Adolescent Health Care: A Practical Guide

Chapter 3

Office Visit, Interview Techniques, and Recommendations to Parents

Elizabeth R. Woods

Lawrence S. Neinstein

The style and personality of the provider and his/her philosophy of medical care are particularly important in the medical care of adolescents. The provider should be mature and open-minded, and genuinely interested in teenagers as persons first, then in their problems, and also in their parents. He/she should not only like teenagers but must also feel comfortable with them. He/she should be able to communicate well with his/her patients and their parents. The provider should help enhance family communication while assuring confidentiality when requested around personal issues.

--(Adapted from Committee on Care of Adolescents in Private Practice of the Society for Adolescent Medicine.)

Providing care to adolescents in a sensitive, flexible, developmentally and culturally appropriate manner requires interest, time, and experience on the part of health care providers. No book can adequately teach the art of relating to patients or adolescents; it is a skill that is ultimately perfected through practice. A good medical interview with the adolescent is important, because it allows the provider not only to collect information but also to set the tone for future interactions. This chapter contains general guidelines for establishing better rapport with adolescents, as well as suggested interviewing techniques. At the end of the chapter there are some suggestions for parents to improve communication with their teen.

General Guidelines for the Office Visit

Liking the Adolescent

To provide effective care and establish rapport with the adolescent patient, the health care provider must like adolescents. If the provider dislikes or is extremely uncomfortable with teenagers, it is best to refer them elsewhere. If the particular condition requires more expertise than the provider has or causes personal conflicts about moral or religious issues, the adolescent should be referred elsewhere.

Meeting the Adolescent and Family: The First Session

It is important for the provider to introduce himself or herself to the family and to the adolescent as the adolescent's provider. At about the time of puberty, a transition should be made to allow more of the visit to be focused on the adolescent. Providers should advance along the visit styles described here as the adolescent matures and the family is known and trusts the adolescent-focused visit. One of three basic approaches may be used to start the interview; the choice may depend on the complexity of the visit, nature of the complaints, knowledge of the individual and family, and the age of the adolescent.

Separate Time for Family and Adolescent

For new, complex patients, the provider may need an extensive history from the family and an understanding of their full agenda. The provider should greet the adolescent first, explain the order of the visit, and request a few minutes to meet with the parents alone, “about when you were a child.” This gives the parents a few minutes to relate the past history, family history, their agenda, and concerns. Some of these items the parents might not feel comfortable stating in front of the adolescent, such as “I am afraid he has cancer” or “I think she is sexually active and needs birth control.” Having this information at the start of the interview will improve the focus of the whole visit, rather than having it spill out at the end of the visit. Next, the adolescent should be seen alone for additional history, discussion of confidentiality, and physical examination. The adolescent should be present from the time he or she meets with the provider, through to the end of the visit so that the adolescent does not feel that the provider is divulging confidential information to the family. This approach allows discussions with the parents about issues they may feel are sensitive. Follow-up visits can start with a very brief meeting with the parents alone, if major issues persist, but should rapidly switch over to one of the other types of visit, described next.

Family Together

Some health care providers prefer to see the family and adolescent together first. This approach can yield a great deal of information in the first few minutes regarding family dynamics. For example, if the adolescent is asked why he or

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she wants to be seen and the mother quickly answers for the adolescent, a sense of the adolescent–mother relationship is gained. When the family is seen together, it is helpful to have the teen introduce the family members to the provider. This gives the adolescent the message that the provider is primarily interested in him or her. After this part of the interview, the adolescent should be interviewed and examined alone.

Adolescent Alone

Another basic approach is to start by interviewing the adolescent alone. Some health care providers favor this approach in the belief that it quickly helps to establish rapport and a sense of trust. However, it is important to inform the adolescent that some input regarding his or her past history will be required from the parent during the initial interview. At this point, the family may be brought in to continue the interview; however, the adolescent should be present to hear what is stated. This approach is especially important for older adolescents.

Summarizing

At the end of any of the three visit types described, the provider should summarize the issues and plans with the adolescent. Issues that can or must be discussed with the family can be summarized with the family and the adolescent together, so that the adolescent can hear how the information is presented and discussed with the family and all concerns can be addressed. As the adolescent becomes a young adult, the full visit will tend to be with the young person. If family members come with the young adult, they can be included in a brief summary at the end of the visit, if helpful for the support of the young person or to assist the young person with adherence to complex treatment regimens.

Office Setup

Space

Adolescents prefer their own waiting area in a pediatrician's office. They do not like to be treated as young children. It is helpful if the waiting room has materials such as magazines that are appropriate for adolescents and health education brochures. A separate waiting area or corner of the waiting room should be set aside for adolescents and young adults, or separate blocks of time should be used so that age-appropriate materials can be displayed. If the office is used for other age groups, one examination room should be set aside for use with teens. For privacy, the examination table should be facing away from the door or an inner curtain should be added.

The office should have enough room to accommodate the family as well as the adolescent. It is preferable not to interview the adolescent and family in the examination room on the first comprehensive visit. The desk in the office should be oriented so that the health care provider sits beside the desk, not behind it. Placing a large desk between the adolescent and oneself can create an artificial barrier.

Appointments

Usually, initial comprehensive visits for an adolescent should be scheduled to last 1 hour. Obviously, there may be time constraints based on the practice setting if the provider is pressed for time. Most follow-up appointments should be scheduled for after-school hours or early in the morning to minimize missed school time. At the end of the first visit, a decision should be made with the teen and the family as to whether the adolescent can make future visits on his or her own. Transportation needs may limit this option for young adolescents in some practice settings, but the permission to come to visits on his or her own is important.

Billing

The issue of fee payment should be discussed early. This can even be done when the first appointment is made. Confidentiality can be maintained by using nonconfidential or symptom-based billing codes when the parents are paying for services. The adolescent must realize that an insurance payment may result in parents finding out about visits and the diagnosis; however, a neutral diagnosis can be used in most situations. Ideally, a mutual agreement can be reached with the adolescent and parents in this area. Alternatives include:

  1. Confidential billing (if the insurance company allows), so that the parents are not aware of the exact nature of the visits
  2. Having the adolescent pay for his or her own bills on a flexible installment plan with reduced fees
  3. Having the adolescent obtain Medicaid funds for conditions such as pregnancy, family planning, and substance abuse
  4. Referral to a clinic that can provide free confidential care

Availability of Educational Materials

It is helpful to place books, pamphlets, hot line numbers, and reliable Web site information in the waiting room or office on topics such as puberty, sexually transmitted diseases, sexuality, and contraception. The presence of such materials helps the adolescent to feel that it is “O.K.” to talk about these subjects. Helpful materials and Web sites are listed at the end of this chapter.

Avoiding Interruptions

Constant interruptions or phone calls during the interview tend to decrease rapport. The office staff should hold all nonemergency questions or phone calls until after the interview.

Taking Notes

The provider should take as few notes as possible during the interview. For referred patients, the content of letters to referring primary care providers concerning confidential issues should be discussed with the adolescent.

Establishing Rapport

Establishing rapport with an adolescent, especially with a nonverbal or hostile teenager, can be difficult. Helpful suggestions include the following:

  1. Begin the interview by introducing yourself to the teen and parents or guardians. It is helpful to shake the hand of the adolescent.
  2. Begin by chatting informally about friends, school, or hobbies. Not only does this decrease tension but it also

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enables the provider to gain important insights into the adolescent's personality, mood, and thought content.

  1. Let the adolescent talk for a while, even if he or she meanders.
  2. Treat the adolescent's comments as seriously as you would an adult's. The teenager should feel you are treating him or her as a person, not as a child or patient.
  3. Start with nonthreatening health questions, such as a review of systems, especially if the adolescent is highly tense or suspicious.
  4. Explore with the adolescent the issues that concern him or her. These issues may differ radically from concerns expressed by the parents.

Ensuring Confidentiality

It is important to establish a sense of confidentiality with the adolescent. The limits of this confidentiality may vary depending on the type of medical practice and current laws of a particular state (English, 2003; English and Ford, 2004; Ford et al., 2004). The adolescent should be aware of these limits. For example, it should be explained that discussions will be kept confidential unless a problem becomes a threat to the adolescent or to others. When there are concerns about safety, the provider should relay to the adolescent that this is a situation that needs to be shared with the parents. Adolescents are often more willing to discuss topics with their parents in the safer environment of the provider's office, and the provider can help facilitate the discussion of difficult topics.

Many parents are naturally concerned about being separated from their teen during the interview process. One approach is to explain to the parents early the philosophy of your practice, for example: “As we are proceeding in gathering information about John, I would like to tell you both how I work with adolescents. After I finish talking with all of you together, I am going to speak with John alone for a few minutes. Then I will take him to the examination room for a physical examination. When this is done, I will call you back to go over the findings and my recommendations. During this time, I may discuss some matters that John would prefer I keep in confidence. It has been my philosophy to respect that confidence. Certainly, if there were any serious problem that was a threat to John's life or health I would inform you. Now, before we break as a group, are there any other concerns that you have about John that we have not discussed?”

Avoiding a Surrogate Parent Role

Rather than being a surrogate parent, the health care provider should function as an extraparental adult. The emphasis should be on listening, advising, and guiding, using as nonjudgmental an approach as possible.

Avoiding an Adolescent Role

The adolescent is looking for a provider who can be a sensitive and mature resource, not someone who is “one of the gang” and who dresses and talks like an adolescent.

Sidestepping Power Struggles

It is difficult to force adolescents into action. In other words, no one is better at being an adolescent than an adolescent. Teenagers respond better if they can arrive at their own conclusions.

Acting as an Advocate

The adolescent encounters any number of adults who are nonsupportive and who stress the adolescent's negative attributes. Try to emphasize an adolescent's positive characteristics and abilities. Keep in mind, however, that supporting the adolescent in “down” times is not the same as supporting inappropriate behavior.

Importance of Listening

Listening can often be the key to developing rapport with an adolescent. However, listening can be difficult, as thoughts usually wander or focus on the next response. The health care provider should practice his or her listening skills to give full attention to the adolescent's statements and feelings. Good listening skills include:

  1. Staying focused on what the teen is telling you
  2. Asking questions that help move the conversation along
  3. Being cautious about giving advice before being asked
  4. Using gender-neutral terms until the adolescent has indicated his or her preferences
  5. Trying to understand the teen's perspective

Instilling Responsibility

Adolescents should be made aware that they are responsible for their own care. The more responsibility that adolescents take for their personal progress, the fewer problems that occur with compliance. Adolescents have a great ability to instill guilt in health care providers. The provider can feel overwhelmed with the burden of changing the adolescent's life and habits. This burden should be shifted onto the adolescent.

Displaying Interest and Concern

The adolescent must be able to feel the health care provider's interest and concern. Shrugging off concerns as unimportant is a sure way to alienate the adolescent.

Family and Parents

Although the adolescent may be the primary patient, the parents cannot be overlooked. Parental input and insight are crucial, for in a real sense the family is the patient. Often the full agenda of the visit cannot be understood without initial input from the parents. To ignore the family's involvement in an adolescent's problem can often prolong the problem. Families must be consulted for the following reasons:

  1. To elucidate past medical history, family history, and present concerns
  2. To understand family dynamics and structure

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  1. To alleviate the parents' sense of rejection or guilt
  2. To help bring about changes in the family unit and in the adolescent
  3. To negotiate fair and consistent limits
  4. To support the adolescent in complex treatment regimens
  5. To ensure consistency of follow-up and referral care

Nonverbal Cues

Much can be learned by observing the adolescent's body language, such as hand movements, manner of sitting, eye movements, or eyes slightly brimming with tears when certain subjects are discussed.

Process Versus Content

Although inappropriate behavior should not be condoned, the health care provider must explore the reasons behind the action. For example, shoplifting may occur secondary to peer pressure or family or school problems. Positive comments supporting the adolescent's health choices can help the adolescent recognize his or her strengths and resist peer pressure.

Hidden Agenda

Adolescents often present with chief complaints that are unrepresentative of their true concerns. A female adolescent presenting with mild sore throat, acne, or pelvic pain may in actuality be afraid she is pregnant or has a sexually transmitted disease. A male adolescent with chest pains may be concerned about gynecomastia. Gentle but persistent exploration of the adolescent's concerns is often necessary before the true chief complaint is evident. If an adolescent girl is extremely reluctant to communicate or has vague symptoms, a pregnancy test should be considered.

