Primary Violence Prevention and the Psychosocial Assessment: Using a Brief Encounter to Change a Life
Kenneth R. Ginsburg, MD, MS Ed
THE PHYSICIAN AND SPORTSMEDICINE ONLINE - MARCH 97
In Brief: Physicians who have contact with adolescents are in a unique position to assess the risk for and the effects of violent behavior in youth. With appropriate techniques, physicians can use these opportunities with adolescents, even in the sports setting, to address violent behavior. If time is sharply limited, a three-question psychosocial screen can bring up relevant issues, and a violence screen can refine the history. If more time is allowed, a more comprehensive psychosocial screen is ideal. The physician can then move to situation- and age-appropriate counseling and role-playing techniques as needed.
Physicians who work with adolescents are understandably frustrated as more of these young patients are victimized by violence. The good news is that physicians do have the potential to help patients reduce their exposure to explosive situations. Knowing what to look for in a brief psychosocial assessment and how to intervene with counseling and role play can empower physicians to make a difference.
A recent Centers for Disease Control and Prevention survey (1) found that the United States has the highest rates of childhood homicide, suicide, and firearm-related death among industrialized countries. The homicide rate for US children under age 15 is five times higher than that for children of other industrialized nations. In our discomfort with our inability to solve this complex problem, we question whether physicians even have a role in prevention. Yet, reality (see "The Reach of Violence" at the end of this article) dictates that if we are to enhance the health of our patients, particularly our adolescent patients, we must address violence.
To succeed, however, adolescent care must shift from crisis intervention to primary prevention. The healthcare provider offering a preparticipation exam or injury-focused physical has an ideal opportunity to address violence, because he or she is offering a service valued by the teenager, is usually highly respected, and can make a natural transition toward guidance for injury prevention.
Setting the Stage
The typical adolescent in the healthcare setting expects to get a check-up, shots, forms completed, or a cast modeled—not to be asked to disclose personal information. If the provider does not "set the stage," the history elicited is likely to be false, and the patient is unlikely to be receptive to guidance.
In the case of the preparticipation examination or evaluation for a sports-related injury, the provider can begin with a statement such as, "An important part of my job is to make sure you avoid injuries. Let me tell you, I'm far more worried about injuries our youth are getting from violence (drug use, depression, unsafe sex) than on the playing field. I'd like to be able to talk to you about this. First, let me tell you the rules that are here to make sure that you feel safe talking to me."
Youth will not—and perhaps, should not—disclose personal information without having a sense of the following issues: (1) Why is the provider asking personal questions? (2) What will this person do with the answers? Will he or she judge me or share my secrets? and (3) Is it worth sharing private information? Can this person do anything to help me?
After addressing all of these issues, the final parameter that needs to be explained is the limit of confidentiality. If the limit is not addressed before obtaining the history, the provider risks losing the patient's trust if he or she needs to intervene. Confidentiality is the norm in the adolescent-provider relationship; however, it cannot be offered for suicidal or homicidal plans or for disclosure of abuse. Ideally, the parent(s) can be included in this initial relationship-defining conversation. If they are present, they will understand that the provider honors confidentiality to encourage open communication, that there are boundaries to confidentiality in life-threatening situations, and that the provider will be an advocate of appropriate parental involvement.
The Brief Psychosocial Screen
Time constraints preclude incorporating a comprehensive psychosocial screen (see "More About the Comprehensive Psychosocial Assessment" at the end of this article) in every encounter. However, we know that teenagers in crisis present to medical care with a hidden agenda. In fact, one study revealed that 50% of youth who committed suicide had seen a healthcare provider in the month before, and 25% in the week before (2).
With this in mind, an abbreviated three-part screen can be incorporated into anyvisit. First, ask the question, "How is school going?" School is a proxy measure for general well-being, as life's stressors are likely to adversely affect school performance. Responses such as, "I had a bad quarter," "Not as well as it used to be," or "I'm not going very much" suggest changes and should arouse concern. These responses represent a challenge from the youth to see if the adult will explore further the causes.
