techniques from brief therapies

MI and SFT are two forms of brief therapy developed by mental health professionals to promote or enable change in people's lives.20,–,23 They enable the clinician to move away from the expert approach, where the young person is told what to do, towards a listening and encouraging approach that respects the young person's views, experiences and wishes. They can be very useful tools for use in standard medical consultations with YP who may be struggling with difficult healthcare decisions in their life. These decisions are often related to managing their chronic illness. Here are five tips that can be easily used in your medical consultation:

1. Spend time not talking about the medical problem (problem-free talk).

   Spending a few minutes of a short consultation not talking about the medical problem may seem like a poor use of time and resources. However, when done effectively, the clinician becomes aware of skills and resources that the young person could use to manage their health. Understanding their goals and interests can be used as powerful motivators to improve health outcomes.

2. ‘What would you like to be different by the end of the consultation?’

   Asking what the young person wants to get out of the consultation allows you to focus on their needs. One young person with cancer reported ‘I don’t really mind that much about all the facts, I don't want to know that much about all that. I just want to know all the silly things, like . . . Well, not like important things, like your hair and school and things'.24

3. Exceptions to the problem: look for resources not problems.

   There are likely to have been times when the young person has managed to take positive steps to control their health. This may be taking medication, attending clinic or checking their blood glucose levels. Find out how they did it, what skills and abilities they used and what resources were available to make this possible. Cycle of change theories tell us that people often relapse from positive behaviours yet can easily re-start them when feeling motivated.25

4. Motivation: assessing importance, confidence and priority.

   It can be hard for clinicians to understand why YP are not undertaking appropriate actions to look after their health. The clinician can get a better understanding of the young person's ‘motivation’ by considering confidence, importance and priority. By asking the young person to rate each from 1 to 10, the clinician can understand if the focus should be on improving confidence, making change seem more important or waiting for other priorities to settle.

5. Discussing expert advice.

   MI uses a non-threatening style to share expert advice. Rather than telling a patient what to do, the health professional asks if the young person wants to know what research or best practice suggests, and if they wish to know, then the doctor acts as a conduit of information rather than an expert telling the YP what to do. By asking the patient what they think of the research, and initiating a conversation about it, the YP is more able to have an open discussion and discuss their concerns and thoughts about any treatment strategy.

The psychosocial history

The psychosocial history is the adolescent equivalent of the developmental history for younger children. The HEADSS framework26 is a tool frequently used by clinicians to enable a thorough psychosocial assessment. HEADSS is an acronym for home, education and employment, peer-related activities, drinks and drugs, sexuality, suicide. The original acronym has been expanded to HEEADSSSS to include eating, and safety which, although useful, can potentially detract from the original acronym's simplicity and make it less helpful in day to day situations.26

Psychosocial history: based on HEADDS Framework26 (example questions).

Home

• ■ Who's at home? If a parent is missing, ask about the YP's relationship with this parent.

• ■ Any other important people in your life (eg, grandparents)?

• ■ Who understands you best?

• ■ How are things at home? Anything stressful recently?

Education and employment

• ■ Are you still in education? Which school/college?

• ■ How much hassle do you get from other people? And from teachers?

• ■ Are you the sort of person who likes to keep themselves to themselves, have a few friends or lots of different friends?

• ■ What are your plans or dreams for the future?

Activities?

• ■ What do you usually do after school/college/work?

• ■ What do you like to do in your spare time? What are you good at?

Drugs and alcohol?

• ■ Now I am going to ask you some more private questions. As I said, the answers to these are confidential between us. Is that OK?

• ■ How much alcohol do your friends drink? And you?

• ■ What drugs have your friends tried? And you?

Sex and relationships?

• ■ Have you had any type of sex?

• ■ How do you protect yourself from getting pregnant? And sexually transmitted infections (STI)?

• ■ Do you know where to get a confidential check-up, or help in not getting an STI or pregnant?

Sleep

• ■ How is your sleep?

• ■ How long does it take you to go to sleep? Does your body wake you up earlier than you want or need to wake up?

Suicide (general mood check)

• ■ How is your mood usually?

• ■ Is there lots of sadness or low mood in your life? Do you think you may be depressed?

• ■ Is there lots of worry in your life?

Several important concepts should be remembered while taking a psychosocial history:

• Look for resources and resilience. Medical training is predominantly based around risk assessment and treating problems; however, resiliency factors are equally important.27 Looking for resources and resilience is integral to the solution-focused approach discussed above.

• Start with the least intrusive questions, about home, school and activities, and then go on to explore more personal domains such as sex and mood. If you see the YP regularly, this could be split over several consultations.

• It is not essential to do this with all YP, but it can act as a fairly comprehensive guide to explore their lives if you suspect underlying difficulties.

• YP usually talk honestly about their friends' behaviours. It is often easier to talk about their friends. If their friends partake in risk-related activities (sex, alcohol, smoking, drugs), then the young person is more likely to either partake in, or be affected by, these activities. Talking about their friends can be a useful way to introduce topics and to avoid the pressure of having to start talking about themselves. Later, you can move on to asking the YP what their own experiences are.

• Respect what the young person is telling you; they may have never discussed this information with anyone before. How you use this information may influence if they decide to share it again. Admire the bravery needed for sharing such private information and thank the YP.

• Do this without parents present – you are more likely to hear the truth.

• YP learn from experimentation and listening to their experiences, with a non-judgemental approach, shows respect for their choices and attempts to improve their health.

• Discussions about sexual partners should remain gender neutral. Clinicians should not assume that the YP's partner is of the opposite sex; YP often experiment with both sexes and this does not define sexuality. It is not the job of the paediatrician to discover what the YP's sexual orientation is; however, they should be aware of the emotional difficulties associated with being a homosexual YP, together with the raised risk of suicide and STI, and work in a way that provides an open environment to allow the YP to discuss such issues.28

• Health promotion is part of a holistic psychosocial overview and can be particularly helpful when discussing sexual health. Check what positive steps the YP is already taking to keep themselves healthy, for example, prevention of pregnancy, STI, knowledge about smoking-cessation support, human papilloma virus (HPV) vaccination uptake and checking that they know where their local sexual health service is.

Useful resources

• ■ Free online e-learning in a range of areas of adolescent health (the Adolescent Health Project) has been developed by the Royal College of Paediatrics & Child Health (RCPCH) and other Colleges. It is free to all National Health Service staff and you can register and access the sessions through e-lfh.org.uk.

• ■ Motivationalinterview.org, especially skills and tools section for clinicians.

• ■ Another useful resource covering a wide range of topics on adolescent health is the ABC of Adolescence, edited by Russell Viner (BMJ 2005). Chapters on consent and confidentiality, sexual health, communicating with YP, drugs and alcohol, eating disorders and weight issues, and fatigue and common somatic complaints, are available free on the BMJ website.

• ■ http://www.youthhealthtalk.org. Resource for both YP and health professionals about YP's experiences of health and lifestyle.