Some providers prefer to start the interview with adolescent and parent(s) together. How the adolescent and parent(s) interact with one another (Does the parent speak for the adolescent instead of letting the patient answer? Are the parent and teen interacting with their phones and texting or using the time to talk and share?) can provide insight into the family interactions and inform the provider’s strategy for addressing issues uncovered during the visit. Additionally, meeting together reinforces the importance of direct adolescent and parent communication. After introductions are delivered, a verbal outline or “roadmap” of the visit should be provided to the patient and the parent(s). This is often a time to discuss medical history, family history, and potentially nonsensitive social topics. Upon conclusion of this segment, the provider then asks the parent(s) to leave the room while the remainder of the history is completed with the adolescent alone.

Some providers like to include separate time at the initial visit with parent(s) and then conduct the confidential interview with the adolescent. This option offers an opportunity for the parent(s) to express concerns about the adolescent in private. After greeting everyone, the clinician explains the order of the visit and establishes confidentiality so that there is no confusion about the process or logistics of the visit. The clinician then meets with the parent(s) first, enabling them to express sensitive concerns at the beginning of the visit so that there is adequate time to address them. The clinician then meets with the adolescent alone to discuss the patient’s concerns, obtain additional history, and conduct the physical examination. The visit concludes with the clinician summarizing with everyone. This approach ensures that the teen sees that the provider is not divulging confidential information to the family. Follow-up visits can start with a brief meeting with the parents alone if major issues persist, but should switch over to one of the other types of visits described.

An alternative approach is to meet first with the adolescent patient. This approach allows the provider to establish trust and focus attention on the adolescent. After meeting with the adolescent privately, the adolescent and parent(s) meet with the clinician together to complete the visit. It is important for the adolescent to understand that his or her parent(s) will likely be asked about the patient’s past medical history as well as any parental concerns. Thus, confidentiality may need to be reviewed twice, once with adolescent alone
so they feel comfortable and again when the parent is present so everyone understands the rules of the clinic.

The assessment usually concludes with a summary of the clinician’s evaluation and management plan, including anticipatory guidance. Most of the discussion themes (e.g., concrete goals for eating healthier, resolution to get help from a math teacher, details about using a medication) can be done with the adolescent and family together, but sensitive concerns (e.g., smarter decision-making around sexual practices) should be discussed with the teen on his or her own. The parent’s role in this process diminishes as the teen matures into young adulthood.

Typically, young adults come to medical visits alone, making these interactions more straightforward. However, when a parent(s) presents with the young adult, it is essential (particularly when a chronic disease is being addressed) that there is a clear understanding that the young adult is in charge of his or her health care. Legal age requirements governing the definition of adulthood vary across the globe (see Chapter 9) relative to who has control of and rights to medical information. It is important for the provider to understand these legal definitions. In most geographic locations, the provider will need verbal as well as written permission from the young adult to speak with a family member to help the patient with a treatment regimen or gain additional history. Regardless, young adults should be given an opportunity to consent to having their parent(s) involved in the summary of nonconfidential issues or participate in a discussion about how the parents can support the young adults in their health care.

AYAs prefer their own waiting room (or separate area) that is relaxed, welcoming, and developmentally appropriate.⁴ Some practices have separate blocks of time devoted to the AYAs in an effort to create this type of environment. If possible, clinic space should include an area that can accommodate larger groups for family or treatment team meetings. The examination room should include an examination table that has a curtain to promote a sense of privacy.

All clinic staff should have training on the developmental and health needs of AYAs. The clinic staff should adopt an AYA-friendly and nonjudgmental approach. Staff and receptionists should be familiar with issues such as confidentiality, crisis calls, and billing procedures. The staff should have flexible appointment booking procedures, including times to accept walk-in patients or a patient and his or her family who are in crisis. Every possible effort should be made to reduce wait times for young people.

Age-appropriate magazines, hotline numbers, posters, and health education brochures both welcome the patient and signal that the provider is ready to talk about all topics, especially among youth who may be more reticent to discuss sensitive issues. Some practices place these materials in private places such as exam rooms and bathrooms to make them easier to obtain anonymously.