For some youth, though, school is a successful respite from other stresses. Therefore, also ask, "Are you happy?" or "How is life going for you?" No matter the response, follow quickly with, "When you're not happy, how do you handle it? Who do you talk to?" The unhappy youth with no one to talk to is at risk. There is no presenting complaint that deserves your time more than a thorough evaluation or referral for depression.
The Violence Screen
After appropriate stage setting, a brief violence screen can give a good sense of a teen's level of risk and open the door to discussion of solutions.
Acute and routine settings. Several indicators point to a patient's degree of risk.
Sense of future. A patient with no future plans may not expect to live. Simply ask, "What do you want to be when you grow up?"
Exposure to violence. Patients' exposure may be in the home, on the streets, or through the media. The patient inured to violence, or who sees it as the appropriate way to handle stress or conflict, is clearly at risk. A patient disciplined violently may know no other way to raise children or to handle a disagreement.
Perception of safety. Learning when and where patients feel safe will reveal much about their risk and what steps they may take to lower that risk. Ask, "Do you feel safe at school? Are there a lot of fights at your school? Do people bring weapons to school?" Also, take this opportunity to explore for a history of physical or sexual abuse. Questions such as, "Do you feel safe at home? Is there anyone who hurts you or touches you when you don't want to be touched?" can explore these issues.
Most critically, learn what patients are doing to make themselves feel safer. "Do you think a knife or gun would make you safer? Do you carry one?" Many youth operate under the belief that a weapon will protect them without even considering that it puts them at much greater risk of death (see subhead "If the patient is considering obtaining a weapon..." below). Remember that patients who carry a weapon are doing so under the belief that their lives have value and deserve to be protected. They should be congratulated for having this self-worth—before being told that a weapon makes them much more likely to be killed.
Threshold for fighting. This is an opportunity to elucidate a critical marker for conflict avoidance with the question, "What makes you mad enough to fight?" (See "Patterns of Violence Escalation" below)
Patterns of Violence Escalation
Essentially, there are four levels of violence escalation that adolescents encounter in their interactions with peers, and different youth reach their threshold for violent retaliation at different levels. First, one teen calls another a name, or insults or disrespects the targeted youth. If this has not achieved the desired outcome, the next step is to insult the target's mother or another family member. Next, the escalator will invade body space; my teen patients call this "in your face." Finally, if the "victim" has not yet successfully de-escalated the situation, the escalator touches or pushes. In my locale, this is called "he was all over me." I have yet to meet an adolescent who feels equipped to walk away once he or she is touched. To do so risks being labeled a "punk" and being repeatedly victimized.
Acute injury setting. It is imperative to know whether a patient being sutured or assessed for concussion following a violence-related injury is in the midst of a cycle of retaliation. Ask "What's going to happen now? Is this over, or are you going to get even? Are people still after you?"
Societal violence, produced through the complex interaction of multiple factors, won't be solved through quick office-based interactions. However, feasible interventions—some direct, such as behavior counseling, others indirect, such as appropriate referrals—can begin in the office. A respected provider can, during any contact with a young patient, use a combination of discussion and role-play to help youth acquire safer behaviors and avoid risky behaviors. (See "Role Play Rules" below)
Role Play Rules
Role play can effectively involve adolescents in a discussion, and help them understand concepts more concretely. However, the technique needs to be practiced with age-appropriate rules in mind:
- Do not act aggressively; rather, stay calm and act out situations in slow motion so that the teenager thinks with his or her brain instead of responding emotionally or aggressively.
- Do not tell patients you are doing a role play (they will run for the hills!). Instead, start with "What would you do if...?"
- Use short, universal phrases and let the patient do most of the talking. If you use too much of your own language, recalling your own youth, the teenager will say "It's not like that" and will tune you out.
The provider's counseling goal, during the critical moments seized upon during routine contacts, can be to guide the youth verbally through "life experiences," allowing them to make "mistakes" in the safety of a medical setting rather than in the increasing peril of the real world. The hope is that "cognitive ahas" (realizations) made in a safe setting hold a portion of the teaching effectiveness of mistakes made in the dangerous world—without the risk. The key to this guidance style is breaking down abstract concepts into multiple concrete steps. Teens are guided through each step until they come to an abstract realization (see "Youth in Transition" below). Skills-building messages can also be transmitted through conversation (that emphasizes listening), role-playing, and diagrams.
