Adolescence is a very tricky time for everyone; it’s tough for the child to come to terms with their transition to adulthood and their relations with parents may be strained. It is imperative that in a healthcare setting, with its additional stress and uncertainly, nurses can quickly gain trust and deal with what can be challenging and complex three-way communication process between a parent and teenage patient.
Nurses should try involve older children and adolescents in the whole decision making process as much as possible, even though the parent is ultimately responsible for giving consent. This requires educating the family and patient appropriately and ensuring communication is on a level that they can understand, setting expectations about future tests and treatments.
This is especially important in the context of adolescents, who will likely have the intellectual capacity of their parents and be perfectly capable of making their own healthcare decisions. The general rule of thumb to follow is that if a child is asked their opinion about the direction of treatment or participation in research, then their views and desires should be seriously considered.
The older the child is, the greater the need to involve them in the decision-making process and obtain assent, or agreement from the child to participate. Depending on the age of the patent, their involvement in this stage would typically be as follows:
- 10 – 12 years: Partially involve the child in the decision-making process to obtain mutual agreement;
- 13 – 17 years: Obtain agreement for treatment even though they are not the primary decision maker.
In trying to obtain assent, it is essential that a nurse firstly develops an understanding of the child’s level of development as well as their age. How well do they understand what’s happening, the process to come and any implications? Are they being influenced unduly? How willing are they to be treated? Could their attitudes change over the course of a treatment programme?
What are the key stages to follow in getting assent?
Each stage needs to be modified in line with the child’s individual developmental level:
- Help the child understand their health condition and inform them of the treatment planned
- Determine what the child understands about their condition
- Ensure they are not being unduly influenced to make any decisions/ follow a course of action
- Ascertain how willing they are to participate in the treatment or pursue a course of action.
Appreciating differences in communication preferences
Adolescents will have very different communication preferences to their parents, so obtaining assent and ensuring they understand their situation may require a different style of approach. For instance, teens tend to use fewer words than adults and may rely more on non-verbal cues, of which silence and pauses in communication are very important.
If a teenager appears shy, focus on the parents initially as they may need extra time to warm up. Some will process information more slowly than their parents and having conversation gaps will allow the young person to assimilate what’s being discussed.
Another aspect to consider is the importance of comfort giving and the establishment of trust. Whereas the parents will be happy with the facts and detailed information to answer their questions, adolescents will need to establish an immediate rapport with their nurse and achieve a level of trust in order to go forward. The best communicators in paediatric nursing are able to quickly find this balance.
Top tips for effective verbal communication with adolescents
- Avoid medical jargon and acronyms when explaining but appreciate many parents and adolescents will have conducted some initial research online and be reasonably well informed from the outset
- Stick to open-ended questions to result in more detailed answers (i.e. avoid yes/no answers)
- If the conversation digresses, actively get it back on track. Manage the conversation to maintain focus on the key topic to be discussed
- Reflect on what has been discussed to verify the parent and child’s immediate feelings
- Demonstrate empathy by reiterating their previous answers
- Acknowledge their emotions
- Demonstrate active listening by using the same words as the child and family in your replies
- Don’t interrupt. Always let the patient and family finish their points.
Ensuring that you communicate effectively with children and guardians according to their age and needs is an easily overlooked aspect of patient care. Doing so with these considerations in mind will help ease the process of managing patient care and build trust with younger patients.
