Interviewing is something of an art that can be developed and improved. It is not a session of questions and answers but more of a conversation in which selected information is sought. The information obtained is combined with body language, the physical appearances and actions of the person during the interview, and used as the basis for evaluation and a course of action. Interviewing adults is relatively straightforward, but adolescents are different. In many instances they do not wish to visit the physician, there is an air of distrust and suspicion, and little information is gained during an interview. Conversely, a youngster may be upset about a problem, real or imagined, and pour out his or her concerns and feelings. Physicians caring for adolescents need to think in developmental terms and assess where along the path from childhood to adulthood the young patient is at the time of the visit.
ADOLESCENT GROWTH AND DEVELOPMENT
Briefly, great changes occur in physical, cognitive, and psychosocial growth. Although each of these proceeds in a sequential manner, they are rarely synchronized, and deviation of one from the norm, temporarily or permanently, can affect the others. The process of adolescence is usually separated into early, middle, and late periods; each category has typical changes related to physical, cognitive, and psychosocial growth. These developmental concepts are applicable during an interview and other facets of health care.
PRINCIPLES OF INTERVIEWING
The purpose and length of an interview depend on many factors. For example, has the adolescent been cared for over a period of years or is this a first visit; was he or she forced to come or is the visit se If- initiated; does the primary complaint suggest a physical illness or a psychological problem; is the interview taking place in a physician's office or a detention facility?
If it is a first visit, more time will be required to take the history and identify significant areas for future interviews. Adolescents are suspicious and wonder if they can trust an unknown adult. If the physician has cared for them over a period of years, will the parents be told everything the teenager reveals? Most young people respond positively to an adult who demon'strates a genuine interest, especially if that person shows promise of help. l The most important part of an initial interview is to establish trust and an atmosphere in which the adolescent feels comfortable. Interruptions should be avoided, and answering the phone, conferring with colleagues, writing or looking at papers on a desk while the adolescent is talking, or avoiding eye contact suggest disinterest. 2
It is important for the physician to be him or herself There is no need to try to be a pal, to use adolescent jargon, or ask to be called by one's first name. Most adolescents prefer a pediatrician to be a professional, a friendly doctor, an adult, and not "one of the guys." They also expect to be treated with respect and not as small children.3,4 A major aim of adolescent health care is to have teenagers accept the responsibility for their health. When the adolescent was a child, the doctor conversed with the parent, usually the mother, who had the responsibility for care. Now the parent is more peripheral and the adolescent central; therefore, attention and concern should be directed toward the adolescent patient. If the doctor cared for the patient as a child, a new relationship must be developed, otherwise the pediatrician will remain closely identified with the parent and often function in a parental role. The physician must also avoid being judgmental. This does not mean approval of the adolescent's actions OT views. Most persons become defensive, and some aggressive, if challenged or belittled. If there are parts of the interview that warrant concern, they may often be noted for exploration and discussion in the future. If one assumes the role of a judge, little will be learned and little accomplished. 5
We have all heard that "it's not what you say but how you say it," and this is especially true in interviewing. If a non-threatening question, such as "Well, how are you getting along these days?" is asked, most adolescents will answer; and, depending on the answer, the next question can be used to expand. It is likely a boy would answer our question with "OK" and stop. One can then ask, "What does OK mean? School? Girls? Extents? Money?" With the next reply, areas can be mentioned and questions asked. Often the patient's own phrases can be used to elicit further information: "OK?" Thinking developmental!?, information is sought that will help evaluate physical, cognitive, and psychosocial changes related to early, middle, and late stages of growth. The interview can proceed along these lines, noting areas the patient is reluctant to discuss. Sometimes an adolescent needs to be prodded to continue; or, it may be wiser to wait until more trust has developed or the patient has greater personal need to bring it in the open.
In any interpersonal relationship, particularly an interview, body language is of great importance. This consists of the physical actions and reactions of the adolescent during the interview. Agitation, anger, tears, shifting position, hand movements, flushing, stuttering, needing to go to the toilet, are all indicators of reaction to sensitive areas of the interview. It is not unusual to find body language of greater significance than verbal expression, for lying is easy for some adolescents. Interpreting the reactions, it may be wise to leave the subject or, in some instances, to express empathetic concern and suggest now is a good time to talk about it. Experience is required to know when to pursue a subject that obviously upsets the young patient, and if there is doubt, it is best to postpone die subject and return to it later.
