The adolescent psychosocial history

INTRODUCTION — 

The psychosocial history is a key aspect of the adolescent and young adult health interview. Addressing information gathered from the psychosocial history is a core component of adolescent health care. Gathering this information often requires more probing than that needed for the pediatric and adult social history. Additionally, the approach should be tailored to each patient's developmental stage.

This topic will focus on the key elements of the psychosocial history and the unique aspects of conducting the interview.

Additional aspects of adolescent health, including anticipatory guidance, are discussed separately. (See "Guidelines for adolescent preventive services".)

Aspects of the psychosocial history that are specific to gay, lesbian, and bisexual youth are discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care", section on 'Psychosocial history'.)

UNIQUE ASPECTS OF PROVIDING CARE TO ADOLESCENTS — 

Adolescence is typically defined as the ages of 11 to 21 years [1]. It constitutes a critical period between childhood and adulthood, during which youth navigate core developmental tasks including identity formation, individuation, and exploration. Some of the behaviors that occur during this exploration phase may increase risk of harm to the adolescent (eg, injury while intoxicated, sexual activity without use of contraception or barrier protection).

During adolescence, individuals develop increasing capacity for more independent questioning, analysis, and decision making [2]. They accrue health knowledge, form attitudes, and establish behaviors that will impact their lifelong wellbeing. Misinformation, particularly through various forms of contemporary media, may lead to poorly informed health decisions if not corrected [3-5].

Adolescence offers a time-limited window of opportunity to promote wellbeing, provide accurate health information, and identify and manage health problems early [6-8]. Many morbidities that are common among older adults stem, at least in part, from health decisions made during adolescence. Subsequent behaviors and health trajectories are potentially modifiable if addressed effectively during adolescence [9].

The term 'adolescent' will be used broadly to include young people between the ages of 11 and 21 years.

CORE PRINCIPLES

Focus on strengths — Positive Youth Development (PYD) focuses on the young person's strengths; builds on these strengths; promotes youth connectedness with supportive adults in their family, school, and community; and engages youth in shaping the care and support they receive [10-12]. PYD provides a conceptual framework for a strength-based approach to clinical care of the adolescent [13-15] and has largely replaced the "storm and stress" narrative of adolescence that focused on conflict, risk, and emotionality [16]. (See 'Strengths' below.)

Respect developing autonomy — Adolescents are in the midst of an ongoing transition with increasing autonomy that, in most cases, will lead to adult independence [17,18]. Honoring the young person's burgeoning autonomy conveys respect for them as an individual. Yet, the complex and dynamic nature of adolescent development requires that the provider continually assess the adolescent's capacity for independent decision-making. This process may be challenging when an adolescent feels ready for and advocates for more independence than may be developmentally appropriate.

Preserve confidentiality — The provision of confidentiality is a key component of adolescent health care. Without this, adolescents are less likely to be candid when discussing issues that they keep private from their caregivers. Furthermore, youth who are not assured of confidentiality often do not seek medical attention [19-23]. This may delay needed care and lead to adverse health outcomes. Situations in which confidentiality must be breached are discussed separately. (See 'Setting expectations for confidentiality' below and 'Approach to breaching confidentiality' below.)

Providing confidential time in acute care settings is just as important as in office-based settings even though time constraints present additional challenges. The "chief complaint" may not fully represent the young person's concerns, and the root of the problem may be missed if the health care provider does not set aside time to speak with the adolescent privately [24,25]. Additionally, many young people do not have a medical home, and the acute care visit may be their only opportunity to discuss their private concerns.

Preserving confidentiality has grown increasingly complicated with advancements in health information technology and the advent of requirements for health record sharing [26-28]. A broader discussion of confidentiality in adolescent health care is provided separately. (See "Confidentiality in adolescent health care".)

Build rapport and trust — Building rapport and developing trust are essential to the provision of high-quality health care, particularly for youth who may be engaging with the health care provider independently for the first time. Youth may feel insecure about communicating without caregiver assistance and may have had little practice in doing so. Further, their concerns may be sensitive and laden with stigma, embarrassment, guilt, or shame.

While rapport and trust are important elements of encounters with any age group, older adults are likely to navigate clinical encounters effectively even without particular attention to these points, and younger children rely on a parent/caregiver to represent them.

Key components of building rapport and trust include conveying an atmosphere of openness, safety, nonjudgment, and youth centeredness. Making it clear to adolescents that they are the primary driver of what is discussed helps them to feel empowered and safe. Describing the encounter as an exchange of expertise between a health care expert and the adolescent (the world's only expert on their personal experiences and perspectives) conveys a goal of collaboration between the adolescent and the health care provider.

●Use a developmentally-appropriate approach – The principles and approaches reviewed in this topic should be modified to suit each patient's developmental stage. Due to the dynamic nature of adolescent development, the approach may need to change for the same patient as they progress through early, middle, and late adolescence. As an example, a provider might compliment a younger adolescent who asks great questions with the parent/caregiver in the room and then suggest that a next step in their progression to independence might be to spend time speaking privately with the provider at the next visit. (See "Sexual development and sexuality in children and adolescents", section on 'General adolescent development'.)

●Acknowledge and address neurodiversity – Health care providers should make every effort to understand the neurodevelopmental status of each new patient before launching into the encounter. Avoid making assumptions based on physical appearance or any listed diagnoses [29]. Interact directly with neurodiverse youth as much as possible. Modify this approach only if prior experiences with the patient suggest the need (eg, moderate or substantial differences in communication abilities) or if caregivers advise a different approach. In general, parents/caregivers will be the best guides on how to effectively communicate and engage with their neurodiverse youth. Private time to speak with the health care provider should be offered to all patients, even if their ability to communicate is limited. However, the patient's and caregiver's comfort with doing so should first be confirmed.

●Avoid assumptions and be inclusive – Youth identity evolves through adolescence and is comprised of many facets (eg, gender and sexual identity, race and ethnicity, differences in abilities). Some facets of identity may impact the ways that the young person is perceived and treated [30,31], and the intersection of some facets may profoundly influence how others interact with the young person. Providers should be careful to not make assumptions about any aspect of a young person's identity or lived experiences. Assumptions convey a lack of respect for the young person as an individual with individual needs.

It is crucial that provider language be inclusive and incorporate all aspects of identity. Use of gender-inclusive language that avoids cisgender and heteronormative assumptions is especially important. This may take practice. Soliciting feedback from youth regularly can be helpful in refining one's skills.

Attend to nonverbal cues — Clinicians should pay close attention to nonverbal cues (eg, anxiety, affect, discomfort, distraction, fatigue). Direct questioning based on the clinician's observations may provide an opening for exploration of key issues. Nonverbal cues may also inform the clinician's interpretation of the interaction.

Adapt approach when encounters are more challenging — It is important to remember that clinical encounters occur within the context of each young person's day, which may be characterized by a range of nonclinical factors that impact their interaction during brief appointments.

●The quiet patient – Limited communication by an adolescent who is quiet and does not interact may be due to a range of reasons including temperament and personality, less developed conversational skills, and/or lack of comfort interacting in clinical settings with unfamiliar adults. Beginning the interview by exploring the patient's "favorites" (eg, favorite musical artist, athlete, video game, book, food) may draw them into the conversation.

It may be necessary to slow the tempo of the interview to allow ample time for the youth to express themselves at a pace that is comfortable. This may require narrowing the focus of the encounter to a subset of key topics during brief visits. Youth may also become more engaged if they have control over the topics discussed.

If a young person remains quiet throughout the visit, and their responses and nonverbal cues do not suggest a specific reason, it can be helpful to explicitly acknowledge that clinical conversations can be challenging for anyone.

•"I've noticed that you haven't had a lot to say, and that's OK. These types of conversations can be hard. If there is any way that I can make these conversations easier for you, please let me know."

●The upset youth – An adolescent who appears anxious, fearful, angry, or sad is unlikely to engage fully in the encounter. Clinicians may need to modify their approach by narrowing the intended scope and focus of the visit. Specific, explicit acknowledgement of the provider's observations conveys concern and affords the patient an opportunity to discuss what is bothering them if they feel comfortable doing so. Shared decision-making about what to cover in the encounter empowers the adolescent to provide input and may increase their engagement in the visit.

●The distracted adolescent – Some youth may not make eye contact and may seem distracted. If an adolescent is distracted by their phone, it is appropriate to ask them to put the phone away so that they can engage as much as they are able. However, it is important to bear in mind that a youth who appears distracted may still be engaged. Sometimes looking away from the clinician is a way to reduce the adolescent's anxiety.

If a young person seems reticent about fully participating in the interview, providers should simply acknowledge the challenges of discussing certain issues, ensure that the adolescent knows that the provider is available if and when they choose to follow up on any issues in the future, and normalize their reluctance to share personal details about their life.

Regardless of what the adolescent shares, the elements of the psychosocial history demonstrate the breadth of issues that impact their life and health and why they are important to consider. Closing the interview with a statement inviting future dialogue can be helpful:

●"I know these questions can be hard to answer. If you think of anything else you want to mention in the future, I am here for you and would be happy to discuss your concerns at any time."

Some youth may be guarded during one encounter but then return prepared with questions or specific concerns to discuss at their next visit.

OPENING THE VISIT

Introductions — The clinical encounter should begin with introductions, including the health care provider, patient, and any other participants in the visit, as well as their relationships to the patient. The patient's pronouns and chosen name should be confirmed.

If the young person is accompanied to the visit by a group home staff member or other adult that is not a legal guardian, it is important to clarify health care decision-making authority.

Seating arrangements — The location of each person's seat indicates to the participants who the primary driver of the visit will be. Frequently, the provider will enter the room and find the caregiver seated closest to the desk and computer and the patient seated more in the periphery. This usually requires rearranging everyone so that the patient is closest to the provider. Everyone should be comfortably seated and positioned so that the provider can maintain eye contact and engagement with all participants.

Health care provider's role — It is important to explain the health care provider's role in the encounter and in the young person's general health care. Many clinicians describe themselves as health advisors, whose job it is to listen to the young person, develop an understanding of their circumstances and needs, and provide expert guidance and options for next steps.

Youth expect seriousness from adult professionals to whom they bring concerns and often sensitive questions. Yet, clinicians can be friendly without being just another friend, and they can be humorous while remaining professional and authoritative. The goal is for the youth to be confident in the clinician's expertise, sense their care, and feel respected.

Triadic relationships — When a child enters adolescence, communication about the child's health transitions from a dyadic relationship between the parent/caregiver and health care provider to a triadic relationship that includes the adolescent. A framework for this triadic relationship has been proposed that places the youth at the center with health care provider and caregiver involvement [32].

●Patient-health care provider relationship – Providers should be mindful of maintaining focus on the youth, cultivating a trusting relationship, and elevating their priorities as much as possible. They should avoid situations in which an adult is the primary informant and driver of conversation.

The health care provider should set aside private time to speak with the adolescent alone. (See 'Setting expectations for confidentiality' below.)

●Parent/caregiver-health care provider relationship – Engaging parents and other caregivers provides an opportunity for them to offer their perspective and additional relevant information. This is particularly true when eliciting the patient's medical history and family history.

In some cases, speaking privately with caregivers may lead to additional insights that positively impact the care of the youth. It is important to seek the young person's permission prior to doing so to demonstrate respect and ensure that doing so will not undermine the adolescent's trust in the provider.

Encouraging communication with the teen's caregivers enhances their ability to provide essential support when their teen is navigating health challenges.

●Health care provider support for patient-caregiver relationship – Participation by the caregiver in the visit may engage them in support of their child's evolving role in their health care. Providers can model effective communication with the adolescent and equip caregivers to be actively involved while respecting their adolescent's privacy and autonomy.

●These dynamics will evolve as adolescents proceed through developmental stages, accrue skills, and gain experience. The primary focus is on centering the youth's perspective and priorities, promoting their active engagement in health decisions, and maintaining a strong connection with and involvement of caregivers throughout. Active involvement, communication, and collaboration of all members of the triad will optimize the adolescent's care experiences and health outcomes.

Prioritize topics to be covered — Elicit the chief complaint(s) from the young person and then the parent/caregiver. During the private/confidential portion of the visit, ask the patient about their chief concerns again. When a positive clinical relationship has already been established, addressing the chief complaint(s) completely can usually be accomplished, even with limited time.

