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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 I 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 (00:36)
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 an 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 (02:01)
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 hard 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 hard topics. And then second section will be dedicated to mental health and dive into self-harm conversations. The 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 (02:54)
Those are some rough topics.
Dr. Alisa Vasileva (02:57)
Oh 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 assume 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 healthcare providers, the key communication principles should be available, which means even 10 minutes of undistracted time can build 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 (04:08)
That's a really good point. Meaning, 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 (04:23)
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, are 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? Or instead of asking them like you're not cutting, right? It probably would be better if we say something like when people feel overwhelmed, sometimes they cope in a way that hurts 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 (05:27)
It's a hard topic to breach as well, but I guess part of being a parent, you know.
Dr. Alisa Vasileva (05:31)
Yes, it’s part of being a parent.
Dr. William Dodd (05:35)
It 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 (06:02)
Yeah, I agree. and I also have a young school-age daughter, and sometimes I feel like it's hard for me to even 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 for 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 it and 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 kinds 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 (07:47)
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 an 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, we can talk about sleep.
Dr. Alisa Vasileva (08:41)
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, you know, this amount of hours, it's actually not enough. And there you can see how they start to 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 and they could not even realize until you ask them.
Dr. William Dodd (09:44)
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 (09:53)
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 be 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, during this conversation, we always want to normalize and bring it up, the confidentiality part of it. 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 in case if something is wrong and they just don't want to bring it up to the conversation.
Dr. William Dodd (11:35)
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 (12:26)
Absolutely, but we never promised them absolute confidentiality if there is something concerning about them 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 matters like depression, anxiety, sometimes if you ask them a direct question, like are you depressed? Are you 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 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 common sense, but it'll be good if we'll just bring it up again.
Dr. William Dodd (16:58)
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. It is a dangerous coping mechanism and there are a lot healthier ways to deal with depression or other harmful feelings.
Dr. Alisa Vasileva (17:39)
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 children 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 go 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 (18:46)
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 (19:26)
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 the blue, he just disclosed that, he has thoughts about, you know, self-harm. And that was kind of came out of the blue. So the visit took lots of time and we had to involve multiple specialties just to help us to.
Dr. William Dodd (19:58)
Yeah, that is always a rough visit. But important. That's why we're doctors, I guess.
Dr. Alisa Vasileva (20:06)
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 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 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 normalize 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 (21:56)
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 (22:21)
Absolutely, and 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 our conversation will remain private unless I'm concerned about your safety, other people's safety or any cases of abuse.
Dr. William Dodd (23:19)
Absolutely.
Dr. Alisa Vasileva (23:20)
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, now, confidential private conversation with your doctor basically.
Dr. William Dodd (24:30)
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 (25:07)
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 (25:24)
Yeah, absolutely.
Dr. Alisa Vasileva (25:27)
So just again trying to, you know, it's part of our life trying to normalize it since this age because it's an important part of their development and their life in future.