O ne goal of medical training is to provide the physician with the knowledge and skills necessary to perform accurate diagnostic and therapeutic procedures. Frequently, however, interviewing technique is an area in training that receives less emphasis, often being considered "the art of practicing medicine." This designation implies that the physician must either have an innate ability as an interviewer or wait until these skills develop with time and practice. Fortunately, many medical schools are now structuring programs specifically to teach interviewing skills and techniques. The necessity for continuing such programs during residency training is increasingly being recognized.1 Although both talent and experience contribute significantly to the ability to conduct a good interview, there are basic guidelines that can be followed. This article is an attempt to provide an outline for interviewing adolescent patients and includes examples of situations frequently encountered in the interview setting.
Although the primary goal of the interview is to obtain a complete history, there are additional benefits that can be gained from it. One of the obvious ones is the personal interaction it generates between the pediatrician and his adolescent patient. How this interaction is perceived by each will provide the basis for the future therapeutic relationship. The interview also provides an opportunity for flexibility, so that the process of obtaining information can be adapted to the specific needs of an individual patient. Were it not for these additional benefits the interview provides, much of the information needed could be obtained with a questionnaire.
Tailoring the interview to fit the individual patient often is challenging. The intern or medical student usually quickly learns that there is "something different" about obtaining a history from an adolescent compared with obtaining one from the parents of a child or from another adult. It is that "something different" about the adolescent interview that will be specifically addressed in this article.
ADOLESCENT PSYCHOSOCIAL DEVELOPMENT
While puberty refers to physical growth and development of the child, adolescence refers to his psychologic growth.2 The psychosocial stages may be divided into early , middle, and late adolescence. An appreciation of the developmental stage a given patient is in will help the clinician anticipate the form an interview should take. Thus, the purpose of outlining specific developmental stages, as we propose to do in the following brief overview, is not to categorize each adolescent but, rather, to provide a format that will make a general understanding of the adolescent's behavior possible.
The adolescent's psychosocial development as he progresses from childhood to healthy adulthood requires fulfillment of four tasks: establishment of independence, becoming comfortable with pubertal changes, development of relationships with others outside the family circle, and development of the ability to reason abstractly (Table 1 ).
Establishment of independence. As he begins to enter the teens, the adolescent begins a separation process from the parents. This process usually includes some rejection of parental values. As a child, the teenager had identified mainly with his parents; now he begins to seek role models outside the family. The teenager also becomes more aware of his responsibility for his own future and the need for decision making and learning economic independence.
Development of comfort with new body changes. Teenagers are acutely conscious of the physical changes of puberty. They become preoccupied with their own bodies in grooming, hairstyling, and clothing. Increased sexual feelings and urges make demands on teenagers requiring that they learn both how to control and how to express these feelings. Adolescents frequently begin to compare their bodies and feelings with their peers'. The comparison is usually a "safe way" to answer many unspoken questions - i.e., "Is this happening to everyone else?" "Am I normal?" "Do others think like me?" "Will I continue to have friends?"
Development of meaningful relationships outside the family. This task emphasizes the strong need for peer support to enable the adolescent to separate from the family. The teenager learns how to nurture close attachments to others in an independent manner without the help of family structure. During early adolescence, these close friendships are with peers of the same sex; in middle to late adolescence, peers of the opposite sex are included and intimate relationships begin.
Beginnings of abstract reasoning. The healthy adolescent proceeds with intellectual maturation and begins to reason in more abstract terms. Generally, this accompanies an increase in verbalization skills. Teenagers, through the exercise of these new traits, become more active in decision making, planning for their future, and forming their own value system.
THE ADOLESCENT INTERVIEW
The pediatrician should assess the teenager's general stage of psychosocial development during the initial interview, at the same time obtaining a complete history and establishing the basis for the therapeutic relationship. The basic interview format should take cognizance of both the developmental tasks shown in Table 1 and the goals of the clinician listed in Table 2.
TASKS OF ADOLESCENCE
The introduction. A general outline of an adolescent interview is shown in Table 3 . The introduction - the first element in the interview - is often not given the attention it deserves, as the pediatrician may be apt to proceed prematurely into the body of the interview itself. The small amount of time required for the introduction by the physician to the adolescent and his family is almost always a good investment. This includes personal greetings and establishing the atmosphere for the interview. The basis for the therapeutic relationship will be initiated by the proper application of this simple social amenity.