Youth in Transition
Teens are in transition between the concrete thinking of childhood and the abstract thinking of adulthood. They move toward abstraction capabilities through neurologic and hormonal maturation and through life experiences. With each new experience and its consequences, the youth takes a small step toward more abstract thinking. Physicians can offer "experiences" through age-appropriate counseling—without the severe consequences possible outside the medical setting.
First, though, providers need to be aware of the patients' cognitive level. Concrete thinkers see things as they are; they don't conceive future consequences, and they view the world and people as "good" or "bad." Thus, concrete thinkers can not look beyond actions to determine underlying motivations. In contrast, abstract thinkers see ambiguities, consider future consequences, and evaluate underlying motivations—all making abstract thinking highly protective.
Understanding the degree to which each youth is able to absorb abstract ideas is a critical first step in counseling the adolescent. If a patient is unable to contemplate the future, warnings about how current actions may have long-term consequences are useless.
One traditional office-based technique that is unlikely to produce any benefit is lecturing or offering facts. Youth in 1997 know the facts, and they all want to avoid violence: What they need is the skill to change or avoid certain behaviors. Without skills, motivation to change will only produce frustration.
Putting Counseling Into Action
Office-based counseling is targeted to the area of concern uncovered by the risk assessment. Following are a few specific examples of how physicians might handle responses they believe indicate a patient is at risk. Certainly, any patient may merit several counseling points. Also, remember that any intervention performed in the office will be far more effective if combined with appropriate referrals and parental involvement.
If the patient is in the middle of a cycle of retaliation. The most effective intervention may be to guide the patient to leave town while tensions are highest. Expect a great deal of resistance for "punking out." However, if the patient's life is in danger, the provider can often work with the patient and family to concoct a viable out-of-town "crisis" that emergently draws the patient away. Of course, the patient's best long-term chance is to break permanently from the delinquent peer group. However, this is highly challenging and for some patients may be dangerous.
Using a decision tree to guide the youth to a "cognitive aha" is another approach. A youth about to engage in a retributive violent act wants an immediate emotional release, but may be unaware of the peril because of the inability to grasp future consequences. The provider discusses the teenager's fantasies and draws a map toward the future, with each junction described by the teenager in response to an open-ended question. At each junction, the provider inquires whether the fantasy is realistic and suggests other possible outcomes. Ultimately, the provider helps the patient realize that the one day he will feel bad for not getting even is minimal when compared to a life outcome that is more to his liking (see figure 1).
If the patient seems vulnerable to violence escalation. Approaches vary according to the patient's threshold for fighting. If the answer is:
"...if someone calls me a name," recognize that this child is at very high risk. Try to get him to realize that the person is calling him names not because he or she believes them, but because he or she is trying to get him angry. Talk to him about the strength of walking away. Ask him, "How could you win in this situation? What could make it worse?"
"...if someone calls my mother a name," the approach can be similar. Questions could include: "Does the person know your mother? How could you win? How could you make this worse? Could you use a sense of humor to help out in this situation?
"...if someone gets in my face [invades body space]," the provider can give practical advice: "Don't let yourself be cornered. You can keep a leg in front of you to help protect your space."
" ...only if someone hits me," recognize that this is a resilient teen! The provider can promote a few educational objectives ("I want you to understand a few things so you won't die..."):
- Carrying a weapon makes you less safe. Fighting clean (using fists only) means the fight will probably stay that way. Pulling out a weapon begins the cycle of retaliation.
- Try not to be around when fights happen—that gets you into the cycle of escalation and retaliation just for being a bystander.
- If you are in a fight, try to break even. If you win big, they may keep coming after you. If you can break even, the anger may be used up.
Provide scenarios for the child and try to have her come up with nonviolent ways to deal with a problem. Be concrete in your advice:
- Avoid fights by hanging out with other kids.
- Don't let someone force you into a fight—think about what you want, not what the other kid wants.
