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Growing Stronger Together is a podcast for people who care about children.
Growing Stronger Together was developed by faculty at East Tennessee State University, including members of the ETSU Health Department of Pediatrics, the ETSU Center for Early Childhood Learning and Development, and the ETSU Child and Family Health Institute.
East Tennessee State University is located in the beautiful Appalachian Highlands. We appreciate the financial support provided through a Community Health Improvement Site Investment from Ballad Health’s Department of Population Health.
Dr. William Dodd (00:02)
I'm your host, Dr. William Dodd, from the East Tennessee State University Health Pediatrics
Adolescent Medicine Clinic.
This podcast is not intended to provide medical advice. If you or a loved one are working
through medical problems related to today's topic, please consult a personal physician. have no
conflicts of interest to disclose. Today we will talk about confidentiality and how it pertains to the
care of adolescents.
Dr. William Dodd (00:00)
Before we get started today, I would like to bring up the fact that there is recent legislation
passed in the state in which I practice, Tennessee, that changes some of the confidentiality laws
that we discuss in this podcast. It's very important to stay abreast of the legal situation, which is
always shifting for the care of these patients. And many of the points that we bring up are still
useful to consider.
⁓
and pertinent to practice in many ways. So without further delay, here's the podcast.
All right, I'd like to welcome everybody to another episode of the Growing Stronger Together
podcast.
⁓ Today, it is my great pleasure to introduce one of our second year pediatric residents
here at East Tennessee State University Pediatrics, Dr. Alisa Vasileva. And Dr. Vasileva is a ⁓
excellent resident. She's gonna enter the field of...
or she hopes to enter the field of pediatric hematology oncology, which is full of difficult
discussions. And that kind of brings us to today's topic, which is how do you have these difficult
discussions with adolescents and teenagers? Thanks for joining Dr. Vasileva.
Dr. Alisa Vasileva (01:24)
Thank you so much, Dr. Dodd for the very kind introduction of myself.
⁓ So today I'd like to talk
⁓ about something that every pediatric provider and every parent struggles with, I think. It's how
do we talk to teens about heart topics? And these conversations sometimes may be
uncomfortable, but they're life-saving, I believe. And so I'll try to break this into
Three to four major sections today. First will be about how to talk to teens about heart topics.
And then second section will dedicate to mental health and dive into self-harm conversations.
Third part will be about confidentiality in adolescent medicine, specifically what teens can keep
private from their caregivers. And the last part will be about STD prevention and contraception
counseling.
⁓
Dr. William Dodd (02:18)
Those are some rough topics.
Dr. Alisa Vasileva (02:21)
yeah, I feel like that's for sure.
⁓ Okay, so let's drive in.
⁓ So how do we actually talk to teens
about hard topics? ⁓ One of the biggest mistakes I feel like most of us as adults make is we
usually assuming teens don't want to talk at all when actually they do. They just don't want to be
judged like everybody else I feel like.
⁓
The American Academy of Pediatrics emphasizes that healthy communication requires
availability, empathy, and active listening. So for us as a healthcare providers, the key
communication principles should be be available, which means even 10 minutes of undistracted
time can build a trust with your patient.
⁓
Try to listen more than you talk, reflect back what you hear, say something like,
⁓ it sounds like
you've been feeling really overwhelmed lately, and try to validate their feelings without endorsing
risks. Validation reduces defensiveness, and you can validate emotions without validating
behavior.
Dr. William Dodd (03:32)
That's a really good
point. mean, teenagers are so, they have such difficult control over their emotions anyway. I feel
like sometimes it just helps to be heard.
Dr. Alisa Vasileva (03:47)
Yeah, and sometimes I feel like instead of just jumping into direct questions, which also can ⁓
push them away sometimes from the conversation, try to frame it in a little bit generalized and
non-judgmental manner. And instead of saying something like, you having sex? Maybe try to
say something like, well, many teens your age are starting to explore relationships. Has that
been part of your experience? ⁓
Thanks
or instead of asking them like you're not cutting, right? It probably would be better if we'll say
something like when people feel overwhelmed, sometimes they cope in a ways that hurt their
bodies, has that ever happened to you? So I just wanted to emphasize that asking directly about
self-injury rather than waiting for spontaneous disclosure is also important because teens are
often relieved when someone asks them first rather than waiting for them to start.
talking.
Dr. William Dodd (04:49)
It's a hard topic to breach as well, but I guess part of being a parent, you know
Dr. Alisa Vasileva (04:55)
Yes, pardon
me apparent.
