Improving Interactions with Teens

Stephani Stancil, APRN, FNP-BCChildren’s Mercy Teen Clinic

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

Communication

Short video clip: • Teen Slang• Watch for how mom in

the video reacts to teens’ use of common slang words

HUH??!?!!?

WHAT??!?!?!

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.

PRCH © 20065

Normal Stages and Tasks of Teens

PubertyPuberty AutonomyAutonomy IdentityIdentity ThinkingThinking

EarlyEarly

10-1410-14

Onset and Onset and tempo tempo variablevariable

AmbivalenceAmbivalence Am I Am I

Normal?Normal?

Concrete Concrete operationaloperational

MiddleMiddle

15-1615-16

Girls earlier Girls earlier than boysthan boys

Limit-testing, Limit-testing, experimental experimental behaviorbehavior

Who am Who am I?I?

TransitionalTransitional

LateLate

>17>17

Adult Adult appearanceappearance

AmbivalenceAmbivalence Who am I Who am I in relation in relation to to others?others?

Formal Formal operational operational (75%)(75%)

Adolescent ThinkingPiaget: Concrete to Formal operations

• Concrete: Here and now (5 senses)

• Formal: Abstraction (algebra, metaphors, symbols, etc); Hypothesizing and Considering the future

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…”

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

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

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

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

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

PRCH © 200613

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 hoursPRCH © 2006

14.

Teenagers are…

• Risk takers• Reactive• Rebellious• Confused• Prone to making errors• Experimenting• Exploring• Believers in a personal fable

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

Elements of Effective CommunicationEffective 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

PRCH © 200617

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…”)

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.)

What about motivation?

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

What influences motivation?Trait Example

• 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

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

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

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

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

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

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

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

Putting it into Practice

Before the Visit• Self-assessment

• Personal biases, judgments, stereotypes

• Don’t try to be too cool • Cool Dad

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

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?”

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

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!

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.”