- You and your friends should talk about and practice what you'd do if someone tried to fight you or pulled a knife on you.
If the patient is considering obtaining a weapon to enhance his or her perception of safety. Congratulate the patient for valuing his life, but convey to him that if he carries a gun, he's more likely to die than to live. A "cognitive aha" role play can be extremely effective in conveying to the youth why this is so. The following role play must be done calmly and in slow motion so that the patient remains intellectual, does not feel threatened, and does not react viscerally.
- The patient takes the role of a person with a gun.
- The physician takes the role of the patient, who may or may not carry a gun.
- Teach that the best option is to keep walking or avoid the conflict entirely.
- Assume that the cycle of escalation has reached the point of no return—a physical conflict is going to occur.
- While standing close to the patient (don't actually invade space), state,
"Suppose a fight is about to happen. You're a guy with a gun and I'm you. You don't know if I have a gun. What would happen if I took a swing at you like this?" (Take a slow-motion swing toward the patient, without actually coming into contact with him.)
- The teen will respond in one of two ways:
a. "I'll swing back at you/hit you/pistol whip you/knock you out." If he says this, say, "Exactly. I'm going to get hurt, but I'm going to live."
b. "I'm going to shoot you." If he says this, respond, "Will you really shoot me if this has been a clean fight up to now?"
To this, most youth will respond, "No, I'd probably still fight clean." Some, though, will say, "You don't know what you're talking about. Where I come from, if you swing at someone, you're a dead man." If he makes the latter statement, say, "You know your neighborhood better than I do. We need to think together how to keep you alive." (See subhead below, "If you are at a loss...")
Assuming he realizes the fight will remain clean, proceed to the following step:
- State, "What if we're in each other's face and a conflict is about to happen, and I do this..." (reach for something at right hip—the patient will know that means reaching for a gun.)
In virtually all cases, he will say, "I would shoot you first." Respond, "Exactly. You should. Do you see that carrying a weapon here made me much more likely to be killed? Even more, if I had a reputation for packing a weapon, do you see that you would have killed me up front, because you wouldn't have taken the chance?"
Youth will generally have acquired the protective abstraction. They may need to repeat the scenario verbally for their other fears, such as being mugged or being the victim of a drive-by shooting. In the case of a mugging, you can clearly demonstrate that a perpetrator needs to kill the victim who has a weapon, but not the unarmed victim. In the case of a drive-by shooting, the presence of a weapon is irrelevant.
If the patient knows what the right behaviors are, but feels unable to escape danger, or if the patient's friends are involved. Teenagers often have the desire to avoid risky behaviors but are thwarted by their peers. For example, it is a learned skill to be able to replace risky activities and behaviors with safer ones. Learn what your patient does with his friends. For example, if they either play basketball or do drugs, teach him to always carry a basketball. This allows him to keep his friends—a critical point for adolescents—while avoiding negative behaviors. As obvious as this skill seems to adults, it is new to younger teenagers.
However, if it comes down to a strong conflict with friends, often the teenager cannot avoid the situation. It is developmentally difficult for a youth to say to her friends, "I am morally, spiritually, and ethically opposed to your behavior." However, it is developmentally appropriate to say, "My mother's a b----." Thus, empower the teenager with an "out" that blames her parents. Have adolescents create a code with their parents. If the parent receives a phone call in which the teen uses the code word or phrase, it signals the parent to demand that the teen return home immediately. "What do you mean you're calling now? You were supposed to be home 2 hours ago!" The parent should say this loudly and aggressively so witnesses hear their anger through the phone. Then, the youth can blame her parents for ruining her fun, and the teenager retains control over her actions without worrying about loss of esteem in the eyes of her friends. If the teen is not able to get out of the situation, she escalates to the next level by being rude to her parent over the phone. "You're just lucky I even called. None of my friends are treated like 8-year-olds! I'll be home when I feel like it!" In response to this escalation, parents must then demand to know exactly where she is, tell her she will lose all privileges if she moves, and arrange for her to be picked up immediately.