Developmentally Oriented Approach

In the course of interviewing and evaluating the adolescent, the health care provider should be conscious of the adolescent's developmental process and tasks. The areas of sex, school performance, family, peer group, identity, and future plans should all be explored. Evaluative expectations should be based on the stage of emotional development the adolescent has attained. Early or middle adolescents, for example, certainly cannot be expected to think and behave as logically as adults. Below are sample questions regarding various adolescent tasks:

  1. Body image: Do you have any questions or problems with the physical changes you are experiencing? Do you like yourself as you are? What would you change? Many teens have questions about periods, wet dreams, or changes in breasts or pubic hair; do you?
  2. Peer relationships: Who is your best friend? How many close friends do you have? What kinds of activities do you participate in? What do you do for fun?
  3. Independence: Do you get along with your parents? Over what issues do family arguments occur? Is your privacy respected at home?
  4. Identity: Are you satisfied with the way things are going for you? If you could change certain aspects of your life, what would you do and why? Are you working now? What are your plans for the future?
  5. Sexuality: Are you dating? Do you have a particular girlfriend or boyfriend with whom you are serious? Do you have questions or concerns about sexual activities, contraception, sexually transmitted diseases, or pregnancy?

Another approach to obtain psychosocial/developmental information is the HEADSS (home, education/employment, peer group activities, drugs, sexuality, suicide/depression) (Goldenring and Cohen, 1988; Ehrman and Matson, 1998) or the expanded HEEADSSS (with eating and safety topics added) interview (Goldenring and Rosen, 2004). An advantage of this approach is that the provider moves from less personal questions to more personal and potentially threatening questions.

Home: Where is the teen living? Who lives with the teen? How is the teen getting along with parents, family, and siblings? Have there been any recent moves? Has the teen ever run away or been incarcerated? The provider should not begin with a statement such as, “Tell me about your parents,” because this question assumes that the teen has two living parents.

Education: Is the teen in school? What is the teen good and bad at in school? What classes are particularly interesting or boring? What grade average does the teen maintain? Has the teen repeated or failed any classes? Are there subjects that are more difficult or require extra help? Has the teen received any suspensions? How is the teen getting along with teachers? What goals does the teen have when he or she finishes school? If the teen is older or out of school, the provider should ask about employment. The provider should avoid asking, “How is school?” because this will lead to the answer, “O.K.”

Eating: What does the teen like or dislike about his/her body? Have there been recent changes in weight? Has the teen dieted to control weight? Has the teen done anything else to control weight? Has the teen every made himself/herself throw up or take diet pills or laxatives to control weight? Does the teen worry about weight? Does the teen eat in front of the television or computer? Does the teen feel that eating is out of control?

Activities: What does the teen do after school? What does the teen do to have fun and with whom? Does the teen participate in any sports activities? Community or church activities? What reading does the teen do? What music does the teen like? Does the teen have or use a car, and does the teen use seat belts? What are the teen's hobbies? Does the teen use a helmet when using a bicycle or roller blades? Does the teen have friends? A best friend? How much time does the teen spend watching television or playing video games?

Drugs: What types of drugs are used by the teen's peers? What types of drugs do family members use? What types of drugs does the teen use and in what amount and frequency? Does the teen use intravenous drugs? What is the source of income to pay for these drugs? The manner in which these questions are asked can significantly alter the responses. Consider the following examples.

  • MD 1:Do you ever use drugs?
  • Teen:No!

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That probably would end the questioning on drug use.

  • MD 2:I know that drugs are fairly common on school campuses. What drugs are common on your campus?
  • Teen:Oh, I don't know, maybe pot and crack.
  • MD 2:It is not uncommon for some teens to try some of these drugs. Have any of your friends tried them?
  • Teen:Some of them.
  • MD 2:How do you handle the situation when your friends are using drugs? Do you ever try?
  • Teen:Yeah, once in a while. I really have only tried pot, and that was only twice.
  • MD 2:The two most common drugs that I have seen teens use are often not thought of as drugs. These are alcohol and cigarettes. How much alcohol do you drink in a week?
  • Teen:Oh, I usually don't drink during the week, but on weekends I really get blasted almost every Friday and Saturday night.

Sexuality:: Is the teen dating? What are the degree and types of sexual experience? Is the teen involved with another individual in a sexual relationship? Is the teen attracted to or prefer sex with the same, opposite, or both sexes? Has the teen had sexual intercourse? How old was the teen during his or her first sexual encounter? How many partners does the teen have? Is there a concern about masturbation? Has the teen had a sexually transmitted disease, and what are the teen's knowledge base and concerns about sexually transmitted diseases? Does the teen use contraception and with what frequency? Does the teen or the partner use condoms and with what frequency? Is there a history of pregnancy or abortion? Does the teen enjoy sexual activity? Sexuality is another area in which the style of questioning can dramatically alter the response. Consider the following examples.

  • MD 1:Are you sexually active?
  • Teen:No.
  • MD 1:Tell me about your boyfriend or girlfriend.
  • Teen:I don't have one.

In this instance, the teen may not even know what “sexually active” means or may think that the term implies a certain frequency of sexual intercourse. In addition, asking only about heterosexual relations may close the opportunity to find out about homosexual concerns or behavior.

  • MD 2:Jane, I mentioned that I may be asking you some questions that were personal but very important to your health. Again, this is information that I will be keeping confidential. The area I want to discuss has to do with relationships. Are you going out with anyone right now?
  • Teen:Yes.
  • MD 2:What is this person's first name?
  • Teen:Bill.
  • MD 2:As you know, there are many teens who are sexually active. By that I mean that they have had sexual intercourse. There are also many teens who have chosen not to have sexual intercourse. How have you handled this part of your relationship with Bill or with other boys you have dated?
  • Teen:I have not had sex with Bill yet, although we are thinking about it. I did have sex once approximately 6 months ago at a party.

