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Improving Interactions with Teens

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1 Improving Interactions with Teens
Stephani Stancil, APRN, FNP-BC Children’s Mercy Teen Clinic

2 Objectives Describe ways to improve communication with teens in the clinical setting By the end of this presentation, participants will be able to: Describe 3 barriers to effective communication with teens Identify 3 key techniques to improve communication with adolescents Utilize motivational interviewing to influence behavior change

3 Communication Short video clip: Teen Slang
Watch for how mom in the video reacts to teens’ use of common slang words HUH??!?!!? WHAT??!?!?! Proper introduction. Stop at 1:18


5 Adolescence Transition between childhood and adulthood
Generally physically healthy period Needs vary by development and personal circumstances Experience shaped by race, ethnicity, religion, socioeconomic status, family/peers, etc. Adolescents are a large and growing segment of the population. During adolescence, young people develop their adult identity, move toward physical and psychological maturity, and become economically independent. Although adolescence generally is a healthy period of life, many adolescents often are less informed, less experienced, and less comfortable accessing family planning and reproductive health services than adults. While there are children with chronic illnesses or birth defects, generally teens are quite healthy. Psychosocial issues and risk behaviors now dominate adolescent primary health care. Adolescents' circumstances and needs vary tremendously depending on individual characteristics such as age, sexual activity, schooling, and employment status, as well as developmental stage of adolescence (early, middle or late). Adolescents, regardless of race or ethnicity, have a culture distinct from the adult culture. Source: Adolescent Friendly Health Services: An Agenda for Change. The World Health Organization, Available at:

6 Normal Stages and Tasks of Teens
Puberty Autonomy Identity Thinking Early 10-14 Onset and tempo variable Ambivalence Am I Normal? Concrete operational Middle 15-16 Girls earlier than boys Limit-testing, experimental behavior Who am I? Transitional Late >17 Adult appearance Who am I in relation to others? Formal operational (75%) Slide source: Daryl Lynch, MD Transition to abstract thinking may be hindered by substance use, physical/sexual abuse. May cause stagnation in developmental progress. “How do you sleep?” “On my left toward the wall.”

7 Adolescent Thinking Piaget: Concrete to Formal operations
Concrete: Here and now (5 senses) Formal: Abstraction (algebra, metaphors, symbols, etc); Hypothesizing and Considering the future This is what our teens see when they look at us.

8 Cognitive Piaget: Concrete to Formal operations
Egocentrism: normal narcissism and self-centeredness Personal fable: invulnerability, invincibility, “nothing bad will happen to me…” Imaginary audience “Everybody is looking at ME and thinking about ME…” Clothes: want to be individual, but all dress the same. Experimenting with body art, clothes, hair. IA: want brand name shoes because if they don’t wear these, everyone will know!

9 Case 1 15 year old Type 1 DM What would you do?
no longer wanting to check BG What would you do? As HCP, our desire is to: Parent: tell them what to do, make them fully informed Discussing long term effects like kidney and eye disease may be ineffective. INSTEAD try: To emphasis current benefits Mutual goal setting Short term-follow up (even 1 month may be too long) To normalize experience Identify other areas of control Mutual goal-setting, short term follow-up, involving parents, normalize experience, identify other areas of control Examples of talking points: If check BG, may be able to correct sugar levels and prevent HA….allow her to participate in activity longer, more effectively…. Many teens have to take medicine to stay healthy (asthmatics, allergies, HA), if you stay in control of your disease, your restrictions can be minimized.

10 Adolescent Thinking and Health Care
Concrete operations Focus on immediate benefits of change Do not emphasize long term complications Egocentrism Form therapeutic alliance Autonomy alignment and readiness to change Personal fable Provide information of personal relevance Imaginary audience Reassure about normalcy Transition from adolescence “in life” to where they are in health care. Example of Type 1 DM: 14 or 15 yo no longer wanting to check BG. Discussing long term effects like kidney and eye disease may be ineffective. Emphasis current benefits, mutual goal setting. If therapeutic goal is 4x/day, pt may agree to 2x/day if “reward” such as privilege… PF: If check BG, may be able to correct sugar levels and prevent HA….allow him to participate in activity longer, more effectively…. Many teens have to take medicine to stay healthy (asthmatics, allergies, HA), if you stay in control of your disease, your restrictions can be minimized.