However, if meeting the patient for the first time or for an annual visit, the scope of the interaction may need to be limited to concerns that are of the highest priority. This is particularly true when the youth is in distress and/or needs private time to discuss concerns that are sensitive in nature [22,23].

In these situations, collaboratively prioritizing the focus of the encounter is essential. When time is limited, addressing the patient's primary concern(s) is wise, even if the clinician's priorities are different. The patient can then be asked to return for a follow-up visit to address the remaining priorities.

SETTING EXPECTATIONS FOR CONFIDENTIALITY — 

Typically, once introductions are made and "chief complaints" are reviewed, clinicians will spend time alone with the young person. Private time is a critical aspect of all health encounters with youth and should be included even in acute care settings, if possible. For some youth, access to care is limited and the acute care setting may be their only opportunity to discuss health concerns.

When possible, expectations for confidentiality should be discussed with both the patient and their parent(s)/caregiver(s) present. This ensures that everyone is fully informed and demonstrates to the youth that their parent/caregiver is in agreement.

●Explanation of confidentiality and limitations – Private time with the young person can be introduced as:

"I always provide my patients with the opportunity to speak with me alone. Although I encourage open communication within families, there are some things that youth are not comfortable discussing with their parents/caregivers. If your child asks me to keep something private, I will do so unless they tell me something that gives me concern that their or someone else's life or health is at risk. In that situation, I will discuss these concerns with you."

Very often the caregiver is familiar with the purpose and rationale for private conversation and will leave the room without hesitation. On occasion, however, the caregiver may express uncertainty, confusion, or overt concern about leaving the room. They may resist allowing one-to-one interaction between the clinician and their child.

Caregiver reluctance to leave the room may be secondary to a wide variety of reasons. These include, but are not limited to, a lack of familiarity with such practices, discomfort with missing key aspects of the visit, skepticism that such interaction is necessary, a personal sense of rejection, or concerns that the youth may disclose something that the adult desires be kept private.

Addressing caregiver concerns and providing a rationale for confidentiality will often result in the caregiver permitting their child to have private time with the clinician. On occasion, caregiver concerns cannot be sufficiently alleviated, and private conversation will not be possible. In general, it is advisable to agree to reconsider private conversation again in a future encounter. If there are concerns for the safety or wellbeing of the youth, then further attempts will need to be made to speak with the youth privately. This may require the assistance of a social worker or other team members [33].

●Rationale for confidentiality – Some caregivers question the need for their child to spend private time speaking with the clinician and want a rationale for the request. The clinician can explain that there is clear research-based evidence indicating that time alone with the clinician promotes open communication by the youth, higher quality care, and better outcomes [33].

It is also helpful to underscore that the objective of confidential time is not secrecy but rather an opportunity for the youth to guide the discussion and speak freely in a developmentally appropriate manner. Very often such conversations are less about sensitive disclosures and more about topics that the youth is curious about. Caregivers can be reassured that this opportunity is offered to all youth that are capable of independent communication, not just to their child, and is considered standard of care. Finally, offering reassurance that acute safety concerns will always be addressed collaboratively with the caregiver is important.

●Limitations of confidentiality – Once the caregiver leaves the room, it is important to ask the young person if they have any questions about the limits of confidentiality. It is also helpful to let them know that if anything does need to be shared with their caregiver, the provider will not go behind their back, will only disclose the essential details, and will allow them to decide whether they would like to be in the room for the conversation. (See 'Approach to breaching confidentiality' below.)

On occasion, the young person will use private time with the health care provider to seek their support in making a sensitive disclosure to a parent/caregiver (eg, sexual or gender identity, sexual relationships). The provider should allow the youth to take the lead and steer the conversation. The provider's role should be determined by the adolescent and may include conveying information, explaining details, or placing the information into context. The provider's primary roles are to offer a frame of reference regarding healthy adolescent development and experience as well as to support and advocate for the youth as needed.

APPROACH TO SENSITIVE TOPICS — 

General principles for inquiring about potentially sensitive topics include:

●Progressing gradually, first asking about general thoughts and questions, then to the behaviors of peers, and finally to the patient's own decisions and behaviors within a particular domain.