Suicide and depression: Does the teen feel sad or down more than usual? Does the teen cry more than usual? Does the teen feel “bored” all of the time? Has the teen had any prior suicide attempts? Does the teen have any current suicidal ideation? It is very appropriate to ask direct questions about suicidal ideation, such as, “Have you ever thought about killing yourself?” or “Have you ever tried?” or “Would you kill yourself?” or “Do you have a plan?” Direct questions do not precipitate suicidal action and are the best way to obtain such information.

Safety: Does the teen use seatbelts? How much of the time? Has the teen ever been seriously injured? Has the teen ever ridden in the car with someone driving who was high or drunk? Does the teen use safety equipment for sports or other physical activities (such as helmets for biking or skateboarding)? Is there violence in the teen's home, school or neighborhood? Has the teen ever been physically or sexually abused? Have you ever been picked on or bullied? Has the teen ever felt that he/she had to carry a gun or weapon to protect himself/herself? Has the teen ever had to run away to be safe? Questions about physical and sexual abuse can be particularly sensitive, but essential to ask any teen with problems in any of the previous areas, especially those who have run away, had early onset of sexual activity, or have a history of suicide attempts (see Chapters 39 and 79).

Physical Examination

The physical examination provides an excellent opportunity to educate the adolescent about his or her changing body. For example, the young adolescent may be reassured about growth and pubertal development. The adolescent may, in addition, raise concerns not mentioned during the initial interview. The true chief complaint may, in fact, be revealed during the physical examination.

Another issue of concern has been the question of who should be present during the physical examination. In general, the adolescent is examined without the presence of the guardian or parent. However, some younger or developmentally delayed adolescents prefer to have the parent present. The teen could be asked first whether he or she preferred that the parent be in the room during the examination. Male providers should use a chaperon during the breast and genital examination of female patients. Theoretically, the same concept would hold for a female examiner during genital examination of a male patient, although this usually has not occurred in clinical practice.

Closure

At the close of the initial or follow-up visit, the health care provider should address the following issues:

  1. Provide a brief summary of the proposed diagnosis and treatment, addressed primarily to the adolescent. Parents who accompany the adolescent to the visit should

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be included in a final discussion of the nonconfidential issues, so that they can help support the plans.

  1. Discuss any other resources available to the adolescent.
  2. Allow the adolescent time to discuss any final questions or concerns.
  3. Schedule any follow-up appointments.
  4. Inform the adolescent that the health care provider is available at other times. The adolescent should feel free to make follow-up appointments or telephone calls for either medical or emotional reasons.

Interviewing

The following is a list of suggestions to assist the provider during the interview:

  1. Shake hands with the adolescent first.
  2. Ask questions in context.
  3. Avoid lecturing and admonishing.
  4. Bring the adolescent into the present. If the adolescent is focusing on his or her homework or on yesterday's date with a girlfriend or boyfriend, the interviewer is unlikely to gather much useful information.
  5. Focus initial history taking on the presenting complaints or problems.
  6. Identify who has the problem (i.e., is this problem the teen's concern or the parents').
  7. Take a neutral stance.
  8. Usually, the less the interviewer says the better.
  9. Be attentive.
  10. Avoid writing during the interview, especially during sensitive questioning.
  11. When asking direct questions (a) use less personal questions before more personal questions, (b) use open-ended questions, and (c) use gender-neutral terms.
  12. Talk in terms that the adolescent will understand.
  13. Do not misinterpret the adolescent's response.
  14. Criticize the activity, not the adolescent.
  15. Highlight the positive.
  16. Assess your own ability to listen. A provider's difficulty in listening may be related to his or her own resentments or opinions of the adolescent's behavior.

Listed next are recommended interviewing techniques. Some aspects of interviewing, such as the initial introduction and establishing of rapport, were mentioned earlier in the general guidelines.

Open-ended Questions

The use of open-ended questions, such as, “Tell me more about it” or “What does your pain prevent you from doing?” or “What was that like for you?” often facilitate communication better than the use of direct questions, such as, “Did that make you feel bad?”

Reflection Responses

The reflection response mirrors the adolescent's feelings. Consider the following example.

  • MD:How do you like school?
  • Teen:I hate it.
  • MD:You hate it?
  • Teen:Yeah, my teachers always….

Restatement and Summation

Stopping to restate the adolescent's feelings or to summarize the interview may often help clarify the problem or encourage the adolescent to make additional comments. An example might be, “Let me see if I understand. You really like Jim, but you do not want to have sexual intercourse with him. However, you feel if you say no, he will stop liking you and drop you for someone else.”

Clarification

Asking the adolescent to clarify a statement or feeling may help crystallize the problem. Asking, “What did you mean by that?” can also be useful in clarifying colloquial jargon. For example:

  • Teen:My friend and I like to go scamming. We doit most every weekend.
  • MD:Scamming? Help me out with that one? What does that mean?

Not only does such a question open up communication but it also makes the teen feel like an authority on a subject and that the provider is human too and does not know everything.

Insight Questions

Some questions may give the health care provider better insight into the adolescent: What do you do well? If you had one wish, what would it be? When are you the happiest? What do you do when you're angry? What do you see yourself doing in 1 or in 5 years? What do your mother and father do when you are not there? What do you do when you are not in school?

Reassuring Statements

The use of reassuring statements when dealing with embarrassing subjects may often facilitate discussion. For example: “Almost all boys your age masturbate or play with themselves, and this is normal. I wonder if you do this sometimes.”

Support and Empathy

A noncriticizing response that recognizes and acknowledges the adolescent's feelings is often helpful during the interview. Examples of this type of response are: “I can really understand how bad that must have felt.” “That really must have made you feel sad.” “I'm impressed that you have taken care of yourself so well, despite all the problems that you've had.” “You are making some really healthy choices.”

Special Interview Problems

  1. Garrulous adolescent: The overtalkative adolescent can sometimes be directed with a statement such as, “I can see you like talking about this. Why?”

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  1. Quiet adolescent: With the quiet adolescent, getting him or her to talk about any subject, such as school, sports, or television, can often help break the silence.
  2. Anxious adolescent: The use of reassuring statements is frequently effective. An example is, “It is often difficult to talk about——.”
  3. Angry adolescent: Clarify how you as the provider might be able to help the adolescent, for example, “It sounds as though some help discussing some of these issues with your parents might be useful.”