INTERVIEWING AND DEVELOPMENTAL STAGES
Early adolescents in general are growing rapidly, uncertain about their appearances and actions, and eager to be accepted by their fellows. Their interests are directed toward themselves, thinking is primarily concrete, and adolescent psychosocial development is just beginning. Although some of them are striving for greater independence, the majority still fit reasonably well into the family unit. Only a small percent of early adolescents are sexually active; drug abuse, if present, is generally in the experimental phase. Interviewing should explore school performance and family relationships, concerns about physical growth, sexual questions or problems, and any other areas indicated by the conversation. A great many early adolescents are embarrassed by questions having a sexual con' notation and are reluctant to answer; only after full confidence has been established do they feel free to comment or to seek the physician's opinions and advice.
Most middle adolescents are more outward in their actions and, although they may wish for a different appearance, they are usually accepting of their bodies. Sexual matters receive much interest and attention and experimentation, or continued sexual activity is present in a large percent. The desire for independence increases and often leads to family conflicts. Risk-taking behavior including drug usage, smoking, sexual activity, and pregnancy tends to increase. School performance may or may not be a problem and it is important to know how well the adolescent is doing. Problems of friends may provide clues about the adolescent patient; many times a detailed discussion about difficulties a "friend" is experiencing is obviously a third-person account of the patient's own problems. In general, the physician wishes to identify any specine problem areas and determine if the young person is making satisfactory progress toward maturity. Questions can generally be more open and direct than those used with early adolescents. The adolescent's thinking should be changing toward abstract functioning and appreciation of the future.
Late adolescents have usually come to the point of accepting themselves for what they are and are inter' ested in the outer world. They still wish to be admired and to belong, have a boyfriend or a girlfriend, are uncertain about a future vocation but have thought about it, and the majority of them have made choices related to sexual activity, drug usage, and other potentially dangerous behavior. Thinking is usually more abstract and evaluative in nature. If long-range goals and objectives have been made, development of formal thinking would seem to be appropriate. Large physical size and greater age cause us to expect adult behavior but most late adolescents have many uncertainties, often react inappropriately, and continue to exhibit risk-taking behavior.6
Interviewing late adolescents requires one to assess quickly the degree of psychosocial and cognitive maturity, for "talking down" to an adolescent will ensure iatture. A common error occurs if an adolescent is physically large for his or her age and cognitive and psychosocial development are less than expected. In such instances, there is a tendency to relate to the patient as an adult rather than the stage of psychosocial and intellectual development. There is great variation in the stages of growth, and interviewing works best when correlated with developmental changes.7,8
INTERVIEWING AND EDUCATION
Interviewing, which often includes counseling, presents the opportunity to educate and influence adolescent patients. If one learns of risk-taking behavior, for example, use of tobacco, the subject can be discussed and the pediatrician can point out potential dangers, ask the young boy or girl to consider why it is being used, and develop a strategy for quitting. Each stage of development has priority areas for learning; most adolescents obtain information from peers and the information is often inaccurate. If the patient receives continuing health care, the physician can build on previous visits and reinforce recommendations. Establishing good health habits for adulthood is a prime objective. Most adolescents, once they have become friends with the pediatrician, wish to please, and compliance is directly related to these feelings.
Physicians and other health professionals who care for adolescents have a unique opportunity to help repair past physical or psychological damage, to provide the fundamental principles for a lifetime of good health habits, and to become the source of information and trusted confidant for adolescent patients. This is frequently complicated if an adolescent is handicapped or has less than average intelligence, and these findings must be identified and considered. To accomplish our aims requires continuing education in the field of adolescent health, tolerance of noncompliance, and acceptance of a variety of young patients for what they are. We need to know and understand our adolescent patients, and interviewing, history taking, counseling, and observation can make this possible.
1. Bates B: The history-talcing interview: Its pulpóse and place in the assessment process, in: A Gude in Physical Assessment, ed 2. Philadelphia, JB Lippincon Company, 1979.
2. Green M: Interview techniques that get route. Contemporary Fb&otrics 1982; 10:23.
3. Wolfish MG: InteiviewingandphysícaJexaminatíonof afclescenB. Seminars m AcUtiKM MeAcmt 1985: 1:79.
4. Spear BA: Adolescent Nutrition. Nutrition Education Modute. Unpublished, 1984.
5. Daniel F?; Interviewing adolescenti, in: Adotucmu m HcaUi and Datase. St. Louis, CV Mosby Co, 1977.
6. Simona RS. Panics N: Undemanding Human Behavior in Health and ISneu. Baltimore, Williams and WiDcini. 1978.
7. Johnson RL: Adolescent growth and development, in Huffman AD (ed): Adokuxni Mediane- M«ilo Pari, California, Addison-Weslcy Publishing Co, 1983.
8. Kneipe RE, McAriamey ER: Psyche-social aspects of adolescent medicine. Seminars m Adolescent Medicine 1985; 1:33.