Improving Interactions with Teens

1. Improving Interactions with Teens Stephani Stancil, APRN, FNP-BC Children’s Mercy Teen Clinic

2. Objectives • Describe ways to improve communication with teens in the clinical setting • By the end of this presentation, participants will be able to: • Describe 3 barriers to effective communication with teens • Identify 3 key techniques to improve communication with adolescents • Utilize motivational interviewing to influence behavior change

3. Communication Short video clip: • Teen Slang • Watch for how mom in the video reacts to teens’ use of common slang words HUH??!?!!? WHAT??!?!?!

5. Adolescence • Transition between childhood and adulthood • Generally physically healthy period • Needs vary by development and personal circumstances • Experience shaped by race, ethnicity, religion, socioeconomic status, family/peers, etc.

6. Normal Stages and Tasks of Teens

7. Adolescent ThinkingPiaget: Concrete to Formal operations Concrete: Here and now (5 senses) Formal: Abstraction (algebra, metaphors, symbols, etc); Hypothesizing and Considering the future

8. Cognitive • Piaget: Concrete to Formal operations • Egocentrism: normal narcissism and self-centeredness • Personal fable: invulnerability, invincibility, “nothing bad will happen to me…” • Imaginary audience • “Everybody is looking at ME and thinking about ME…”

9. Case 1 • 15 year old Type 1 DM • no longer wanting to check BG What would you do? • As HCP, our desire is to: • Parent: tell them what to do, make them fully informed • Discussing long term effects like kidney and eye disease may be ineffective. INSTEAD try: • To emphasis current benefits • Mutual goal setting • Short term-follow up (even 1 month may be too long) • To normalize experience • Identify other areas of control

10. Adolescent Thinking and Health Care • Concrete operations • Focus on immediate benefits of change • Do not emphasize long term complications • Egocentrism • Form therapeutic alliance • Autonomy alignment and readiness to change • Personal fable • Provide information of personal relevance • Imaginary audience • Reassure about normalcy

11. Adolescent Autonomy • Limit-testing (challenging rules) • Experimental behavior (smoking, alcohol) • Risk-taking (D.U.I., Ø contraception) • Need for control (resisting authority) • Being listened to is more important than getting one’s way

12. Autonomy and Health Care • Legal rights of minors • Confidentiality • Treatment non-adherence (forget or refuse) • Passive-aggressive behavior • Determine what is essential (no compromise) • Negotiate what is optional • Authoritative, not authoritarian, approach

13. Internal Barriers to Care for Adolescents • Reliance on peers or family members for health information • Perceived/actual negative past experience with health and/or social system • Sense of invincibility/vulnerability • Low self-esteem • Cultural and linguistic barriers

14. External Barriers to Care • Perceived lack of confidentiality and restrictions (parental consent/notification) • Poor communication by providers • Insensitive attitudes of care providers • Lack of provider knowledge and skills • Lack of money, insurance and transportation • Inaccessible locations and/or limited services • Limited office hours .

15. Teenagers are… • Risk takers • Reactive • Rebellious • Confused • Prone to making errors • Experimenting • Exploring • Believers in a personal fable

16. Most health care providers are... • Adults • Too busy and overworked • Not very tolerant of teen behavior • Wanting to help people achieve health • Used to completing a task to get something done • Feeling a sense of obligation to give a plan for improvement for problem patient behaviors

17. Elements of Effective Communication Effective Communication Involves: • Verbal cues (adolescent appropriate) • Non-verbal cues (tone, gestures, proximity) • Listening, responding (active listening, convey empathy, elicit and validate emotions) Poor Communication Examples: • Judgmental statements • Ignoring emotions • Eye contact not consistent with adolescent’s culture • Culturally inappropriate language • Perceived gender stereotypes

18. Effective communication Don’t • Use “pet” names (honey, sweetie, hun…) • Use judgmental language (“why would you do that?”) • Use slang unless offered first Do • Assure confidentiality • Explain why you are asking sensitive questions • Practice active listening (“I heard you say …”) • Validate feelings (“Many teens your age feel this way…” or “It’s normal to feel like…”)

19. Toddlers and Teens With toddlers, we: • Give choices • Encourage independence within safe boundaries • Allow teachable moments With teens, we need to: • Give choices, encourage independence and allow teachable moments by: • Involving teen in development of care plan, give “leader” or “co-leader” role with adequate support and encouragement • Not expecting perfection! This is still a vital period of learning for the teen (Problem-solving skills, self-confidence, etc.)