Interview Structure

The interview may meander, but it should have structure, including a beginning, middle, and end:

  1. The beginning of the interview should include introductions, attempts to put the adolescent at ease, and an explanation of what will be happening and why.
  2. The middle part of the interview should move into defining the adolescent's problems and feelings.
  3. The end of the interview should include informing the adolescent about the results of the examination and about what will happen next. Time should be provided for the adolescent to ask questions before summarizing with the adolescent and the parents.

As stated at the beginning of the chapter, developing interviewing skills requires practice and interest on the part of the examiner. Reviewing one's interviews through the use of video equipment is an excellent technique for improving skills. Such techniques are of special value for providers, who rarely undergo observation in their training. Appropriate consent from both the teen and the parent or guardian should be obtained. Alternative techniques such as written questionnaires and computer surveys can also be used in conjunction with the verbal interview to obtain information about the adolescent. Personal questions and answers that could be seen by the parents or others in the waiting area should be avoided.

Written Questionnaires

Several questionnaires are found in Chapter 4. Cavanaugh (1986); Frazar (1998); Suris et al. (2005) have described office questionnaires. If confidential questions are included the forms should be completed privately in a confidential space. Providers may also benefit from written screening tools to increase delivery of preventive services (Ozer et al., 2005).

Computer Surveys

The computer can be a nonthreatening format to some adolescents, and can sometimes increase the disclosure of personal information. Paperny developed interactional questionnaires for teens on areas such as psychosocial risk profile, adolescent pregnancy, and family planning. These are available from David Paperny, Teen Health Computer Programs, 2516 Pacific Heights Road, Honolulu, HI 96813-1027 (Paperny and Hedberg, 1999). A private carrel in the clinical area may be required when sensitive issues are included.

Family Considerations

As noted earlier, the patient is the product of the family. To fully understand the adolescent or to effect change requires interviewing and working with the family. The definition of family has changed over time, and part of understanding a patient includes understanding the patient's definition of family. There are many possible family constellations, including single-parent families, stepfamilies, blended families, foster families, adoptive families, extended families, and families of choice. The dynamics of the family and the relationships among the different subsystems (spouse, parent/child, or sibling) should be understood. Family cultural and ethnic backgrounds are important for providers to understand. Not all health care providers want to or should provide family therapy. But any provider who wishes to provide comprehensive care to adolescents must feel comfortable working with families. The “Other Resources” section at the end of the chapter lists articles that may be especially helpful.

Internal Considerations

Although the health care provider should be careful not to project feelings about his or her own adolescence onto a teenager being treated, remembering one's own adolescence can help the professional empathize with teenagers. Providers need to move beyond their personal experiences, but still remember complexities of their own adolescent experiences, such as: What did I feel at 13 years old? 15 years old? 18 years old? What things embarrassed me the most? What physical problems worried me the most? What was my first date and first sexual experience like? What things did I enjoy most during those years? Who was my best friend? What did we do together? What things started arguments between my parents and me? How did I feel about my parents and my siblings? How much did I confide in my parents? What did I like most about school? What did I like the least? What dreams did I have for the future? How did I develop as an individual separate from my family?

Optimize the Adolescent–Provider Communication

Adolescents' perceptions of their provider's behavior contribute to their willingness to return for follow-up visits and adhere to the treatment regimen. Ginsburg et al. (1995) showed that cleanliness, honesty, respect, carefulness, experience, confidentiality, and equal treatment of all patients rank highest in affecting adolescents' decisions to seek health care. Provider's honesty, listening, answering questions, statements of confidentiality, showing respect, exchanging information enhance satisfaction and return for follow-up (Kahn et al., 2003; Ong et al., 1995; Ford et al., 2004; Woods et al., 2005).

Recommendations to Parents of Adolescents

Parents often ask health care providers for suggestions of reference books or of methods for coping better with adolescents. Helpful methods for parents might begin with the same recommendations previously stated for health care providers.

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General Guidelines

  1. Listen to the teenager.
  2. Treat his or her comments seriously.
  3. Avoid power struggles.
  4. Be flexible.
  5. Show interest and concern in the adolescent's activities.
  6. Spend time together and time alone together.
  7. Show trust in the teenager.
  8. Make resources available to the adolescent.
  9. Strive for a good communication in the family between working together, playing together, and loving. Playing and having fun together is an important part of establishing good parent-teen relationships.

Challenges of Teen Years

Parents should be aware that although most adolescents do well and go through adolescence without too much distress, it can be a challenging time period. The challenges faced by parents of teenagers include the following:

  1. Parents must adapt to change in the relationship with their teen, as the teen's peers become an increasingly important influenceand the teen seeks increasing independence.
  2. Parents must limit testing and experimentation by teens. Teens may experiment with many different types of behaviors, including sex, drinking, and using other drugs. However, parents should remember that, despite how teens may act, the vast majority accept their parents' basic values. In one study, more than 75% of adolescents reported accepting their parents' discipline practices (Rutter, 1980). Teen experimentation does not mean that teens reject their parents' basic values.
  3. Parents must not overreact to rejectionof one or both parents by the teen for a time period.
  4. Parents must recognize that separation is difficult for teens and their parents, and there may be harder and easier times.
  5. Adolescents are at maximal growth velocity and changeand may be more vulnerable to social risks such as drugs, sexuality, domestic violence, and poverty.
  6. Modern family issues,such as less family support, more divorce, less extended families, and more working families, add additional challenges.
  7. Excessive exploitive and violent messages through the mediaadd to the challenges of the teen years for parents.
  8. Adolescents' feelings of invulnerabilityalso add to their willingness to expose themselves to risks.

Daydreaming

Parents worry about teenagers' wasting time and daydreaming. However, parents should be reassured that this is a normal part of the adolescent developmental process. If school and learning issues coincide, concerns about distractibility, impulsivity and poor organizational skills may suggest attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) (see Chapter 80). Depressed mood or anxiety may suggest psychiatric diagnoses (see Chapter 78)

Communication

The provider should encourage parents to avoid barriers to communication, including:

  1. Comparison with other teenagers
  2. Lecturing or moralizing
  3. Minimizing a problem
  4. Excessive talking
  5. Taking over an adolescent's problem
  6. Taking everything too seriously
  7. Overreacting, especially reaching conclusions based only on appearance, dress, or language
  8. Phrases such as
  9. The trouble with you is….
  10. How could you do this to me?
  11. Is that all? I thought it was something important.
  12. In my day….
  13. You're wrong.
  14. How could you feel like that?
  15. That's a dumb thing to say.
  16. Don't bother me now.
  17. You're stupid…crazy…incompetent.
  18. The “shoulds”: My child should be what I want him to be, he should satisfy my needs, or she should always feel loving.

