Establishing herself or himself as the primary care physician
for an adolescent patient is a formidable task for a pediatrician.
A transition interview with patients and their families at approximately
10 years of age is an effective approach for developing a new relationship.
During this interview, the pediatrician must inform the parents
and the patient about the changing nature of the relationship with
the doctor: the need for the doctor to have time alone with the
patient, the need to query the young person directly, the need for
the patient to be examined alone, and the need of the patient to
be encouraged to generate his or her own questions for the doctor.
These changes are best done through a discussion of normal adolescence
and the need for adolescents to begin to make some decisions in
a more independent manner with guidance and support from their families.
During this transition interview, the clinician should provide the
adolescent and family with some general information regarding the
normal physiological and psychosocial changes of adolescence. Depending
on the age and psychosocial functioning of the adolescent, the clinician
may want to encourage the young person to come to the next clinical
visit alone. As the adolescent completes the second decade of life,
the pediatrician wants the young adult to be capable of assuming
responsibility for his or her own health care.1-3
Confidentiality issues are fundamental to the delivery of health
care to adolescents; they need to be able to discuss all matters
with the physician openly and honestly. Some physicians may feel
uncomfortable with these principles and may want to clarify their
position. From the first visit, the physician must assure the young
person of the confidentiality of all information within the confines
of the legal system. The physician may need to restate this position
on confidentiality during the gathering of information in such sensitive
areas as sexual behavior and substance use. In the areas of life-threatening
disease or behavior (eg, suicide, management of chronic disease),
the physician always has the right to intervene on behalf of the
patient’s well-being, which generally involves identifying
a parent, guardian, or supportive adult who can assist the young
person with the problem.4,5
The Clinical Interview
It is important to create an environment in which the adolescent
is able to disclose information regarding his or her health habits.
History taking should be guided by the developmental stage of the
adolescent (see Chapter 66, Table
66-1). The physician also must recognize that many of the adolescent’s
concerns may not be disclosed on the first visit and may unfold
after a relationship has been established. A follow-up visit for
a rather minor problem may be the visit at which other health concerns
and risky behaviors are disclosed.
The screening history must focus on risk-taking behaviors (substance
use, sexuality, recreational/motor vehicle ...