20. What about motivation?

21. What is Motivation? • Motivation is key to change • Motivation is multidimensional • Motivation is a dynamic and fluctuating state • Motivation is interactive • Motivation is a state of readiness or eagerness to change, which may fluctuate • Motivation can be influenced

22. What influences motivation? TraitExample • Money Shift differential • Authority Legal system • Pain “I give up” • Fear “Am I pregnant?” • Empathy “You really understand” • State of readiness “I’ll do it now” to change

23. Motivational Interviewing • A technique and clinical strategy designed to enhance the patient’s motivation or willingness to change • A therapeutic style intended to help providers work with patients to address ambivalence, with resultant change of behavior which improves health outcomes • This is a way of interacting with patients

24. Transtheoretical Stages of Change Model by Prochaska and DiClemente • Precontemplation—not considering change • Contemplation—considering, but ambivalent • Determination—preparing to change • Action—involved in change • Maintenance—sustaining change • Relapse—may be undecided again

25. Techniques for Successful Motivational Interviewing • Ask open-ended questions • Express empathy through reflective listening • Use as a method of clarifying communication • This approach allows for patient and provider to understand each other and explore common ground or compromise • Characterized by brief statements and reiterations of what the patient has said

26. Techniques for Successful Motivational Interviewing • Three types of reflective comments: • Simple repetition • Using a synonym • Paraphrasing the statement • Affirm and support • Summarize • Elicit self-motivational statements

27. Techniques for Successful Motivational Interviewing • Establish a nonjudgmental, collaborative and accepting relationship • Compliment rather than denigrate • Listen rather than tell • Gently persuade, with the understanding that change is up to the patient • Develop discrepancy or doubt between incongruent behavior and stated goals

28. Helpful provider characteristics • Focusing on a person’s strengths rather than weaknesses • Respecting other’s autonomy and decisions • Using empathy, not authority or power • Celebrating interim goals (“baby steps”), incremental or even temporary steps toward a goal

29. Helpful provider characteristics • Become an advocate FOR the patient; a cheerleader or mentor role • Let the patient be the expert • Active listening and reflection cannot be over emphasized

30. Putting it into Practice

31. Before the Visit • Self-assessment • Personal biases, judgments, stereotypes • Don’t try to be too cool • Cool Dad

33. Introduction • Shake hand with teen • Ask what they prefer to be called • Michael, Mike, Mickey • Ask teen to introduce others in room • “Who did you bring with you today? “ • Explain what to expect during visit • Disclose the need for private discussion at the beginning so parents know what to expect

34. Interview • Ask about unique features • Bright hair color, body jewelry, tattoos… • Open-ended questions • Tell me about…. • Carve out time for private discussion • Ask parent to leave the room • Use non-judgmental statements • “Some teens your age use cigarettes, have you ever tried those before?”

35. Summary Pointsfor effective communication • Active listening • Demonstrate empathy • Access readiness to change • Engage in motivational interviewing • Accentuate positives • Mutual goal setting • Short team follow up

36. Reality • 16 year old male presents for a routine physical • Smokes ½-1 pack of cigarettes a day • Smokes marijuana every other weekend • Tried drinking alcohol but doesn’t really like it because it made him get sick • He is an A and B student in high school • He is not interested in being in your office—Mom made him come to this appointment!

37. The Dilemma • “Wow, there’s so much I need to do for this young man.” • “He should stop smoking and using marijuana. Doesn’t he know how bad it is for him?” • “He needs to listen to me because I used to be a smoker and I know how hard it is to quit.” • “Just wait ‘til I give him a piece of my mind about smoking. I’ll tell him how bad it is.”