If you are at a loss or the patient states, "How can you know what it's like for me?" Frequently, adult guidance is rejected by the teenager, or adults are at a loss to suggest effective strategies for survival in an adolescent world so different than the one we remember. Now is the time to listen. Listening, if nothing else, is a deep sign of respect. Active listening prompts people to develop their own solutions. When I have reached this point of helplessness, I simply state, "I know you're in trouble, but I just don't know the right thing to say. It is up to you to figure out how to stay alive. I do know that there are two possible roads you're headed down. One is to make and follow your dreams, and the other might be death and destruction."
At this point I draw a simple diagram. Its starting point is the present. It has two endpoints represented by open boxes. I fill one box with the teenager's dreams for his future. The other box is filled with the words "death and destruction." I draw a ladder toward both endpoints and tell the teenager that his assignment is to figure out what the steps are that will take him in the alternative directions. Usually, the teenager has no difficulty figuring out what behaviors move him toward death and destruction. All I ask at this first visit is for him to think of the first step in the positive direction. Ideally, this is the beginning of a relationship in which I guide him to take one step at a time. If that is not possible, the teenager should be referred to some trusted adult, a parent or professional, who can help him formulate these important steps. I have found that even the toughest of street youth are moved by the awareness that they do have some control over their future.
Other interventions. Several authors have offered suggestions for other forms of intervention for youth at risk from violence (3-9). These include involving the family and referral to mental health services, mentoring programs, school tutoring programs, or after-school programs. Further, parents can be guided toward effective discipline techniques that recognize the adolescent's need for increasing autonomy. Remind parents that "discipline" means "to teach," not "to punish."
Healthcare providers cannot independently change the lives of adolescent patients. However, if we make ourselves consistently available to them as trustworthy adults, we can position ourselves to make a difference. If we are familiar with the community resources available to teenagers in crisis, then our role as assessors can be invaluable. For those adolescents not in crisis, we can serve as adults who offer gentle, respectful guidance and who teach effective strategies to maintain healthy behaviors. A first step is in the commitment to communicate effectively with them in every available opportunity. The sports physical and injury assessments are ideal opportunities.
The Reach of Violence
In the United States, violence and injury head the list of avoidable causes of morbidity and mortality for youth. Homicide is the second leading cause of death among adolescent males 15 to 19 (1,2). In addition, the US homicide rate for 15-to-24 year olds is quadruple the rate for 20 other Western nations combined (2). For children under age 15, the homicide rate is five times higher than that for children in 25 other industrialized nations that were surveyed (3). For our minority youth, homicide is the leading killer, though the correlation between race and violence does not exist once controlled for economic factors (2). For every adolescent who is fatally injured as a result of violence, 41 adolescents are hospitalized and 1,100 are treated in emergency rooms (4).
Suicide—violence turned inward—is the third greatest source of mortality among adolescents (5). The most recent data from the Centers for Disease Control and Prevention note that 8.3% of a national sample of 9th through 12th graders reported a previous attempted suicide (6). While most youth do not seek medical care specifically related to the event, many seek care for routine health concerns in the weeks or months preceding the attempt (7-9). They may present with a hidden agenda or somatic complaint in a conscious or subconscious help-seeking gesture (10-12).
