Presentation on theme: "Improving Interactions with Teens"— Presentation transcript:
1 Improving Interactions with Teens Stephani Stancil, APRN, FNP-BCChildren’s Mercy Teen Clinic
2 ObjectivesDescribe ways to improve communication with teens in the clinical settingBy the end of this presentation, participants will be able to:Describe 3 barriers to effective communication with teensIdentify 3 key techniques to improve communication with adolescentsUtilize 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 wordsHUH??!?!!?WHAT??!?!?!Proper introduction.Stop at 1:18
5 Adolescence Transition between childhood and adulthood Generally physically healthy periodNeeds vary by development and personal circumstancesExperience 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 PubertyAutonomyIdentityThinkingEarly10-14Onset and tempo variableAmbivalenceAm INormal?Concrete operationalMiddle15-16Girls earlier than boysLimit-testing, experimental behaviorWho am I?TransitionalLate>17Adult appearanceWho am I in relation to others?Formal operational (75%)Slide source: Daryl Lynch, MDTransition 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 futureThis is what our teens see when they look at us.
8 Cognitive Piaget: Concrete to Formal operations Egocentrism: normal narcissism and self-centerednessPersonal fable: invulnerability, invincibility, “nothing bad will happen to me…”Imaginary audience“Everybody is looking at MEand 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 BGWhat would you do?As HCP, our desire is to:Parent: tell them what to do, make them fully informedDiscussing long term effects like kidney and eye disease may be ineffective.INSTEAD try:To emphasis current benefitsMutual goal settingShort term-follow up (even 1 month may be too long)To normalize experienceIdentify other areas of controlMutual goal-setting, short term follow-up, involving parents, normalize experience, identify other areas of controlExamples 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 operationsFocus on immediate benefits of changeDo not emphasize long term complicationsEgocentrismForm therapeutic allianceAutonomy alignment and readiness to changePersonal fableProvide information of personal relevanceImaginary audienceReassure about normalcyTransition 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 wayDon’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 minorsConfidentialityTreatment non-adherence (forget or refuse)Passive-aggressive behaviorDetermine what is essential (no compromise)Negotiate what is optionalAuthoritative, not authoritarian, approachStructured guidance, not dictation in most instancesLook 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 informationPerceived/actual negative past experience with health and/or social systemSense of invincibility/vulnerabilityLow self-esteemCultural and linguistic barriersTeens 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 providersInsensitive attitudes of care providersLack of provider knowledge and skillsLack of money, insurance and transportationInaccessible locations and/or limited servicesLimited office hoursAdditionally, 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 errorsExperimentingExploringBelievers in a personal fable
16 Most health care providers are... AdultsToo busy and overworkedNot very tolerant of teen behaviorWanting to help people achieve healthUsed to completing a task toget something doneFeeling a sense of obligationto give a plan for improvement forproblem 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 statementsIgnoring emotionsEye contact not consistent withadolescent’s cultureCulturally inappropriate languagePerceived gender stereotypesAdapted 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’tUse “pet” names (honey, sweetie, hun…)Use judgmental language (“why would you do that?”)Use slang unless offered firstDoAssure confidentialityExplain why you are asking sensitive questionsPractice 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 boundariesAllow teachable momentsWith 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 encouragementNot expecting perfection! This is still a vital period of learning for the teen (Problem-solving skills, self-confidence, etc.)
21 What is Motivation? Motivation is key to change Motivation is multidimensionalMotivation is a dynamic and fluctuating stateMotivation is interactiveMotivation is a state of readiness or eagerness to change, which may fluctuateMotivation can be influencedNot dictated
22 What influences motivation? Trait ExampleMoney Shift differentialAuthority Legal systemPain “I give up”Fear “Am I pregnant?”Empathy “You really understand”State of readiness “I’ll do it now”to changeFor 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 changeA therapeutic style intended to help providers work with patients to address ambivalence, with resultant change of behavior which improves health outcomesThis is a way of interactingwith patients
24 Transtheoretical Stages of Change Model by Prochaska and DiClemente Precontemplation—not considering changeContemplation—considering, but ambivalentDetermination—preparing to changeAction—involved in changeMaintenance—sustaining changeRelapse—may be undecided again
25 Techniques for Successful Motivational Interviewing Ask open-ended questionsExpress empathy through reflective listeningUse as a method of clarifying communicationThis approach allows for patient and provider to understand each other and explore common ground or compromiseCharacterized by brief statements and reiterations of what the patient has saidI 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 repetitionUsing a synonymParaphrasing the statementAffirm and supportSummarizeElicit self-motivational statementsEx: 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 relationshipCompliment rather than denigrateListen rather than tellGently persuade, with the understanding that change is up to the patientDevelop discrepancy or doubt between incongruent behavior and stated goalsLook 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 weaknessesRespecting other’s autonomy and decisionsUsing empathy, not authority or powerCelebrating interim goals (“baby steps”), incremental or even temporary steps toward a goalBack 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 roleLet the patient be the expertActive listening and reflection cannot be over emphasizedThis 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.
33 Introduction Shake hand with teen Ask what they prefer to be called Michael, Mike, MickeyAsk teen to introduce others in room“Who did you bring with you today? “Explain what to expect during visitDisclose 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 questionsTell me about….Carve out time for private discussionAsk parent to leave the roomUse 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 listeningDemonstrate empathyAccess readiness to changeEngage in motivational interviewingAccentuate positivesMutual goal settingShort team follow up
36 Reality 16 year old male presents for a routine physical Smokes ½-1 pack of cigarettes a daySmokes marijuana every other weekendTried drinking alcohol but doesn’t really like it because it made him get sickHe is an A and B student in high schoolHe 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.”