The provider should encourage the parents to stress positive aspects of communication:

  1. Empathize with the adolescent.
  2. Stress the positive attributes of the adolescent. Adolescents get enough negative feedback. A dose of positive feedback and reinforcement when they do good work, such as follow-through on their chores, can go a long way in positive communication.
  3. Deliver clear messages.
  4. Respect each other's privacy.
  5. Keep a sense of humor.
  6. Resolve conflicts together. Decisions that occur in the home about the adolescent should involve the adolescent's input. This can take place in the form of weekly family meetings or brainstorming sessions. In this way, the adolescent is much more likely to carry through with the decisions. During brainstorming sessions to resolve conflicts, parents should:
  7. Involve all family members in the process.
  8. Come up with at least five possible solutions.
  9. Write down all possible suggestions even if they seem outrageous.
  10. Avoid criticisms.
  11. Employ some humor when possible.
  12. Take a break if the session becomes too argumentative.
  13. Discuss the pros and cons of the most viable alternative ideas.
  14. After writing down several possible suggestions, try to agree on one solution or a solution that combines two different suggestions. Parents may also wish to ask other families how they solved similar problems and situations. (A good resource on family problem solving is Forgatch and Patterson (1989)
  15. Involve teens in topics they like. When several hundred youths were asked what they wished to discuss with their parents, the top eight topics were
  16. Family matters: Discussions about decisions that affected the whole family or themselves, such as allowance, curfew, and rules
  17. Controversial issues locally or nationally
  18. Emotional issues
  19. The “whys” of life
  20. The future

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  1. Current affairs
  2. Personal interests of the teen
  3. Parents' life histories

Parents should also remember that, overall, parents may in fact be more bothered and remember conflicts with their teens longer than the teens do and recover more slowly.

Setting Limits

Adolescents need firm, fair, and explicit limits. Again, involvement of the adolescent in the limit-setting process is beneficial.

House Rules

Some families work better together if there is a set of “house rules.” These prescribe the expectations for behaviors and guidelines for the family to live together as a group. Well-defined house rules can become quite important during the adolescent years. Having these rules discussed and written down can avoid conflicts over what behaviors are acceptable. If there is a particular problem in following a rule, then the parents may want to implement associated consequences if the rule is broken. However, the rules should be fair and consistent and should involve input from the teen. Adolescents may be eager to participate in the establishment of such rules when they find out that they might include a rule such as, “No one will enter someone else's room without knocking first.” Rules are mainly needed for teen or family member behaviors that are a problem. There should probably be a maximum of 5 to 10 rules. Here is a sample set of house rules adapted from Patterson and Forgatch (2005):

  1. Dinner will be at approximately 6 p.m. and everyone is expected to be home and ready to eat at that time.
  2. Family members are expected to speak courteously to each other.
  3. Before opening someone's door, knock and wait for an answer.
  4. If you make a mess, you clean it up.
  5. Going out on school nights must be discussed in advance. Schoolwork must be caught up beforehand.
  6. Parties must be prearranged, and an adult must be present at the party.
  7. Without an adult present, only teens of the same sex are allowed in the home.
  8. Curfew on weekdays is 10:30 p.m. and midnight on weekends.
  9. The car must be returned when borrowed, with the same amount of gas that it had previously.

These are just samples and should be changed to meet each family's needs, expectations, and values.

Requests that Work

A key to making requests that work is limiting their number. Trained observers have found that normal mothers make 17 requests/hour, and mothers from problem families average >27 requests/hour. Lobitz and Johnson (1975) found that when parents were asked to increase the number of requests they made to their children, the rate of problem behaviors and noncompliance doubled. Key components in making useful requests from teens include the following:

  1. Decrease or limit the number of requests.
  2. Make well-timed requests. Timing of requests or other feedback to adolescents is critical. Poorly timed requests (e.g., while teen is doing homework, on the phone, or in a bad mood) will surely be met with anger, refusal, or rebellion.
  3. Make requests in a polite and pleasant manner.
  4. Make requests, one at a time. Dumping three or four requests on a teen at once is another behavior sure to trigger noncompliance and anger from the teen.
  5. Use statements rather than questions in making a request.
  6. Question approach:
  • Parent:John, how would you like to take out the garbage tonight?
  • John:No Dad, I'm busy with homework tonight.
  1. Statement approach:
  • Parent:John, please take out the garbage now, it is your turn.
  • John:I'm busy Dad.
  • Parent:John, take out the garbage.
  1. Make requests specific. For example, if giving the teen a time to be home from a movie, it should be a specific time, not “early.”

In a study of compliance to parental requests, Patterson and Forgatch (2005) found that the average rate of compliance from normal children to requests from mothers was 57% and from fathers 47%. So parents should expect a 50% to 60% rate of compliance. Providers can refer parents to numerous books, articles, Web sites, and other resources, a sampling of which are listed here.

Supported in part by the Leadership Education in Adolescent Health Training grant #T71MC00009 from Maternal and Children Health Bureau, Health Resources and Services Administration.

Web Sites

For Teens and Parents

http://www.iwannaknow.org/. American Social Health Association Web site for teens.

http://www.youngwomenshealth.org. Center for Young Women's Health at Children's Hospital Boston with educational information on a broad range of topics.

http://www.adolescenthealth.com. Links to young women's and men's health by Children's Hospital Boston.

http://www.teengrowth.com. TeenGrowth is a Web site specifically tailored toward the health interests and general well-being of the teenage population; it includes information on alcohol, drugs, emotions, health, family, friends, school, sex, and sports.

http://www.awarefoundation.org. AWARE is devoted to educating adolescents about making responsible decisions regarding their wellness, sexuality, and reproductive health.

http://www.kidshealth.org. Health information for teens and parents.