- Simons J: The Adolescent and Young Adult Fact Book. Washington, DC, Children's Defense Fund, 1991
- Schwarz DF: Violence. Pediatr Rev 1996;17(6):197-201
- Centers for Disease Control and Prevention: Rates of homicide, suicide, and firearm-related death among children—26 industrialized countries. MMWR 1997;46(5):101-105
- Gans J: America's Adolescents: How Healthy Are They? Chicago, American Medical Association, 1990
- National Center for Health Statistics: Advance Report of Final Mortality Statistics, 1991. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, Centers for Disease Control; 1993. Suppl, vol 42, no. 2, 0364-0396
- Centers for Disease Control: Health objectives for the nation: attempted suicide among high school students-United States, 1990. MMWR 1991;40(37):633-635
- Hawton K, O'Grady J, Osborn M, et al: Adolescents who take overdoses: their characteristics, problems and contacts with helping agencies. Brit J Psychiatry 1982:140(Feb):118-123
- Slap GB, Vorters DF, Chaudhuri S, et al: Risk factors for attempted suicide during adolescence. Pediatr 1989;84(5):762-771
- Smith K, Crawford S: Suicidal behavior among 'normal' high school students. Suicide Life Threat Behav 1986;16(3):313-325
- Porter SC, Fein JA, Ginsburg KR: Depression screening in adolescents with somatic complaints presenting to the emergency department. Ann Emerg Med, to be published
- Capelli M, Clulow MK, Goodman JT, et al: Identifying depressed and suicidal adolescents in a teen health clinic. J Adolesc Health 1995;16(1):64-70
- Schneider MB, Friedman SB, Fisher M: Stated and unstated reasons for visiting a high school nurse's office. J Adolesc Health 1995;16(1):35-40
More About the Comprehensive Psychosocial Assessment
Ideally, the violence risk assessment occurs in the context of a comprehensive psychosocial screen. Clearly, this is not realistic in all healthcare encounters. This commentary focuses on violence; however, following is a brief exposure to the comprehensive SHADESS screen. Several resources exist for in-depth exposure to the adolescent psychosocial screen (1-3). The screen must be done without the parent in the room after the parent has contributed to the history and offered their concerns.
Once in private, the provider should ask the youth if any concerns were not stated in the parent's presence. The screening should adhere to the following general rules:
- Before making psychosocial screening a routine part of adolescent encounters, the provider be familiar with community resources. This positions the provider to be genuinely helpful.
- No interview should begin unless the stage has been properly set. (See "Setting the Stage", above in mainbar.)
- The interview should proceed from less intimate to more personal topics (the SHADESS mnemonic helps remind interviewers of this rule). This allows teenagers the time to warm up, to determine whether you are judgmental, and to gauge if the provider has a sincere interest in their answers.
- Questions should initially be impersonal; for example, "are many of the teens in your school getting in fights?" Often, teenagers will not reveal information about themselves, but will readily share their peers' behaviors. Whether or not they reveal private information, the provider can still offer appropriate counseling.
- All questions must be asked without judgment, and the provider must not express dismay to the responses. There is time later to offer guidance to the patient. Quick reactions disrupt further disclosures.
- Similarly, the provider must not express great pleasure or satisfaction to the responses. If the interviewer "cheerleads" or gets excited about positive behaviors, youths will not be likely to disclose information later that they think will disappoint the interviewer. The interviewer needs to praise the process of communication rather than the content.
- The interviewer should be cognizant that teenagers who share a great deal of information may be in crisis. Many interviewers assume that they have done a particularly good job of connecting with adolescents when youths disclose readily. While this may be true, it is also true that people near crisis share private information readily.
- Finally, while listening to responses, find something to admire or respect about the teen. Even the highest risk teen whose behavior is offensive may have been "honest" or could be seen as a "survivor" in a world very different from the provider's. The restatement of this positive aspect of the patient allows a less offensive move toward the desired intervention. Examples are, "You know, I enjoyed talking to you. You have really been honest with me, and that can be rare for teenagers; it says something very positive about you," or "That's exciting that you want to build a recreation center to help kids like you. You are a very caring person," or "I don't know if people have made this clear to you, but you're a survivor. You are strong enough to have made it through what sounds like a very tough life. But, I have to tell you, I feel worried for you because..."
School performance tells a lot about overall well-being. Remember that school is the job of the patient and that problems at home, depression, or drug use will all affect that job. Thus, worrisome responses here are predictive of other problems. Any answer that implies a recent change, such as "School was OK until this marking period," is an invitation to the interviewer to ask "Why? What has changed in your life?" In general, do not focus on specific grades, as that can embarrass a hard working but mediocre student. Instead ask, "How is school going? Are you doing as well as you think you can? What is your favorite subject in school?"
After learning how the patient feels about school, ask, "What would you like to do when you get older?" The response is very revealing: Youth with no plans may not believe they have a future, and consequently are more likely to put themselves at greater risk now.