●There isn't one right way to ask sensitive questions. There are, however, incorrect, ineffective, and even potentially harmful ways of doing so. One common pitfall is asking questions in a way that conveys judgment and/or suggests that there is a desirable or "correct" response (eg, "You don't vape, do you?").

●Questioning should be age and developmentally appropriate, avoiding jargon, and checking on a shared understanding when any uncommon language such as slang is used.

●Questions should be open-ended whenever possible, although follow-up, closed-ended questions may offer greater specificity and clarity at times.

●Clinicians should use inclusive language when framing questions, taking into account the broad range of youth identities, experiences, and values.

●Clinicians should avoid conveying any sense of judgment in the framing of questions and the responses to the patient's answers.

COMPONENTS OF THE PSYCHOSOCIAL HISTORY

Screening questions — Helpful assessment frameworks are available that cover the key domains of the psychosocial history. Examples include the Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation, and Safety (HEEADSSS) [34-36] and Strengths, School, Home, Activities, Drugs, Emotions/Eating, Sexuality, and Safety (SSHADESS) questions (table 1) [37]. They are particularly helpful as an organizing framework when a full psychosocial history is indicated. Notably, these questions progress from topics that are less sensitive to those that are more sensitive. The SSHADESS questions also provide an explicit, purposeful focus on youth strengths.

With each domain, it is important to seek, acknowledge, and amplify any strengths or assets shared by the youth. This is accompanied by the identification of opportunities for improvement and support. Young people are more likely to engage fully and share candidly if the clinician demonstrates a holistic interest in them and their experiences.

The psychosocial history itself often prompts young people to ask their own questions. It may also provide opportunities for education and anticipatory guidance by the clinician.

Some providers request that adolescents complete previsit questionnaires and screening instruments, which may uncover key issues that the adolescent would not otherwise discuss [22,38-45]. Answering questions in written form may be an easier way for an adolescent to communicate about sensitive concerns than responding to direct questioning. Additionally, these tools may provide information that facilitates initiation of the psychosocial history with the adolescent. However, it is important to not rely solely on such instruments or use them as replacements for direct questioning.

Strengths — Start the history by asking about strengths. A focus on the adolescent's strengths will set a positive tone. (See 'Focus on strengths' above.)

Examples of questions include:

●"What is something about yourself that you are proud of?"

●"How would a good friend describe you?"

These questions can be asked with the parent/caregiver in the room to garner their perspectives as well. The caregiver can be asked:

●"If you were going to brag about (patient's name) to other parents, what would you say?"

This type of question may shed further light on the parent-teen relationship [14,15,37].

School — An appreciation of the adolescent's school experiences is important given that most youth spend a substantial portion of their waking hours in school settings. Their academic performance is important but is only one aspect of their school experience. Connectedness in school settings is an important, positive influence on health outcomes [9]. Interactions with peers in social contexts and the presence of trusted adults in the school setting are additional subjects to explore.

Examples of questions include:

●"What is a typical school day like for you?"

●"Are there other students you interact with regularly, or do you mostly keep to yourself?"

●"Are there any adults at school that you trust and can go to for support?"

●"Do you ever feel unsafe or unwelcome at school?"

Home — Insights on the adolescent's home life provide a glimpse of how connected they are to supportive family members and shed light on the feasibility of following through with clinical recommendations.

Key aspects include identifying regular members of the household, trusted adults, sense of stability in terms of housing and food access, and safety in the home [46-48].

Examples of questions include:

●"Who else lives at home with you?"

●"If you have a question or a problem, is there someone at home you can go to?"

●"What is living in your home like?"

●"Do you feel safe at home?"

●"Do you spend time with your family?"

•"What do you usually do together?"

●"Does your family/household usually have enough money for things that you need?"

Activities — Many youths derive satisfaction, joy, and a sense of identity and competence from activities they are involved in. Learning about these activities provides insights about the young person's social, educational, and vocational interests and their degree of connectedness with peers [9].

Examples of questions include:

●"What do you like to do for fun?"

●"Can you tell me about your closest friends?"

●"Are you involved in any sports, clubs, or other activities?"

●"What is an activity you've never done that you'd like to try in the future?"

●"Do you have a part-time (or full-time) job?"