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http://www.teenwire.com. Information for teens from Planned Parenthood Federation of America.

http://www.thebody.com. AIDS and HIV information resource.

http://www.glbthealth.org. The Gay Lesbian Bisexual and Transgender Health Access Project is a collaborative project between the Massachusetts Department of Public Health and its founding partners, the Justice Resource Institute, The Medical Foundation, and JSI Research and Training.

http://www.goaskalice.columbia.edu/. Go Ask Alice! is the health question and answer Internet site produced by Alice!, Columbia University's Health Education Program, a division of the Columbia University Health Service.

http://TeenHealthFx.com. Site to provide teens with a fun way to get factual health and medical information, funded through the Atlantic Health System's Morristown Memorial Hospital, Overlook Hospital, Mountainside Hospital, and The General Hospital Center at Passaic.

http://TeensHealth.org. Nemours foundation site to answer questions for teens and parents.

http://familydoctor.org/x5575.xml. Family Doctor has components for teens and parents concerning health issues.

For Parents

http://www.tnpc.com. Site dedicated to providing parents with comprehensive and responsible guidance. http://www.healthfinder.gov. Federal government site to find health information.

http://www.4women.gov. National Women's Health Information Center from Office of Women's Health. http://ncadi.samhsa.gov. National Clearinghouse on Drug and Alcohol Information.

http://dmoz.org/Kids_and_Teens/Health/Teens/. Cincinnati Children's Hospital site with references on a broad range of topics relating to teens.

http://parentingteens.about.com/parenting/parentingteens/mbody.htm. Parenting site. http://www.parentingadolescents.com/. Parenting site.

http://www.pflag.org/. Site for Parents, families, and friends of lesbians and gays (PFLAG) provides support and resources for parents.

http://www.childdevelopmentinfo.com/. Site of the Child Development Institute contains information about developmental issues of adolescents.

For Health Professionals

http://aap.org/. Resources and position papers of the American Academy of Pediatrics.

http://www.adolescenthealth.org/. Position papers and information from the Society for Adolescent Medicine; go to links and then categories.

http://www.healthfinder.gov. Finder of health sites from federal government.

http://www.4women.gov. National Women's Health Information Center from Office of Women's Health.

http://www.medlineplus.gov. Medline for health information.

http://ncadi.samhsa.gov. Clearinghouse on drug and alcohol information.

www.usc.edu/adolhealth. Adolescent health online curriculum.

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Other Resources

Books and Articles for Health Professionals

Malone CA. Child and adolescent psychiatry and family therapy. Child Adolesc Psychiatr Clin N Am 2001;10(3):395.

Sargent J. Family therapy in child and adolescent psychiatry. Child Adolesc Psychiatr Clin N Am 1997;6(1):151.

Walsh F. The concept of family resilience: crisis and challenge. Fam Process 1996;35:261.

Zayas LH. Family functioning and child rearing in an urban environment. Dev Behav Pediatr 1995;16:S21.

The following books also provide some excellent references for dealing with families:

Allmond BW, Tanner LJ, Gofman HF. The family is the patient: using family interviews in children's medical care, 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999.

Eron JB, Lund TW. Narrative solutions in brief therapy. New York: Guilford Press, 1996.

Fishman HC. Treating troubled adolescents: a family therapy approach. New York: Basic Books, 1988.

Patterson GR, Forgatch MS. Parents and adolescents living together: Part 2: family problem solving, 2nd Edition. Champaign IL: Research Press, 2005.

Haley J. Problem solving therapy, 2nd ed. San Francisco: Jossey-Bass, 1987.

Haley J. Leaving home: the therapy for disturbed young people. Philadelphia, PA: Brunner/Mazel, 1997.

Hartman A, Laird J. Family-centered social work practice. New York: The Free Press, 1983.

Lobitz WC, Johnson SM. Parental manipulation of the behavior of normal and deviant children. Child Dev 1975;46:719.

McGoldrick M, ed. Re-visioning family therapy: race, culture and gender in clinical practice. New York: Guilford Press, 1998.

McGoldrick M, Carter B. Understanding the life cycle: the individual, the family, the culture. In Walsh F. Normal family processes, 3rd ed. New York: Guilford Press, 2002.

Minuchin P, Colapinto J, Minuchin S. Working with families of the poor. New York: Guilford Press, 1998.

Minuchin S. Family healing: strategies for hope and understanding. New York: The Free Press, 1998.

Pittman FS. Turning points: treating families in transitions and crisis. New York: WW Norton, 1987.

Visher EB, Visher JS. Old loyalties, new ties: therapeutic strategies with stepfamilies. New York: Brunner/Mazel, 1988.

White M, Epson D. Narrative means to therapeutic ends. New York: WW Norton, 1990.

Woods ME, Hollis F. Case work: a psychosocial therapy, Chapters 14 and 15. 5th ed. New York: McGraw-Hill, 2000.

Books for Parents and Families

Fairchild B, Hayward N. Now that you know: a parent's guide to understanding their gay and lesbian children. New York: Harcourt Brace, 1998.

Kaufman M, ed. Mothering teens: understanding the adolescent years. Charlottetown, PEI: Genergy Books, 1997.

Patterson GR, Forgatch MS. Parents and adolescents living together: Part 1: The Basics, 2nd Edition. Champaign IL: Research Press, 2005.

Patterson GR, Forgatch MS. Parents and adolescents living together: Part 2: family problem solving, 2nd Edition. Champaign IL: Research Press, 2005.

Pipher MB. Reviving ophelia: saving the selves of adolescent girls. New York: Putnam, 1994.

Ponton L. The sex lives of teenagers. New York: Dutton, 2000.

Romer D. Reducing adolescent risk: toward an integrated approach. Thousand Oaks: Sage Publications Inc, 2003.

Slap GB, Jablow MM. Teenage health care: the first comprehensive family guide for the preteen to young adult years. New York: Pocket Books, 1994.

Steinberg L, Levine A. You and your adolescent: a parent's guide for ages 10 to 20. New York: Harper Perennial, HarperCollins, 1997.

Books for Teens

Canfield J, Hansen MV, Kirberger K. Chicken soup for the teenage soul: 101 stories of life, love and learning. Deerfield Beach, FL: Health Communications, Inc, 1997.