Many teenagers have tense relationships with their parents, but it is critical to determine when the relationship is reaching crisis proportions. If caught early, families can be guided to more appropriate levels of communication and discipline. Questions can include, "How are things at home? Do you get along well with your parents and siblings? Do you feel that people at home understand you? If you have a problem, who can you go to?"
This is also the opportunity to learn about abusive situations at home. A general screening question for abuse is, "Do you feel safe at home?"
Peer relationships are of exceptional importance to the teenager. Knowing what a patient's friends are doing offers a strong clue into what type of negative pressures the patient is likely to encounter. Further, a youth with "nothing to do" is more likely to fill his or her time with negative behaviors.
To gauge patients' activities ask, "What kind of things do you do outside of school? Who is your best friend? What is he or she like? What kind of things do you do together? Do you have many other friends? What are they like? Sometimes I worry about teenagers being influenced by their friends. If I knew your friends, would I think they were a good or bad influence on you? How do you deal with it when your friends are doing something that you don't want to do?
Drugs and Substance Use
Mind altering substances contribute sharply to the mortality of injuries and violence, the morbidities of school failure and depression, and the risk for sexually transmitted diseases. Be aware that many youth do not consider marijuana a drug because it is natural. Particularly in the sports setting, do not forget to inquire about anabolic steroid use. Cigarettes and alcohol use should not be minimized as these substances can lead to long-term addictions with dire health consequences. Remember that substance users can be roughly divided into two groups: 1) experimenters who are having "fun", and 2) self-medicators who use drugs to take away the pain of depression, the discomfort of attention deficit disorder, or the frightening thoughts of evolving thought disorders.
An approach to assess the patient's substance use is, "Are many teens in your area smoking cigarettes, drinking alcohol, or using drugs? Are any of your friends doing the same? Have you ever used...? How often? Do you think you have a problem with ... ? If not, convince me! Why do you think you are doing drugs? I work with a lot of teens who use drugs to escape from something that is troubling them. I usually try to get those teens the help they deserve. I'm going to ask some more questions about how you are feeling about yourself to determine if I can be helpful to you."
Emotions and Depression
Not all adolescents who commit suicide are depressed—some are impulsive. Because depressed youth often do not exhibit classic vegetative signs, teenagers must be asked questions about depression and suicide directly. If any initial response is worrisome, a comprehensive screen should be done that includes past history of suicide attempts by the patient or a person close to them, existence and lethality of a plan to commit suicide, and access to the means to carry out the plan, particularly to a firearm. If the patient has suicidal intention or strong ideation, he or she must be referred to mental health services immediately. As previously stated, suicidal intention is never treated with confidentiality. Questions can include, "How is life going for you? Would you describe yourself as a happy or a sad person? Who can you talk to if you have a problem? Have you ever thought of hurting yourself?"
While the interview is focused on mental health, the provider can explore self-esteem and body image. This is particularly important in the sports setting as many athletes are dissatisfied with their body. Others need to meet weight requirements and may use steroids, starvation, purging, or excessive exercise to alter their body. Consider asking patients, "You are at the age when your body is going through a lot of changes. Do you feel like you understand these changes? How do you feel about the way your body is developing? How do you feel about how you look?"
It is extremely important to approach this subject with no preconceptions of level of sexual activity. Some teenagers resent adult assumptions that they have had sex. Others worry deeply that they are the only people not to have engaged in sexual activities. Remember that to many youth, abstinence implies that they are not allowed to even touch another person. This is very different than in earlier decades when youth were aware that sexual exploration could be a slow process that went through several stages ("the bases"). Youth today are exposed to a popular media that offers few messages of interim sexual behaviors. Rather, people are seen as asexual or as having intercourse. This may partially explain the earlier initiation of sexual intercourse of recent decades. Thus, when counseling toward abstinence, the provider may find it helpful and somewhat illuminating to discuss safe sexual behaviors.