•"What type of job do you have?"

Drugs/substance use — Some youth experiment with substance use including, tobacco or other nicotine products, alcohol, cannabis, and other drugs. It is important that the provider directly ask about substance use during the interview.

Examples of questions include:

●"Many of my patients are curious about smoking, vaping, drinking, and drugs. Some experiment with these substances or use them regularly. Do any of your friends smoke, vape, drink, or use drugs, including marijuana?"

●"Have you ever thought about or experimented with any of these substances?"

•"What did you think of it?"

●"What about supplements or medications not prescribed to you?"

●"Have you ever been in a car when the driver (including yourself) was either drunk or high?"

If a patient denies use, the clinician should affirm their decision, while reassuring them that they will not be judged if this changes in the future. When patients acknowledge any substance use, the provider should assess further [49]. (See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening'.)

Emotions/eating/depression — Psychological development and wellbeing are crucial aspects of a young person's overall health. Providers should ask directly about mood, anxiety, and concerns about body image and eating.

Examples of questions about emotions and depression include:

●"What is your mood like on a typical day?"

●"Do you ever feel really sad or down for more than a day?"

●"How often do you feel stressed or anxious?"

●"Do you ever feel really irritable or struggle with anger that is hard to control?"

●"Have you ever wished that you weren't alive or had never been born?"

•"Have you thought about killing yourself?"

-If the answer to this question is yes, an urgent full suicide screening should be performed. (See "Suicidal ideation and behavior in children and adolescents: Evaluation and disposition".)

●"Have you ever harmed yourself as a way of coping with difficult emotions?"

Examples of questions about eating include:

●"Can you tell me about what you eat and drink during a typical day?"

●"What sorts of physical activity do you usually do?"

●"Do you ever stress or worry about the shape or size of your body?"

●"Have you ever done anything to try and change the shape or size of your body?"

Affirmative responses to the latter two questions should prompt assessment for potential disordered eating. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

Sexuality — Asking about sexuality and gender gives the provider a fuller understanding of the youth's self-concept. Patients may not be candid with their answers if the provider has not built sufficient trust or does not ask questions with sensitivity [50-55]. This may lead to missed opportunities to support the young person. Sexual and gender development are discussed in more detail elsewhere. (See "Sexual development and sexuality in children and adolescents" and "Gender development and clinical presentation of gender diversity in children and adolescents".)

Asking about sexual activity, contraception, and use of barrier protection helps to determine whether sexually transmitted infection screening is indicated or if a more effective method of contraception is needed [50,56-60].

Examples of questions include:

●"How do you describe your gender?" or "What is your gender identity?"

•"Do you ever feel confused or concerned about your gender identity?"

●"Which gender or gender(s), if any, of people do you find yourself attracted to?"

●"Have you ever dated?"

●"Have you ever been in a sexual relationship or had sex with someone?"

•"Was it a positive experience for you?"

●"How do you keep yourself and your partners safe from infection?"

●"Have you ever felt unsafe in a relationship?"

●"Has anyone ever touched you or tried to get you to do something with your body or sexually that you didn't want to do?"

•"Are you comfortable talking with me about it?"

Safety — Safety includes physical safety from unintentional injury (eg, motor vehicle accident, sports-related injury, other physical injury) and interpersonal violence (including intimate partner violence) [61]. Psychological and emotional safety within relationships and online safety are additional facets of safety.

Examples of questions include:

●"In thinking about your home, school, neighborhood, relationships, and online experiences, do you have any concerns for your safety?"

•"Have you ever felt unsafe?"

●"Do you wear a seatbelt in the car?"

Asking adolescents about their digital media use, including internet and social media, is an increasingly important aspect of a comprehensive psychosocial history and can be included in a general discussion of safety. Digital media is a pervasive influence in the lives of youth, with both positive and potentially harmful impacts [62,63].

Questions about social media go beyond simply quantifying use. Health care providers should ask about the types of digital media that the young person engages with, explore their motivations and experiences, and identify both positive and harmful impacts on the adolescent.

Examples of questions include:

●"Many people spend a lot of time online. What sorts of things do you like to do online?"

●"How do you maintain your privacy and stay safe online?"

●"Have you ever had any negative interactions with other people online?"