GOALS OF THE INTERVIEW
It is during the introduction that the physician begins to convey to the patient a sense of interest in his problem. An uninterested, hurried introduction will influence how a teenager will interact during the interview. The time limitations the physician may have for the interview should be explained during the introduction also. For example, the physician might say, "John, I thought we would spend about 30 minutes together so I could get to know you. Then I'll see your parents for about 20 minutes afterwards." Clarification of the time limitations serves two purposes. First, it gives the teenager and his parents a basic idea of how the physician plans to structure the interview. Second, it allows the physician to later direct the interview without appearing uninterested. For instance, if during the interview the teenager continues to talk in detail about a particular area, the physician may need to say, "This subject certainly seems important, and we may want to discuss it more at another visit. However, right now, because of our time limitations, let's talk about some additional areas of interest to you." Such an approach lets the teenager know that no subject is taboo and that they are free to discuss an area of concern in the future.
Whether to see the parents first or the teenager first may depend on the clinician's preference and the particular circumstances. Certainly, if the adolescent sought help on his own, the physician would proceed with the interview and might then request the teenager's permission to meet his parents. An advantage of seeing the teenager first is that it is easier for the interviewer to identify primarily as the adolescent's physician, thus furthering the therapeutic relationship. On the other hand, seeing the parents first may provide the interviewer with some reason for the teenager's visit. In some instances, a teenager may simply say, "I don't know why Fm here - nothing's wrong." In that case, an interview with the parents first could be more helpful. Later, the adolescent would be able to express his own opinions about the problems the parents had previously mentioned.
THE ADOLESCENT INTERVIEW: GENERAL STRUCTURE
Regardless of which approach is taken, the clinician should make it clear to the whole family that the primary concern is helping the adolescent. The physician should avoid being used to gather information for the parents or to take sides in a family disagreement. An unbiased, understanding approach does much to encourage a therapeutic relationship with both the adolescent and his parents.
Confidentiality needs to be directly addressed during the interviews with both the teenager and his parents. The adolescent should be told that anything he says will be held in close confidence by the physician. The adolescent must be aware, however, that if there is a threat of potential harm to himself or others the physician cannot keep this secret. Indeed, breaching confidentiality is obviously necessary if the physician is concerned about suicidal or homicidal behavior. Clarifying these exceptions does not seem to keep teenagers from discussing such issues but, rather, conveys a feeling of honesty in the relationship. Some aspects of confidentiality are defined by law. Many states protect the adolescent's rights to confidential medical care for such problems as drug abuse, venereal disease, contraception, pregnancy, and abortion. The laws of each state should be considered in such situations and the adolescent's right to privacy respected. Occasionally, the teenage girl may be encouraged to discuss a confidential problem with the family - for example, when considering abortion. In such an instance, the physician could provide a neutral, supportive setting to discuss options in solving a problem.
During the introduction phase of the interview, the physician should also explain the purpose of the interview. This may vary with each patient situation but generally is intended to identify an area of concern to the adolescent or his parents. Additionally, the interview introduction should promote physician-teenager rapport. In an effort to establish rapport, the physician should be careful not to "overidentify" with the adolescent. Adopting the teenager's style of dress or slang does not encourage a trusting relationship but, rather, creates suspicions about the physician's motives. Body of interview. The introduction leads naturally to the body of the interview. Complete information about four main areas should be obtained: (1) the chief complaint, (2) the family, (3) peers, and (4) the school.
The chief complaint will have already been considered during the introduction but will need to be re-examined in more detail at this time. The duration of the problem, solutions that have been attempted, and who (teenager, parents, teacher) is most bothered by the situation should all be considered. Additionally, the perception of exactly "what the problem is" may differ with each of the family members. Clarification of the problem will then be one of the major tasks for the physician.
The family history should include a general overview of family interaction. Asking with whom the teenager lives, with whom he shares a room, what are his chores, and what the family does together gives some basic ideas about how the teenager interacts with his family unit. An adolescent, if simply asked, "How do you get along with your family?" may just say, "We get along okay." It is more productive with such adolescents to give some examples of common conflicts present in families. For example, the clinician may say, "Many teenagers I know disagree with their parents about things like curfew, clothes, hairstyles, money, boyfriends, girlfriends; how about you and your family?" This technique will usually stimulate a response from the teenager. It is important to give several examples and use the third person ("many teenagers") so that the adolescent is free to give an honest response to what may be a leading question.
