Tricks of the trade for managing adolescents

February 2007

You have to be a jack-of-all-trades to manage adolescents in your practice.

That’s according to Stan Block, MD, a clinical professor at the Universities of Louisville and Kentucky, who spoke about the nuts and bolts of caring for adolescents at the 19th Annual Infectious Diseases in Children Symposium.

“Teens crave adult opinion, they want your feedback. They desperately need us to tell them if they’re doing well or not,” said Block, who has been practicing in Kentucky for more than 25 years.

When dealing with the adolescent patient, your knowledge must span the gamut from behavioral problems to sexual issues.

Optimal adolescent care

The demand for adolescent physicians is high; only 1% of pediatricians are going into rural adolescent medicine today compared with 14% in the past, according to Block, who considers this type of practice a great experience. “Finally you have a patient who can talk with you, can interact with you. It’s kind of fun,” he said.

But when is the right time to suggest the teenager stop coming to their pediatrician? For some adolescent practices it is 16 years of age, some 18 years, some up to 23 years. “If they still want to come to you, don’t chase them off,” Block explained. “I feel honored they still want to come visit with me.”

The office itself plays a big role. When dealing with adolescents, the office should have separate waiting areas, paper gowns, curtains for privacy, nonbaby tables and stirrups. The visits may be longer, too, so allow an extra two to 20 minutes per visit.

The staff must be friendly, positive and nonjudgmental, Block said.

An approach to adolescents

Attention is key, but only through a nonjudgmental and noncondescending eye.

“You’ve got to coach them. I tell them, ‘You’ve got to do this,’” said Block, who said teens and adolescents really do listen. “You have to know that teen girls are drama queens but really are the most sincere,” said Block, who is a father of four daughters.

Update patient history on a regular basis. Block said one way to get the most from questions is to ask how things are affecting the teen. Examples include: How do you feel? Are you happy lately? How are your grades? What are you doing after school? How are things going with your family? Using open-ended questions can open up the discussion much more.

Some additional tips to get the most out of each adolescent visit:

• Take a firm approach.
• Do not preach, but rather advise.
• Maintain good eye contact.
• Greet the adolescents warmly, for example with a handshake and a smile.
• Use humor, if that is your style, but don’t use it to belittle them.
• Try self-deprecation.
• Ask them about their day.
• Give compliments, especially for what they do right, such as grades.
• Be somebody they can trust.

Handling the parents

Confidentiality is very important for teens and adolescents and also for parents. “I say, ‘What you have to say to me is confidential unless you are going to hurt yourself,’” he said. There are many things kids in this age group won’t say around their parents, or adults in general, so gaining their trust is vital.

After age 13 or 14, parents don’t need to be in the examination room and shouldn’t be, according to Block. If they insist on being in the room, accommodate them for the general examination and then ask them to leave to have the opportunity to speak with the teen alone.

For gynecological and genital examinations, it may be a good idea to have both male and female doctors available. “I don’t think it’s a good idea to have girls only see female doctors and boys only see male doctors. I think they need to go through this because it can be helpful for them in the future to not be skittish about being around either sex doctor,” Block explained.

Also beneficial about having the opposite sex physician available is the chance to give valuable wisdom from the other point of view. He encourages his office to split appointments so that a teen girl can’t schedule a female physician every time, with the exception of genitalia examinations.

Managing everything else

Drug and alcohol use and family dynamics are critical in adolescent care. The specialist should know what parents are thinking and doing with their children, such as how they discipline, Block explained.

Peer pressure plays an important role in the lives of teenaged patients. “One pearl of wisdom for you regarding marijuana use, usually with boys: Ask if they’ve been smoking marijuana because it is a common cause of chest pain,” he suggested. Be honest with them and lay out the adverse events and seriousness of illegal substances.

Peer pressure for sex is another big issue with both boys and girls. Quoting Jimmy Buffet’s song, Block said he tells his patients: “It’s a permanent reminder of a temporary feeling.” He said he also appeals to their financial sensibilities as well.

“I tell them, ‘Think of the thousands of dollars you will spend,’” he said. “They understand economics much better sometimes.” He emphasized barrier methods and birth control for those patients who are sexually active or are contemplating sexual activity.

Similarly, it may vary within practices when to do the first gynecological examination. For girls, Block suggested by the age of 20 and/or three years after her first intercourse or sexual debut. Any thing more than basic examinations and information about oral contraceptive pills goes to the obstetrician.

Other key things to consider: the thyroid in a neck examination, acne and treatment, the back in sports examinations, and blood pressure and signals of chest pain in the cardiac examination.

Red flags

When dealing with teens, there will be tears, confusion and hostility. But, a few key red flags could signal more serious problems, Block said.

A depressed mood could be triggered by drugs and alcohol. Block recommended questioning the patient about drug and alcohol use, grades and smoking habits. For patients with poor grades, consider screening for drug use and/or attention-deficit/hyperactivity disorder. Also, check the arms and pull up the sleeves to look for marks that could indicate cutting.

If a patient presents with chronic abdominal pain and a bad mood, consider the possibility of sexual abuse, Block said. Pain in the abdomen can signal sexual activity, urinary tract infections and more. “About 95% of teens are sexually active,” Block said. “You can’t find that number anywhere, but it’s true. This is not evidence based, but what I have observed over the past two decades.”

He said the same about teens that smoke cigarettes and the link to sexual activity. “That means they are immune to peer pressure,” he explained. Parents going through a divorce should also raise a red flag about depression and the possible influence of peer pressure.

The bottom line with teens and adolescents, Block said, is to ask a lot of questions.

For more information:

• Block S. Enjoying adolescent care: the (are you) nuts and bolts. Presented at: 19th Annual Infectious Diseases in Children Symposium; Nov. 18-19, 2006; New York.