The fundamental skill necessary for effective assessment of adolescents is empathy and a nonjudgmental approach. Praise of the young person is another, frequently forgotten aspect of communication with this age group, and is key to success. As in pediatrics, acknowledging the reciprocal influences of growth and development during adolescence on health and illness is imperative (44) (see Chapters 2,3). Using this development as a lens through which effective communication takes place is useful in practice.
Assessment of cognitive development is important when considering communication with young people, particularly the development of new cognitive skills, including abstract thinking capacities in mid adolescence. The "bullet proof" idea of personal invulnerability characteristic during mid adolescence has challenging implications for disease education and
Table 4 "You're Welcome": The 4 Ps of Young-Person-Friendly Rheumatology
Offer a professional of preferred gender when feasible. Acknowledge that this may vary between visits, depending on the needs of the young person at the time.
Involve all team members. For example, another team member can see the parent(s) when the young person is being seen alone. If another team member is in the clinic room, he or she could have debriefing role at the end of the visit, spending some time with the young person and going over what has been discussed.
Identify the key person for each young person who will help to coordinate the transition process.
Ensure professional sensitivity towards apparently routine clinic tasks, e.g., weighing, urine testing, ascertaining the date of the last menses for X-rays.
Provide training for all new staff members.
Involve the whole team, e.g., secretaries/receptionists should be trained to take messages from young people.
Use peers in disease-education programs.
Use role models, e.g., young adults with JIA who successfully made the transition to adult care, into work, etc.
Create an advisory panel of young people for service developments, etc.
Foster multidisciplinary and interagency involvement—among the health, social services, youth service, education, and voluntary sectors.
Provide an emotionally and physically safe environment. A gender balance among staff is important, particularly where physical examinations are undertaken.
Hide toys if the area usually used by a pediatric service.
Dedicated clinic and waiting area
May be within a larger general waiting area
May be the later appointment slots of a general pediatric/adult clinic
Consider consultation room set up—position chairs to ensure maximum eye contact between professional and young person.
Consider need for additional rooms to facilitate independent visits and to meet needs of parents.
Access—ensure convenient timing of clinic appointments (e.g., after school) access for advice, text messaging, e-mail, helpline.
Encourage all team members to encourage independent behavior, e.g, receptionists can give the young person the appointment slip; secretaries can encourage young people to phone with questions.
Aspire to continuity of care personnel between visits when possible.
Schedule appointments so friends can attend, to facilitate peer support.
Table 4 "You're Welcome": The 4 Ps of Young-Person-Friendly Rheumatology Service Delivery (Continued)
Provide age and developmentally appropriate information resources in a range of formats—paper-based, internet, text messaging.
Consider credit card-size information handouts, particularly for sensitive issues (e.g., sexual health advice), which the young person can to keep private in a wallet.
Make information available in a relatively private place to encourage use (e.g., toilets!) and avoid gatekeeping.
Hang posters describing confidentiality practices, generic health issues etc. In multiuser areas, consider use of projector and PowerPoint slide show for adolescent-friendly informational material.
Create computer access with reasonable privacy to encourage information-seeking behavior facilitate to anonymity when accessing sensitive information.
Keep notes. Document the patient's progress and preparation for independent visits, especially if personnel continuity cannot be guaranteed.
Send clinic letters routinely to young person, bearing in mind confidentiality issues in case letters are intercepted by parents. Consider asking the young person to bring a list of questions. ("Think of three questions for me for your next visit!") and remember to ask for them.
Send a follow-up letter to patient recapping the information exchanged during the clinic visit and suggesting issues that need further discussion or review at the next visit.
Provide up-to-date teenage magazines—for boys and girls! Ask your patients which ones to buy.
Place a suggestion box/book in waiting area to encourage feedback from patients.
prevention. The use of immediate motivators ("here and now") rather than future motivators ("if and then") to improve adherence is usually more fruitful at this stage (see Chapter 15). Chronic illnesses may impact cognitive development through the effect of certain therapies, pain, depression, fatigue, or school absence. Conversely, cognitive development will influence communication, health education, decision-making and self-care. Adolescence is also characterized by rapid change: as they get older, their developmental capacities change, and information provided earlier may need to be repeated. Reassessment of developmental needs is an important aspect of adolescent rheumatology care. This is shown in studies that report significant misunderstandings and lack of disease knowledge in established attendees of rheumatology clinics (45,46).
In practice, health professionals also need to assess and facilitate transfer of responsibility, communication, and "ownership" of disease from parents to the young person—key tasks of transitional care (see Chapter 16). In practical terms, it is useful to redefine relationships in early adolescence
(e.g., at 11-12 years). This might be take the form of a discussion about the philosophy of transition and the transfer to an adolescent service. Using the comparison of changing schools (primary to secondary) at this time is useful— "After all, you wouldn't stay in primary/junior school for ever, would you?" Such discussions can usefully facilitate opportunities for young people to be seen alone for part or all of their consultation, assuring their parents some time to address their needs as well.
An interactive, rather than a traditional adult medicine interrogative approach, is preferable in adolescent rheumatology. Interview strategies can be divided into two types—unidirectional and bidirectional (47). The unidirectional approach is characterized by the provision of facts, opinions/ advice, closed questions, and suggestions of alternatives. This strategy requires the young person to have the confidence to interrupt the conversation and assert themselves. The bidirectional approach is more interactive and involves the professional asking for understanding, the use of problem solving, open questions, and posing hypothetical situations. The latter is the preferred strategy in adolescent health, as it conveys the real message that the young person has options and is expected to respond and/ or participate. In a study of health education, doctors were found to use bidrectional strategies only 22% of the time with an adolescent: doctor ratio for talking of 0.14 in the unidirectional discussions compared to the healthier 1.06 in the bidirectional discussions (p = 0.004) (47).
Taking a psychosocial history is a useful strategy for engaging young people, in addition to identifying risk factors and eventually formulating interventions. A useful interview tool described in the literature is HEADSS (Home, education, activities, drugs, sexual, health, suicide) (48,49). Unfortunately, the evidence suggests that general adolescent health issues are not always addressed in specialty clinics (21,50,51), but screening for such issues can be improved by participation in a coordinated transitional-care program (21). Adolescents have been reported to have more diverse and serious health concerns than expected by health care providers (52). Carroll et al. reported that adolescents with chronic illness report more age-related concerns, e.g., acne, menstrual periods, sexual health, worries about height and weight, substance use, etc., than their healthy peers (53). What is less well known is how such issues are addressed in specialty clinics. Since adult health behaviors become established during adolescence, every health-related encounter, irrespective of setting, should be considered a potential health-promotion opportunity. Barriers to such health promotion have been reported (21,38) and are reflected in Table 2.
A proactive approach to adolescent health facilitates the addressing of such issues in the rheumatology clinic, "if you have a problem about-, know that you can come and talk to me; I'm willing to help." Including psychosocial issues in individualized transition plans (54) is a useful way to raise awareness among adolescents attending the clinic that such issues matter to the rheumatology team, and, even if they are not relevant immediately, when they do become so, adolescents will know that they can ask related questions when they come to clinic.
Useful interviewing strategies in the specific context of the triadic consultation involving parent(s) and the adolescent include circular questioning and turn-taking, which are detailed in Chapter 14. One of the most important skills for triadic consultations is to take care how the opinion of the parents is obtained, and to ensure it is not perceived as a lack of belief in the young person.
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