Dr. William Dodd (04:58)
amazes me just kind of thinking about these topics as a parent who's, you know, I have two
younger school-aged children and it just seems like yesterday they were toddlers. I don't even
want to think about when they're teenagers. Like it'll just be ⁓ very difficult to kind of shift my
mind frame into ⁓ doing what's best to have a healthy relationship with them.
Dr. Alisa Vasileva (05:26)
Yeah, I agree. And I also have a young school-age daughter. And sometimes I feel like it's hard
for me even to shift from, you know, healthcare provider mindset to the parent mindset. when it
comes to hard conversations, because when they're seven, eight, nine, they're growing, they're
developing and we...
somehow have to start this conversation with their own children. so speaking of the mental
health ⁓ issues in teenagers,
⁓ let's maybe talk about the most common teen mental health
themes that could be ⁓ the reason of their mental health breakdowns.
⁓ For example, academic pressure, social comparison, especially these days, teens are, most
of them are spending lots of time in social media, so that also could be a big social pressure.
⁓
Relationship stress, family conflict, identity struggles, any trauma,
⁓ any substance use overlap
also could be a possible risk for any mental health issues.
⁓
Also, we always have to ask about in...
I try to normalize it at any adolescent visit with any families. I always have to ask about sleep
because that could be a huge marker if something goes wrong.
⁓ Always ask about substance
use, bullying, and relationship safety. Those kind of topics are usually the part of our HEADS
exam that we do with all of our teens. So that also could be and should be normalizing with
every adolescent visit that we do.
Dr. William Dodd (07:11)
Yeah, and
that's a really good point about sleep too, because sleep is so important to health. It's also like a
socially acceptable topic to just jump right into. And you know, a lot of times it brings up bigger
issues. So a lot of times when I have a adolescent visit and I'm talking to the parent and the
teenager together, you know, talking about sleep is a good way to maybe breach the topic of.
stress and get the parents perspective without Without jumping into some of the Confidential
topics that we're going to talk about here in a little bit, you know the that you don't want to make
⁓ adolescent divulge whether they're Feeling depressed without their permission to talk about
it, but sleep, you know, if we can talk about sleep
Dr. Alisa Vasileva (08:05)
⁓ Yeah, and sometimes even from what I've noticed ⁓ for the most part of adolescent visits,
sometimes nothing could be a marker until you ask them about sleep. And they're like,
⁓ I sleep
only two hours. And you're like, why? How are you functioning? How do you even function? And
then when they start thinking about, actually, yeah, I've never thought about why am I sleeping
that, you know, this amount of hours, it's actually not enough. And there you can see how they
start into
reflect about what's going on with them and just literally starting to think about things right there
with you and you're like well that's actually could be the reason why you not feeling well and so
you kind of dive into it with them together ⁓ because yeah again sometimes the sleep could be
the only marker ⁓ about that something may go wrong
Dr. William Dodd (08:48)
Yeah.
Dr. Alisa Vasileva (09:03)
and they could not even realize until you ask them.
Dr. William Dodd (09:06)
Yeah, and the same way, you know, if you're talking to your own kids, I think, sleep issues, it's
like the tip of the iceberg.
Dr. Alisa Vasileva (09:16)
Yeah. And so I feel like that could be a good part of mental health conversations with them. We
always should ask about the functioning. So again, sleep, appetite.
⁓
Energy level school performance. Those are all first things we always should ask to get a better
idea What is their base level of functioning? So that way something is wrong with this baseline,
you know ⁓ aspects of their life we can kind of Dive deeper and see what else may going on
with them ⁓ Because again sometimes
any of these aspects could be the first sign of that, something might get wrong. But they actually
never realized that before until you ask them directly about that.
⁓ And of course,
conversation, we always want to normalize and bring it up, the confidentiality part of it.
⁓ during this
⁓ And
before asking anything sensitive,
⁓
It is always good to set a frame and say something like ⁓ that we spend time alone with all
teens, that is part of our adolescent well child check visits, and what we talk about is private
unless I'm worried about your safety. Usually teens disclose more when confidentiality is clearly
explained.
⁓ And if you skip this step, they might...
under report if in case if something is wrong and they just don't want to bring it up to the
conversation.
Dr. William Dodd (10:59)
Absolutely,
it's not only,
⁓ know, whenever information is legally protected by privacy laws as it is in
Tennessee for certain ages and certain topics, you know, whenever that information is legally
protected, there's also an ethical implication that you're ethically required to maintain
confidentiality of that information.
⁓
You know, in addition to the fact that that information being confidential is also therapeutic
because it allows the patient to discuss their mental health concerns. It's also, you know, you're
also ethically obligated to have that conversation, protect that information.
Dr. Alisa Vasileva (11:50)
Absolutely.
⁓ But we never promised them absolute confidentiality if there is something
concerning about their harming themselves or harming other people. And we always should
bring it up before we start the conversation for the caregivers in the room as well so they can
understand what could be behind this conversation. And ⁓ with.
All of my patients, I already figured that, again, when you talk to them about sensitive matter like
depression, anxiety, sometimes if you ask them like direct question, like are you depressed? Are
you being anxious lately? That's, they can read it as a kind of like a, not rude but,
you know, a little bit pushy kind of question. And so instead of asking them directly about that,
maybe try to frame it in general.
make it more generalizable and say something like a lot of teens your age deal with the stress,
anxiety, mood changes, and how things been lately for you,
⁓ which can normalize and reduce
the shame and defensiveness with whenever they're gonna reply you after you ask them.
⁓
And usually, I'll always try to start broad and then go to more specific questions. Again, always
ask about mood, like how's your mood most days? What's been the hardest part of this year or
this week for you? ⁓ We already talked about the functioning.
⁓ And...
Teens, I just also wanted to emphasize that teens often present with a...
Like somatic complaints before emotional language. So that's why again, we always have to ask
them about Sleeping hygiene and their appetite and their energy level because if any of those
complaints will come up there could be a first marker of Any like, know emotional dysregulation
or like emotional mood problems that may come up later That may not even be able to
themselves until we talk about it during the visit.
⁓ Moving to the self-harm and suicide
conversation,
⁓ when we talk about this, that's where we should be more...
Direct because we should not avoid this conversation for sure and I also wanted to separate a
little bit and clarify that the non suicidal self-injury is deliberate self-injury without intent to die
And the common methods include cutting burning scratching ⁓ and usually it
functions as an emotional regulation again try to when they try to regain a sense of control of
something on the situation especially when they're undergoing through some kind of a stress or
trauma
An important clinical point here would be that the self-injury and suicidal behavior are not the
same, but they overlap. And non-suicidal self-injury increases the future suicide risk. So as a
part of our ⁓ mental health conversation,
And questions about the self harm, we always should assess and ask directly about intent,
frequency, function, suicide risks, and always do it calmly and again, trying to normalize and let
them know that, you know, we ask these questions to everybody, like every teenager, patient,
and just normalize it, normalize it, because again, I've seen like some of the teenagers, really
like getting, some of them may get ashamed that they've been asking about
that they've been asked about that. Some of them may be getting scared that they've been
asked about that. So just trying to normalize it as much as we can.
⁓ And again, keeping in
mind things that would be good not to do,
⁓ things like yelling, threatening, shaming, name
calling. I feel like that's a common sense, but it'll be good if we'll just bring it up again.
Dr. William Dodd (16:22)
For sure, yeah. Hopefully that's not gonna happen at the doctor's office. But also, that's a really
good point on the cutting, on the deliberate self-injury behavior. It is a coping mechanism, and
the patient's really trying to cope with these emotions that they're having in the best way that
they can.
Dr. Alisa Vasileva (16:26)
it
Dr. William Dodd (16:50)
It is a dangerous coping mechanism and there are lot healthier ways to deal with depression or
other harmful feelings.
Dr. Alisa Vasileva (17:03)
Absolutely. And usually the reason why I try to normalize the fact that we, you know, we always
remain calm and we remain non-shaming, non-judgmental is the reason because the fear shuts
them down. But if you, if you will, you know, remain calm and again, normalize this
conversation, there'll be more chances that they will open up and they'll reply to you. And when
we ask Kingdom direct questions about the self harm,
We always want to, you know, ask directly something like, have you ever hurt yourself on
purpose? ⁓ I always ask this question, like, have you ever wished you weren't alive or you wish
you were dead? Have you thought about killing yourself or do you have a plan? So all those four
or five questions kind of going through this intent, frequency, you know, risk and plan and intent
that we must assess at every ⁓ adolescent well child check visit.
just to make sure that they're safe, they're okay,
⁓ things like that.