It is also important not to assume heterosexuality. Many homosexual youth are in a state of turmoil and have no responsible adult to turn to if they reach a point of crisis. While little is known about these youth, we do know they are at increased risk of suicide (4,5). Even if we ask all of our sexual histories with a nonjudgemental, open-ended style, it will still be rare that homosexual youth will reveal their sexuality in the interview. It is not the provider's job to expedite the coming-out process. Rather, the intent is that youth will get the message that, in time of crisis, their health provider is someone who may understand and may be helpful. Open-ended ways of obtaining a sexual history include, "Have you begun dating? Are you currently seeing someone? What is the person like? Have you begun to become sexual with that person? By this I mean hugging, kissing, or even touching in private places. What do you think makes a person ready for intercourse? Have you had intercourse with this or any other person?
If the patient is sexually active, inquire whether they are minimizing their risks by asking, "What do you think makes a person ready for intercourse? Have many of your friends become sexually active? Have you had intercourse with this or any other person? How many sexual partners have you had? Are you aware of the negative consequences of sexual intercourse (disease, pregnancy, emotional pain)? Have any of the consequences ever happened to you? Are you doing anything to make sure that none of these consequences will happen to you? Ask youth whether they wear condoms and use birth control. Most teenagers will say that they do wear condoms; ask whether they wear them always or sometimes. Many teens wear condoms only if they do not trust their partner. In fact, producing a condom can be interpreted as a sign of mistrust. Youth need to be taught the abstract epidemiological principle that a sexual encounter with one person, in fact, exposes one to a potential of thousands of people. This can be done with a diagram.
While on the subject of sexuality, it is worth exploring whether patients might be getting into destructive relationships that are a setup for violence and exploitation. Teenagers often feel flattered by the early stages of destructive relationships and soon find themselves deeply entrenched. In these relationships, assessments and interventions must occur early. Destructive relationships often begin with one partner so "deeply in love" that they get insanely jealous over other relationships in their partner's lives. This jealousy evolves into the victim needing to choose between the lover and her family and friends. Once isolated from his or her other relationships, he or she is much more easily convinced that she is lucky to have anybody. The physician can say, "Tell me about your boyfriend or girlfriend. Are you still able to stay close with your other friends? Does he or she ever get very jealous if you spend time with someone else?
Safety and Violence
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- Hodgman CH, Jack MS: Interviewing, in McAnarney ER, Kreipe RE, Orr DP, et al (eds): Textbook of Adolescent Medicine. Philadelphia, WB Saunders Co, 1992, pp 180-185
- Proctor CD, Groze VK: Risk factors for suicide among gay, lesbian, and bisexual youths. Soc Work 1994;39(5):504-513
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- Centers for Disease Control and Prevention: Rates of homicide, suicide, and firearm-related death among children—26 industrialized countries. MMWR 1997;46(5):101-105
- Hawton K, O'Grady J, Osborn M, et al: Adolescents who take overdoses: their characteristics, problems and contacts with helping agencies. Brit J Psychiatry 1982:140(Feb):118-123
- Jenkins EJ, Bell CC: Adolescent violence: can it be curbed? In Brown RT, Cromer BA (eds): Adolescent Medicine State of the Art Reviews, Vol 3, No 1. Psychosocial Issues in Adolescents. Philadelphia, Hanley and Belfus, Inc, 1992, pp 71-86
- Preventing gunshot injuries among children and adolescents. American Academy of Pediatrics, Center to Prevent Handgun Violence. October, 1991
- Prothrow-Stith D: Can physicians help curb adolescent violence? Hosp Pract 1992;27(6):193-207
- Rivara FP, Farrington DP: Prevention of violence: role of the pediatrician. Arch Pediatr Adolesc Med 1995;149(4):421-429
- Slaby RG, Stringham P: Prevention of peer and community violence: the pediatrician's role. Pediatr 1994;94(4 pt 2):608-616
- Stringham P, Weitzman M: Violence counseling in the routine health care of adolescents. J Adolesc Health Care 1988;9(5):389-393
- Webster DW, Wilson ME: Gun violence among youth and the pediatrician's role in primary prevention. Pediatr 1994;94(4 pt 2):617-622
Dr Ginsburg is assistant professor in the Section of Adolescent Medicine, Division of General Pediatrics, Department of Pediatrics, at The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine. Address correspondence to Dr Ginsburg at the Section of Adolescent Medicine, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104; e-mail to [email protected].
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