11 Adolescent Autonomy Limit-testing (challenging rules)
Experimental behavior (smoking, alcohol) Risk-taking (D.U.I., Ø contraception) Need for control (resisting authority) Being listened to is more important than getting one’s way Don’t make it a struggle of wills. Active listening can be very effective followed by mutual goal setting, if appropriate. For example, “I see that you’re upset about ….., tell me about that…”

12 Autonomy and Health Care
Legal rights of minors Confidentiality Treatment non-adherence (forget or refuse) Passive-aggressive behavior Determine what is essential (no compromise) Negotiate what is optional Authoritative, not authoritarian, approach Structured guidance, not dictation in most instances Look at the whole picture of the teen. “Step out of yourself.” Put yourself in the patient’s shoes. “Tell me why you feel that is hard for you….” Going from 0-60 may not be realistic. BG 4x/day might be very overwhelming, some concrete thinking can barely remember to go the bathroom. PILL REMINDER from Jodi

13 Internal Barriers to Care for Adolescents
Reliance on peers or family members for health information Perceived/actual negative past experience with health and/or social system Sense of invincibility/vulnerability Low self-esteem Cultural and linguistic barriers Teens and young adults often face serious barriers related to sexual and reproductive health care—barriers that may severely limit their ability to avoid pregnancy and STIs, including HIV. During adolescence, a teenager’s peer group has substantial influence over his/her decisions and behaviors, and often teens turn to one another for information regarding sexual health. In many cases, the information garnered from peers can prevent the adolescent from seeking medical advice or care. However, many teenagers are affected by their peers, parents and family members are still very important. Negative past experiences with a health care provider can contribute to a teen’s reluctance to seek additional services. Additionally, low self-esteem and other concerns such as internalized homophobia (fear of disclosing sexual orientation or same-sex behaviors to the health care provider) can prevent teens from seeking care. Nearly one-third of teens report episodes of sadness, depression, and hopelessness. Source: YRBSS – Youth Risk Behavior Surveillance Survey – United States, Available at: These feelings may prevent youths from seeking preventive health care and complying with health regimens. In a study of 1,900 adolescents conducted by the Robert Wood Johnson Foundation, researchers found that 47% of adolescents with depressive symptoms reported problems accessing health services. Source:

14 External Barriers to Care
Perceived lack of confidentiality and restrictions (parental consent/notification) Poor communication by providers Insensitive attitudes of care providers Lack of provider knowledge and skills Lack of money, insurance and transportation Inaccessible locations and/or limited services Limited office hours Additionally, adolescents face many structural and external barriers that may limit access and willingness to utilize health services. Primarily, confidentiality concerns can significantly limit health care utilization for adolescents. A recent study of girls younger than 18 years attending family planning clinics found that 47% would no longer attend if their parents had to be notified that they were seeking prescription birth control pills or devices, and another 10% would delay or discontinue STI testing or treatment. [i] Clinician related barriers also exist, including insensitive attitudes on the part of providers, lack of knowledge and skills regarding reproductive and sexual health, insufficient or inadequate communication and clinician discomfort with the discussion of sexual behavior with adolescents. [ii] Since teenagers often rely on others for transportation, geographically inaccessible locales can be formidable structural barriers to care. Sources: [i] Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA 2002;288:710-4. [ii] Huppert JS, Adams Hillard PK. Sexually transmitted disease screening in teens. Curr Womens Health Rep 2003;2:451-8. .

15 Teenagers are… Risk takers Reactive Rebellious Confused
Prone to making errors Experimenting Exploring Believers in a personal fable

16 Most health care providers are...
Adults Too busy and overworked Not very tolerant of teen behavior Wanting to help people achieve health Used to completing a task to get something done Feeling a sense of obligation to give a plan for improvement for problem patient behaviors “I pity the fool…” Teen do not fit the mold…

17 Elements of Effective Communication
Effective Communication Involves: Verbal cues (adolescent appropriate) Non-verbal cues (tone, gestures, proximity) Listening, responding (active listening, convey empathy, elicit and validate emotions) Poor Communication Examples: Judgmental statements Ignoring emotions Eye contact not consistent with adolescent’s culture Culturally inappropriate language Perceived gender stereotypes Adapted from AMWA Reproductive Health Initiative. RHI Model Curriculum, 2nd Edition. Alexandria, VA: American Medical Women’s Association; 2004. It is important to note that in some cultures/groups eye contact with an adult would be considered disrespectful.

18 Effective communication
Don’t Use “pet” names (honey, sweetie, hun…) Use judgmental language (“why would you do that?”) Use slang unless offered first Do Assure confidentiality Explain why you are asking sensitive questions Practice active listening (“I heard you say …”) Validate feelings (“Many teens your age feel this way…” or “It’s normal to feel like…”)

19 Toddlers and Teens With toddlers, we: Give choices
Encourage independence within safe boundaries Allow teachable moments With teens, we need to: Give choices, encourage independence and allow teachable moments by: Involving teen in development of care plan, give “leader” or “co-leader” role with adequate support and encouragement Not expecting perfection! This is still a vital period of learning for the teen (Problem-solving skills, self-confidence, etc.)