At this point it is sometimes difficult for a physician to avoid offering his own personal and moral feelings about family structure, discipline, or interpersonal interactions. However, if complete information is to be obtained, it is necessary to maintain an unbiased and non judgmental approach.
The history of peer interaction will include determining if the teenager has a variety of friends, the gender of his friends, and some of the activities in which they participate together. This is the time in the interview when sexual issues usually are considered. Adolescents may feel uncomfortable discussing sexual matters and need to be reassured that the interviewer realizes this may be a difficult topic to discuss. An honest, unembarrassed approach to talking about sex is usually most helpful. Asking about sex-education classes in school and what some of their friends think about sex helps displace the teenagers' anxiety of being questioned about their own sexuality. Again, the physician should be careful to avoid giving opinions or moralizing during this discussion so that complete information can be obtained and the adolescent can feel free to bring up any sexual concern in the future.
Sometimes a teenager may actually be verbose and proceed to talk about many sexual experiences. In the initial interview, it is usually best for the interviewer to limit the discussion. Otherwise, after the interview a teenager may feel that he told "too much" and be reluctant to return for further appointments. Also, such elaboration by the adolescent about any topic (including sex) can be a defense to keep the interviewer from asking further questions. For example, a teenager might talk in detail about a sport, explaining numerous rules and regulations. A helpful approach in such a situation is to say, "This seems to be something we may want to talk about in the future, but right now I'd like to consider some other topics."
The school history should provide the interviewer with a general idea of the adolescent's functioning outside the family. More complete information will be obtained by asking specifics than by simply inquiring, "How's school?" Such issues as year in school, specific examples of achieved grades, favorite subject, and best and worst things about school should be addressed directly. The teenager may then feel more at ease in discussing his opinions about teachers, students, and school. This is also the time the interviewer can learn what some of the hobbies and activities a teenager has other than schoolwork.
Occasionally, information obtained directly from the school may be helpful. At such times the physician may say, "I'd like to contact your school for more history. Would that be all right with you if I call?" It is important to give the teenager some control and a feeling of respect from the clinician even if the parents have already signed a release-of-information form.
Ending. After obtaining the history, it is necessary to consider how to end the interview. The clinician should summarize the history just taken. He may at this point give an opinion about several areas he thinks may be of concern to the adolescent - for example: "It seems that the area that gives you most trouble is interaction with your parents. Have I interpreted our discussion correctly?" The pediatrician should, of course, be aware of his own feelings and the possibility that these feelings may affect his judgment. It is best to avoid giving advice unless specifically requested to do so, and even then one should include the disclaimer "It's my opinion . . . ."
Providing alternative approaches for problem areas may be discussed at this time. If specific referrals or recommendations are thought to be indicated, the adolescent should be informed what these are and the rationale for them. Lastly, the teenager should know what recommendations the physician may give the family and what further appointments may be necessary.
The pediatrician's skill and confidence in his ability to work with teenagers will both increase, we believe, if he follows the few guidelines outlined above and practices the techniques we have mentioned. New situations and problems will continually arise, however, and many physicians have found it helpful to discuss a case with their peers or to participate in supervised demonstrations of interviews conducted by clinicians with adolescents and their parents. Videotapes of supervised demonstrations are now available and may be helpful.
Obtaining complete information about an adolescent patient and developing a good therapeutic relationship with him are always easier when the pediatrician himself is comfortable during the interview and confident about his abilities to help the teenager and his parents. Both competence and confidence will be increased with experience. We need to develop more ways for the pediatrician in private practice to improve and practice his interviewing skills with adolescent patients.
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2. Erickson, C. J., and Friedman, S. B. Understanding and evaluating adolescent behavior problems. J. School Health (1978), 293-297.
3. Erikson, E.H. Childhood and Society. New York: W. W. Norton & Company, 1963, 247-274.
Buckingham, W. B., et al. (eds.): A Primer of Clinical Diagnosis. New York: Harper & Row, 1971, pp. 1, 2, 297-303.
Hammar, S. L., and Hoiterrnan, V. Interviewing and counseling adolescent patients. Clin. Pediatr. 9 (1970), 47-53.
Kappelman, M, M. The adolescent and his dangen». Clin. Pediatr. 10 (1971), 154-1S9.
Tumulty, P. A. The Effective Clinician. Philadelphia: W. B. Saunders Company, 1973, pp. 1-43.
TASKS OF ADOLESCENCE
GOALS OF THE INTERVIEW
THE ADOLESCENT INTERVIEW: GENERAL STRUCTURE