Columbia University Health Education Program. The “Go Ask Alice” book of answers: a guide to good physical, sexual and emotional health. New York: Henry Holt & Co., 1998.

Kimball G. The teen trip: the complete resource guide. Chicago: Equality Press, 1997.

Madaras L. What's happening to my body? Book for boys: the new growing up guide for parents and sons, 3rd ed. New York: Pocket Books, 2000.

Madaras L. What's happening to my body? Book for girls: the new growing up guide for parents and daughters, 3rd ed. New York: Pocket Books, 2000.

McCoy K, Wibbelsman C. Life happens: a teenager's guide to friends, failure, sexuality, love, rejection, addiction, peer pressure, families, loss, depression, change and other challenges of living. New York: Perigee, 1996.

McCoy K, Wibbelsman C. Teenage body book. New York: Perigee, 1999.

Weston C. Girl talk: all the stuff your sister never told you. New York: Harper Perennial, HarperCollins, 1997.

References and Additional Readings

Boggio N, Cohall AT. Evaluating the adolescent: the search for the hidden agenda. Emerg Med 1990;30:18.

Braverman PK, Strasburger VC. Office-based adolescent health care: issues and solutions. Adoles Med: State-of-the-Art Rev 1997;8:1.

Cavanaugh RM Jr. Obtaining a personal and confidential history from adolescents: an opportunity for prevention. J Adolesc Health Care 1986;7:118.

Council on Scientific Affairs, American Medical Association. Confidential health services for adolescents. JAMA 1993;269:1420.

Elster A, Kuznets N. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams & Wilkins, 1994.

English A. Changing health care environments and adolescent health care: legal and policy challenges. Adolesc Med: State-of-the-Art Rev 1997;8:375.

English A, Ford C. The HIPAA privacy rule and adolescents: legal questions and clinical challenges. Perspect Sex Reprod Health 2004;36(2):80.

English A, Kenney KE. State minor consent laws: a summary, 2nd ed. Chapel Hill, NC: Center for Adolescent Health & The Law, 2003.

Ehrman WG, Matson SC. Approaches to assessing adolescents on serious or sensitive matters. Pediatr Clin North Am 1998;45:189.

Ford C, English A, Sigman G. Confidential health care for adolescents: position paper of the society for adolescent medicine. J Adolesc Health 2004;35:160.

Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care: a randomized controlled trial. JAMA 1997;278:1029.

Frazar GE. A private provider's approach to adolescent problems. Adolesc Med : State-of-the-Art Rev 1998;9:229.

Ginsburg KR, Slap GB, Cnaan A, et al. Adolescents' perceptions of factors affecting their decisions to seek health care. JAMA 1995;273:1913.

Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5:75.

Goldenring JM, Rosen DS. Getting into adolescents heads: an essential update. Comtemp Pediatr 2004;21(1):64.

Green M, ed. Bright futures: guidelines for health, supervision of infants, children and adolescents. Arlington, VA: National Center for Education in Maternal and Child Health, 1994.

Greydanus DE. American Academy of Pediatrics: caring for your adolescent–ages 12 to 21. New York: Bantam, 1991.

Johnson RL, Tanner NM. Approaching the adolescent patient. In: Hofmann AD, Greydanus DE, eds. Adolescent medicine, 2nd ed. Norwalk, CT: Appleton & Lange, 1989.

Kahn JA, Goodman E, Huang B, et al. Predictors of papanicolaou smear return in a hospital-based adolescent and young adult clinic. Obstet Gynecol 2003;101:490.

Klein JD, Slap GB, Elster AB, et al. Access to health care for adolescents: a position paper of the Society for Adolescent Medicine. J Adolesc Health Care 1992;13:162.

Latta RJ, Lee PD. Counseling adolescents in office practice. J Curr Adolesc Med 1981;3:15.

MacKenzie RG. Approach to the adolescent in the clinical setting. Med Clin North Am 1990;74:1085.

Ong LML, De Haes CJM, Hoos AM, et al. Doctor-patient communication: a review of the literature. Soc Sci Med 1995;40(7):903.

Ozer EM, Adams SH, Lustig JL, et al. Increasing the screening and counseling of adolescents for risky health behaviors: a primary care intervention. Pediatrics 2005:115(4):960.

Paperny DM, Hedberg VA. Computer-assisted health counselor visits: a low-cost model for comprehensive adolescent preventive services. Arch Pediatr Adolesc Med1999;153(1):63.

Patterson G, Forgatch M. Parents and adolescents: living together. Part 1: the basics. Eugene, OR: Castalia Publishing, 1987.

Patterson GR, Forgatch MS. Parents and adolescents living together: Part 2: family problem solving, 2nd Edition. Champaign IL: Research Press, 2005.

Perrin EC. Sexual orientation in child and adolescent health care. New York: Kluwer Academic/Plenum Publishers, 2002.

Rainey DY, Brandon DP, Krowchuk DP. Confidential billing accounts for adolescents in private practice. J Adolesc Health 2000;26:389.

Rutter M. Changing youth in a changing society. Cambridge: Harvard University Press, 1980.

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Ryan C, Futterman D. Lesbian and gay youth: care and counseling. Adolesc Med: State-of-the-Art Rev 1997;8:259.

Suris JC, Nebot M, Parera N. Behavior evaluation for risk-taking adolescents (BERTA): an easy to use and assess instrument to detect adolescent risky behaviors in a clinical setting. Eur J Pediatr 2005;164:371.

Society for Adolescent Medicine. Meeting the health care needs of adolescents in managed care: position paper. J Adolesc Health 1998;22:271.

Society for Adolescent Medicine. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 2004;35:160.

Thrall JS, McCloskey L, Ettner SL, et al. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med2000;154:885.

Wender EH, Coupey SM. Interviewing adolescents. In: Hoekel-man RA, ed. Primary pediatric care, 4th ed. St. Louis, MO: Mosby, 2001:915.

Woods ER, Klein JD, Wingood GM, et al. Development of a new adolescent patient-provider interaction scale (APPIS) for youth at-risk for STDs/HIV. J Adolesc Health 2005, 2006;35(6):753.e.1.