20 What about motivation?

21 What is Motivation? Motivation is key to change
Motivation is multidimensional Motivation is a dynamic and fluctuating state Motivation is interactive Motivation is a state of readiness or eagerness to change, which may fluctuate Motivation can be influenced Not dictated

22 What influences motivation?
Trait Example Money Shift differential Authority Legal system Pain “I give up” Fear “Am I pregnant?” Empathy “You really understand” State of readiness “I’ll do it now” to change For teens, we can focus on showing empathy in our interactions and assessing readiness to change.

23 Motivational Interviewing
A technique and clinical strategy designed to enhance the patient’s motivation or willingness to change A therapeutic style intended to help providers work with patients to address ambivalence, with resultant change of behavior which improves health outcomes This is a way of interacting with patients

24 Transtheoretical Stages of Change Model by Prochaska and DiClemente
Precontemplation—not considering change Contemplation—considering, but ambivalent Determination—preparing to change Action—involved in change Maintenance—sustaining change Relapse—may be undecided again

25 Techniques for Successful Motivational Interviewing
Ask open-ended questions Express empathy through reflective listening Use as a method of clarifying communication This approach allows for patient and provider to understand each other and explore common ground or compromise Characterized by brief statements and reiterations of what the patient has said I heard you say, “I want to get into college.” How do you think your current choices will contribute to that goal?

26 Techniques for Successful Motivational Interviewing
Three types of reflective comments: Simple repetition Using a synonym Paraphrasing the statement Affirm and support Summarize Elicit self-motivational statements Ex: Newly diagnosed DM in 15 yo patient who states: “It’s gonna be hard to do all these new things.” This has got to be very tough, scary, etc. You’ve just heard a lot of information today about your new diagnosis, checking your blood sugar. I think that the schedule you planned, you can be successful with this.

27 Techniques for Successful Motivational Interviewing
Establish a nonjudgmental, collaborative and accepting relationship Compliment rather than denigrate Listen rather than tell Gently persuade, with the understanding that change is up to the patient Develop discrepancy or doubt between incongruent behavior and stated goals Look for positives and give appropriate praise: I see you making good choices by avoiding situations where alcohol is present. “I heard you say that you want to go to college. You also shared that you are failing every class.”

28 Helpful provider characteristics
Focusing on a person’s strengths rather than weaknesses Respecting other’s autonomy and decisions Using empathy, not authority or power Celebrating interim goals (“baby steps”), incremental or even temporary steps toward a goal Back to 14 yo T1DM patient: I see from your log that you checked your BG at least once every day last week. You should be proud of yourself.

29 Helpful provider characteristics
Become an advocate FOR the patient; a cheerleader or mentor role Let the patient be the expert Active listening and reflection cannot be over emphasized This is a transition period for parents to allow the TEEN to take a more leading role in their health care. May have to coach parents as well.

30 Putting it into Practice

31 Before the Visit Self-assessment
Personal biases, judgments, stereotypes Don’t try to be too cool Cool Dad Start at 30s and STOP at 1:17


33 Introduction Shake hand with teen Ask what they prefer to be called
Michael, Mike, Mickey Ask teen to introduce others in room “Who did you bring with you today? “ Explain what to expect during visit Disclose the need for private discussion at the beginning so parents know what to expect

34 Interview Ask about unique features Open-ended questions
Bright hair color, body jewelry, tattoos… Open-ended questions Tell me about…. Carve out time for private discussion Ask parent to leave the room Use non-judgmental statements “Some teens your age use cigarettes, have you ever tried those before?” Look for the story hiding behind their appearance. If something make you feel uncomfortable, ask about it: I see you chose to color your hair pink, tell me about that.”

35 Summary Points for effective communication
Active listening Demonstrate empathy Access readiness to change Engage in motivational interviewing Accentuate positives Mutual goal setting Short team follow up

36 Reality 16 year old male presents for a routine physical
Smokes ½-1 pack of cigarettes a day Smokes marijuana every other weekend Tried drinking alcohol but doesn’t really like it because it made him get sick He is an A and B student in high school He is not interested in being in your office—Mom made him come to this appointment!

37 The Dilemma “Wow, there’s so much I need to do for this young man.”
“He should stop smoking and using marijuana. Doesn’t he know how bad it is for him?” “He needs to listen to me because I used to be a smoker and I know how hard it is to quit.” “Just wait ‘til I give him a piece of my mind about smoking. I’ll tell him how bad it is.”

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