Dr. William Dodd (18:09)
Yeah, and you know, how many patients have I had who maybe they score positive for mild
depression on their PHQ-9, which is the screener that we use for depression. You know, maybe
they have mild depression symptoms, but when you ask them about self-harm, they endorse it. I
mean, it's happened several times over my practice and...
and just out of the blue. So it's always important to specifically mention the self-harm. Otherwise
you won't know about it and a kid may come to harm because of it.
Dr. Alisa Vasileva (18:49)
Yes, I absolutely agree.
⁓ And I also had ⁓ recently just the same kind of case when I ⁓
Had a patient and the conversation went really well and then out of a blue, he just disclosed
that, he has thoughts about, you know, self-harm. And that was kind of came out of a blue. So
the visit took lots of time and we had to involve multiple specialties just to help us to.
⁓
Dr. William Dodd (19:22)
Yeah, that is always a rough visit. But important. That's why we're doctors, I guess.
Dr. Alisa Vasileva (19:30)
Yes,
absolutely. again, part of this, while we're these conversations with them, it's always important
for us to understand, like you said earlier, why they're doing that while they're maybe having like
a self-harm behavior as well, because often it functions as an emotion of regulation that can
help them to release intense emotions, to feel something went numb or reg...
basically to regain the control over the situation or some kind of like a stressful circumstances
that they might going through.
⁓ And so for us as a healthcare providers understanding the
function guides as basically a treatment so we can understand better how we can help in certain
circumstances.
⁓ And again when our conversation coming to the active suicidal intent when we have ⁓ Active
suicidal thoughts. We always have to be clear about limits of the confidentiality and Bring it up at
the very beginning of our heads exam ⁓
that when it comes to suicidal intent, plan, imminent danger, we have to break through the
confidentiality and basically try to involve parents for a higher level of care and we must do that.
⁓ But also we always should try to involve the teen in that process and just normalizing it,
normalizing again and let them know that because we care about them, because we care about
their safety, we just need basically more support.
and let's figure out together how we can tell your parents and just never blind sign them.
Dr. William Dodd (21:20)
Yeah, you know, the phrase I usually use is, we've just gotta do something about this, you know,
about these impulses. We need to do something for your safety. And usually the patient is, I
think, relieved to talk about it and kind of wants things to change.
Dr. Alisa Vasileva (21:45)
Absolutely. again, here, this is one of those examples where we must clearly explain the
exceptions and breaking through the confidentiality because it comes to a suicidal risk or
homicidal ideations or any other.
abuse ⁓ abusive situations and certain STIs as well and As I told it before ⁓ We never can ⁓
Promise them absolute confidentiality Given the certain circumstances. So yes most of the All of
our conversation will remain private unless I'm concerned about your safety other people
safeties ⁓
or any cases of abuse.
Dr. William Dodd (22:42)
Absolutely.
Dr. Alisa Vasileva (22:44)
⁓ And again, studies show that adolescents disclose more about sexual behavior, substance
use, and mental health when they're assured confidentiality.
⁓ So the best practice for every
pediatrician or
family health care provider would be to start the visit with the parents and then ask the parents
to step out, normalize it, like say something, for example, I spent time alone with all teens during
their teenage or well child check visits and...
just bring it up and normalize it. Because I've seen like some of the parents really struggle with
that. Some of them think that, no, it should not be that way. But also like starting doing that and
normalize it to the parent, normalize it to the child and let them know that that could be a good
start for you because as soon as you grow up, you'll start seeing a doctor on your own. So that
could be a good practice for you to learn how to talk to your doctor on your own and to have
this, know, confidential
⁓ private conversation with your doctor basically.
Dr. William Dodd (23:54)
Yeah, I always just say I have some teenage questions for the patient. Would you mind stepping
out? And I don't think any parent is eager to hang out in the room while you're asking a kid if
they're having sex and talking about risks associated with that. It just kind of would be an
awkward situation. I think it seems like most parents are pretty...
or glad to kind of have that conversation occur, occur, but occur elsewhere.
Dr. Alisa Vasileva (24:31)
Yeah, I would agree.
⁓ I probably made only a few families when parents were like, he or she
will never have sex. What are you talking about? And I was like, well, maybe, but we still have to
talk about these things.
Dr. William Dodd (24:48)
Yeah, absolutely.
Dr. Alisa Vasileva (24:52)
So just again trying to, you know, it's part of our life trying to normalize it since this age because
it's important part of their development and ⁓ their life in future.