Adolescent Insights

Adolescents are different from other patients, and not just because they are teenagers. Adolescence spans the transition from childhood to adulthood, a time when teens establish their own identity by testing boundaries and trying on different adult behavior patterns.

"It is not fair to assume that all adolescents are full of problems," said Nicole Chaisson, M.D., University of Minnesota in Minneapolis. "Seventy-five percent of them survive adolescence without a single major life event. There can be a lot of fun in this period, too. Our role is to help guard them through the transition."

One of the problems in dealing with teens is that every adolescent moves back and forth across the child-adult boundary at different speeds. Today's seeming-adult may be tomorrow's child and may flip again ten minutes later. Parents, caregivers, teachers and physicians have as much trouble keeping up with a teen's state of maturity as the teen has.

"It's easy to realize that a three-year old needs adult guidance and supervision," noted Alison Warford, M.D., medical director for Face to Face Clinic in St. Paul, MN. "It's just as easy to forget that a 6'2", 180 lb teen's brain is going through the most rapid transformation since the very first year of life. Brain development has a tremendous impact on adolescent though, behavior, and outcome. They may look adult, but they don't think or act adult."

Not surprisingly, most health issues during the adolescent years are associated with risk taking or poor choices, behavioral risk rather than biomedical risks. Three-quarters of adolescent deaths are behavior-related: accidents (51.7%); assaults (13.7%) and suicide (11.0%). An increasing number of teenage biomedical problems are also related to behaviors such as poor dietary choices or drug/alcohol/tobacco use, including obesity, diabetes, and hypertension.

"Working with teens is a model for family medicine's holistic mission," Dr. Warford said. "Because the adolescent health problems we most often encounter deal with behaviors, we ask about the whole person, their environment, their family, their emotions."

At the same time, many teens are reluctant to enter a physician's office. Every visit is a vital opportunity to screen for potentially risky behaviors and intervene. Adolescents with repeat office visits are more likely to be at risk. "There might be a reason kids keep coming back to see you," Dr. Warford explained. "You need to find out. We don't generally do a very good job of screening teens for the risks they face."

Every visit should include screening questions on home and family, school, activities, drugs, safety, sex, and suicide or depression, she explained. Since patient contact time is limited, it helps to structure visits and use a checklist to be sure to touch on all the important topics.

It is vital to focus the visit on the teen, not on his or her parent. That means shaking hands with the teen first and talking to the teen even if the parent tries to control the conversation, Dr. Chaisson said.

At least part of every visit should be spent with the teen under a promise of confidentiality, Dr. Warford added. Anything said in confidence must remain in confidence unless it represents a clear and immediate danger, she added. "This is not going to be a 15-minute exam, especially in the early years," she cautioned. "You have to watch scheduling."