●"Have you ever done anything online that you regret?"

APPROACH TO BREACHING CONFIDENTIALITY — 

Confidentiality should only be breached when there is concern for the safety of the youth or someone else. Ideally, an explanation about why it is necessary to involve their caregiver(s) will lead to agreement on the part of the adolescent. If not, it is essential to involve the adolescent in the decision about how to inform the caregiver(s) about the concern. (See "Confidentiality in adolescent health care".)

Examples include:

●Provider speaks with caregiver alone

●Provider speaks with caregiver in the presence of the patient

●Patient first speaks with caregiver alone, then provider joins the discussion

●Patient speaks with the caregiver in the presence of the provider

Providers should not breach confidentiality without first informing the patient. It is important to gauge whether disclosure could lead to an unsafe situation for the young person (ie, risk of harm from their caregiver) prior to speaking with the caregiver.

It is best to disclose only as much information as is necessary to gain the assistance of the caregiver in the needed intervention. There is no need to provide every detail of what the adolescent shared when explaining the reason for concern.

VIRTUAL CARE SETTINGS — 

Advancements in telemedicine have increased access to care for many youths. In general, the same core principles of in person visits apply to virtual visits [64-67]. Additional practical considerations include:

●Directly ask the patient about visual and auditory quality of the connection.

●Confirm the youth's identity and ask about the identity of other participants in the encounter.

●Ensure that the patient has privacy, as needed. Use of headphones and sitting in a room with the door closed are generally adequate measures.

●Confirm the patient's geographic location to ensure compliance with regulatory requirements about interstate care.

●Confirm callback contact information in case connectivity is lost.

SUMMARY AND RECOMMENDATIONS

●Unique aspects of providing care to adolescents – Adolescence is typically defined as the ages of 11 to 21 years. This a critical period between childhood and adulthood during which youth navigate core developmental tasks including identity formation, individuation, and exploration. (See 'Unique aspects of providing care to adolescents' above.)

During this developmental stage, adolescents accrue health knowledge, form attitudes, and establish behaviors that will impact their lifelong wellbeing. If not corrected, misinformation, particularly through various forms of contemporary media, may lead to poorly informed health decisions.

Many morbidities that are common among older adults have their origin in health decisions made during adolescence. Health care visits during adolescence offer opportunities to change this trajectory by promoting wellbeing, providing accurate health information, and identifying and managing health problems early in their course.

●Core principles – The core principles of conducting an interview with an adolescent include focusing on strengths, respecting developing autonomy, preserving confidentiality, building rapport and trust, and attending to nonverbal cues. (See 'Core principles' above.)

●Opening the visit – Opening an adolescent visit differs somewhat from opening a pediatric or adult visit and requires special attention to introductions, seating arrangements, description of the provider's role, and addressing triadic relationships when the adolescent is accompanied by a caregiver. (See 'Opening the visit' above.)

●Confidentiality – Providing confidentiality, with limits, is a key component of adolescent health care.

Setting expectations for confidentiality with the parent/caregiver includes (see 'Setting expectations for confidentiality' above):

•An explanation of what will be kept confidential

•A rationale for providing adolescent confidentiality

•A discussion of the limitations of confidentiality

Breaching confidentiality is rarely required. When it is, important components of the process include (see 'Approach to breaching confidentiality' above):

•Disclosure to a caregiver should not be done without the adolescent's knowledge.

•The adolescent should be involved in the decision about how to inform the caregiver(s) about the concern.

•Details of the disclosure should be limited to only what is required to gain the assistance of the caregiver for the appropriate intervention.

●Components of the psychosocial history – The components of the adolescent psychosocial history are divided into domains that differ in many ways from those of the pediatric and adult social history.

Within each domain, it is important to seek, acknowledge, and amplify any strengths or assets shared by the youth. Identifying opportunities for improvement and support should take place concurrently. Young people are more likely to engage fully and share candidly if the clinician demonstrates a holistic interest in them and their experiences.

The SSHADESS pneumonic provides a useful framework for organizing questions within each domain (table 1). It starts with questions that are less sensitive and proceeds to questions that are more sensitive. Example questions are detailed in the main topic. (See 'Components of the psychosocial history' above.)