Ideally (though perhaps not possible in some office settings), initial comprehensive visits should be given an hour in the schedule. Provision of after-school/early evening hours is critical for the patient to avoid missing school or employment. Discussion of who is needed at follow-up appointments (patient alone versus family and/or partner versus both patient and family and/or partner) should be identified at the end of the first visit. Finally, consult with the adolescent or young adult alone on the best way to make contact for follow-up test results to protect his or her confidentiality.

In the United States, billing for services that the adolescent or young adult wishes to keep confidential is highly dependent on the patient’s insurance. The legal age of majority (18 years in most US states) allows the young person to control his or her medical record. Insurance coverage now allows the parents to continue to maintain the adolescent or young adult on his or her health care plan through age 26 years. Thus, when confidential services are billed to the insurance, the patient’s services will likely result in an explanation of benefits to the primary holder of the insurance plan (e.g., parent(s)) about the nature of the visit. Many issues can be disguised by billing under general symptom codes (e.g., “dysuria” or “cervicitis” instead of “chlamydia,” if appropriate).

When a practice has general screening rules, it is much easier to explain certain tests. For example, “Mrs. Jones, our clinic policy is to run a pregnancy test on all females with abdominal pain.” Some practices elect to bill the adolescent or young adult directly or absorb the costs of certain diagnoses or tests to protect the patient, but this is not always possible. Other options include directing the adolescent or young adult to obtain Medicaid funds for conditions such as pregnancy, family planning, or substance abuse or refer him or her to a health care setting that can provide low cost or free confidential services.

Patients should be aware that confidential aspects of care might be included in notes, letters, or electronic communication with other providers when appropriate. While there are benefits to electronic health records (EHRs), they also add layers of complexity around documenting sensitive diagnoses, patient information, and lab results (see Chapters 9 and 10). As more clinicians embrace EHRs, the ease with which accessing patient data increases, as does the ease with which confidentiality can be broken. For example, an emergency department provider sharing lab results with a patient and family may inadvertently reveal a positive screen for sexually transmitted infections or mistakenly disclose the adolescent’s use of birth control when showing them a computer screen. To protect the AYAs’ confidentiality when EHRs do not allow for sensitive information to remain confidential,⁵ it may be necessary to establish mechanisms or protocols by which sensitive diagnoses or topics are not disclosed to parents. Patient portals, which allow patients access to their medical record or lab results remotely, also need to be considered carefully. The adolescent patient may be under pressure from a parent to allow unrestricted access to his or her record. Some strategies include creation of confidential diagnoses, fields, and/or medication sections that can only be accessed by in-system providers (see Chapters 9 and 10).

More providers are using written questionnaires completed by the patient either at home or in the waiting room to gather information. These questionnaires may help prompt the adolescent or
young adult to consider important topics that he or she might want to address during the encounter. However, answers to sensitive questions may not be accurate if the surveys are completed in public spaces. Some providers use written screening tools to increase delivery of preventive services and screen for social determinants of health.⁶,⁷ For mental health issues, the Patient Health Questionnaire (PHQ-9)⁸ is a validated depression screen for teens and young adults (see Chapter 70), and the Self-Report for Childhood Anxiety Related Disorders (SCARED) has been validated as a screen for common anxiety disorders in adolescents.⁹ The American Academy of Pediatrics has developed questionnaires for early, middle, and late adolescents/young adults to screen for a variety of issues at each visit through the Bright Futures project.¹⁰

With increased use of social media, many AYAs find the computer a nonthreatening way to disclose personal information that can be addressed in the clinical session.¹¹,¹²,¹³ Electronic screening allows collection of data before entry into the clinician’s office, saving time in the encounter for discussing results rather than obtaining information.

Creating rapport is of paramount importance in the AYA patient-provider relationship, and it may require more than one visit to establish.¹⁴,¹⁵ However, if rapport and trust are not built, subsequent visits will likely be ineffective. Helpful ways to engage AYAs include the following: