Adapting the H&P: Adolescents
Adolescence is a time of exploration, growth and often, risk-taking. An in depth psychosocial history, often framed as a HEADSSS assessment, can identify a teen’s strengths, stressors and potential threats to health. Confidentiality is a critical issue – research shows that teens will share more if physicians create the space for teens to speak privately with them.
Adolescent development
Like younger children, adolescents usually develop in a predictable way: physically, cognitively and psychosocially.
The physical changes of puberty reflect hormonal changes that you will study in depth in the Lifecycle block. The order of changes is similar for males and females, but the timing and rate of of puberty differs. In those assigned female at birth, the average onset of puberty is at age 9-10 and lasts 3-4 years. For those assigned male, puberty begins about a year later, and lasts 4-6 years. The onset of puberty varies across individuals, with a wide range considered normal.
Psychosocially and cognitively, adolescence is often divided into 3 stages, with advances at each stage as outlined below
- Early adolescence, from ages 10-13
- Middle adolescence, from ages 14-17
- Late adolescence, from ages 18-21
| Cognitive | Psychosocial | |
| Early | Retain concrete thinking Begin to question authority and societal standards Conformist morality of childhood Learning by trial and error Beginning of abstraction Imaginary audience, on stage all the time – others are thinking about them |
Begin to separate from parents and identify with peers
Confrontational with parents Preoccupation with self/privacy Preoccupation with being like peers Conformity Lack of impulse control |
| Middle | Thinking less childlike – more abstract, analytic, introspective
Begin to realize they are sexual beings Can analyze facts and make better choices, based on the consequences of their decisions Sensitive to criticism |
Peak conflict/peer/risk behavior Conformity with peer values Feeling of omnipotence and immortality Increasing independence Less idealistic vocational aspirations Questioning “who is the real me?” Behave differently with different people |
| Late | Conceptualize/verbalize thoughts Full adult reasoning/identity Ability for abstract thinking Understanding consequences of behavioral choices Increased thoughts about more concepts |
Integration of diverse views of self
Willingness to compromise Less importance placed on peer group Accepts parental values or develop own Realistic vocational goals |
Privacy and confidentiality
Beginning at age 11-12, most providers spend part of each well visit talking to an adolescent privately about sensitive topics like puberty and risky behaviors. Parents are usually relieved that their child’s physician is discussing these topics, but it’s important to address confidentiality up front, with both teens and parents. Teens need to understand what will be kept confidential so they’ll give you accurate information about health concerns and behaviors. Parents need to understand that you’re all still on the same team, and that you encourage teens to communicate with their families about anything important that comes up.
Your preceptors can guide you, but in general, there is very little that you can’t keep confidential between you and your adolescent patient except concerns about abuse or safety. Confidentiality must be breached if a teen is at risk of harming themselves or others and cases of child abuse or neglect must be reported to child protective services. The definition of statutory rape and reporting laws vary by state, with the age to consent ranging from 16 to 18 years old.
State law also governs which health care services minors can access without parental consent. For example, in Washington, any adolescent can receive reproductive health care and prenatal care without their parents’ consent, and those 13 and older can access mental health services and substance use treatment independently. Patients 18 and older are considered adults. Current information on consent laws by state can be found at the Guttmacher Institute’s website ( https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law ).
Interviewing techniques
Teens tend to be a lot more reticent than younger children or adults, so open ended questions often don’t work as well. If you ask questions like “how’s school?” you’re likely to get “fine” or “ok.” If you ask specific questions like “what did you do after school yesterday?” you’ll learn much more about what’s going on with your teen patient.
It’s especially important to ask about risky behavior. Adolescents are establishing their autonomy but may not have the judgment to keep themselves safe. The prefrontal cortex, which is responsible for planning and impulse control, isn’t fully mature until the mid-20s, so pediatricians often consider “adolescence” to extend to 21. Late adolescents tend to have better impulse control than younger teens, but are still more likely to take risks than they will when they’re older.
HEADSSS Assessment
HEADSSS is an acronym for psychosocial topics important to cover with teens – you’ll see many clinicians use it to guide their interviews. The original acronym was HEADS – as in getting into adolescent heads – but more S’s have been added over time.
| HEADSSS: Possible questions (follow-up questions for positive responses in italics ) | |
|---|---|
| H ome | Who lives at home with you? What are the rules like at home? How do you get along with your parents? What happens when there’s a disagreement? |
| E ducation | What school do you go to? What do you like and not like about school? What’s your favorite and least favorite subject? What are your grades like? |
| A ctivities | What do you do for fun? What do you and your friends do together? Do you have a best friend? Are you in any clubs or teams? Do you do any regular sports or exercise? |
| D rugs & diet | Do any of your friends smoke or drink? Have you ever tried smoking or drinking? What about other drugs? Do you or your friends drive when you’ve been drinking? Do you like your body? Why or why not? Do you ever skip meals to lose weight? |
| S exuality & gender identity | Have you ever dated someone? Are you dating anyone now? How old are they? Do you feel safe with them? How do you see yourself in terms of gender – boy, girl, non-binary, other? How would you describe your sexual orientation or romantic attraction – gay, straight, bisexual? Have you had sex? Was it a good experience? Add appropriate questions from sexual history. |
| S uicide & mental health | Have you felt sad? Have you ever felt depressed? Have you felt like hurting yourself? Killing yourself? Have you ever tried? Have you felt like hurting someone else? |
| S afety | Have you ever been seriously injured? (How?) How about anyone else you know? Is there a lot of violence at your home? At school? In your neighborhood? Are there any weapons in your home? How much time are you spending on screens every day? What do you do? Do you bike? Do you wear a helmet? |
Physical exam
The general approach to the PE in adolescents is the same as for adults. Be thoughtful and talk to your preceptor about whether a parent or a chaperone should be in the room for any part of the exam – there’s no single right answer.
Resources and References
Levine, S. (2009). Adolescent Consent and Confidentiality. Pediatrics in Review. 457-458
Ford, C., Millstein, S., Halpern-Felsher, B., & Irwin, C. (1997). Influence of physician confidentiality assurances on adolescents’ willingness to disclose
information and seek future health care. A randomized controlled trial. JAMA, 1029-1034