For further reading, the General Medical Council has further information on the subject:
//www.gmc-uk.org/guidance/ethical_guidance/children_guidance_14_21_communication.asp
1. Coles MS, et al. If you do not ask, they will not tell: evaluating pregnancy risk in young women in pediatric hospitals. J Adolesc Health. 2016;58(3):251–2. [PubMed] [Google Scholar]
2. Sawyer SM, et al. Adolescence: a foundation for future health. Lancet. 2012;379(9826):1630–40. [PubMed] [Google Scholar]
3. Finer LB, Philbin JM. Sexual initiation, contraceptive use, and pregnancy among young adolescents. Pediatrics. 2013;131(5):886–91. [PMC free article] [PubMed] [Google Scholar]
4. Nordin JD, et al. Adolescent primary care visit patterns. Ann Fam Med. 2010;8(6):511–6. [PMC free article] [PubMed] [Google Scholar]
5. Kost K, Maddow-Zimet I. US teenage pregnancies, births and abortions, 2011: national trends by age, race and ethnicity. New York: Guttmacher Institute; 2016. Apr, //www.guttmacher.org/sites/default/files/report_pdf/us-teen-pregnancy-trends-2011_0.pdf. [Google Scholar]
6. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2014. Atlanta: 2015. Nov, //www.cdc.gov/std/stats14/surv-2014-print.pdf. [Google Scholar]
7. Owusu-Edusei K, Jr, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis. 2013;40(3):197–201. [PubMed] [Google Scholar]
8. Centers for Disease Control and Prevention. Vital signs. Atlanta: 2012. Nov, HIV among youth in the US: protecting a generation. //www.cdc.gov/vitalsigns/HIVAmongYouth/index.html. [Google Scholar]
9. Satterwhite CL, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187–93. [PubMed] [Google Scholar]
10. Centers for Disease Control and Prevention. HPV vaccine information for young women. 2015 //www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm.
11. Reagan-Steiner S, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(29):784–92. [PMC free article] [PubMed] [Google Scholar]
12. Kepka D, et al. Human papillomavirus vaccine practices in the USA: do primary care providers use sexual history and cervical cancer screening results to make HPV vaccine recommendations? Sex Transm Infect. 2012;88(6):433–5. [PubMed] [Google Scholar]
13. Thompson VL, et al. African American parents’ attitudes toward HPV vaccination. Ethn Dis. 2011;21(3):335–41. [PMC free article] [PubMed] [Google Scholar]
14. Bednarczyk RA, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics. 2012;130(5):798–805. [PubMed] [Google Scholar]
15. Dorell CG, et al. Human papillomavirus vaccination series initiation and completion, 2008–2009. Pediatrics. 2011;128(5):830–9. [PubMed] [Google Scholar]
16. Guerry SL, et al. Human papillomavirus vaccine initiation among adolescent girls in high-risk communities. Vaccine. 2011;29(12):2235–41. [PubMed] [Google Scholar]
17. Ylitalo KR, et al. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US National Immunization Survey. Am J Public Health. 2013;103(1):164–9. [PMC free article] [PubMed] [Google Scholar]
18. Vadaparampil ST, et al. Missing the target for routine human papillomavirus vaccination: consistent and strong physician recommendations are lacking for 11- to 12-year-old males. Cancer Epidemiol Biomarkers Prev. 2016;25(10):1435–46. [PMC free article] [PubMed] [Google Scholar]
19. Moss JL, et al. Disparities in collaborative patient-provider communication about human papillomavirus (HPV) vaccination. Hum Vaccin Immunother. 2016;12(6):1476–83. [PMC free article] [PubMed] [Google Scholar]
20. Curtis KM, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(4):1–66. [PubMed] [Google Scholar]
21. U.N. Committee on the Rights of the Child (CRC) General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24) New York: 2013. Apr 17, //www.refworld.org/docid/51ef9e134.html. [Google Scholar]
22. Society for Adolescent Health and Medicine, et a. Sexual and reproductive health care: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2014;54(4):491–6. [PubMed] [Google Scholar]
23. Gavin L, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep. 2014;63(RR-04):1–54. [PubMed] [Google Scholar]
24. Romero LM, et al. Improving the implementation of evidence-based clinical practices in adolescent reproductive health care services. J Adolesc Health. 2015;57(5):488–95. [PMC free article] [PubMed] [Google Scholar]
25. Irwin CE, Jr, et al. Preventive care for adolescents: few get visits and fewer get services. Pediatrics. 2009;123(4):e565–e572. [PubMed] [Google Scholar]
26. Ma J, et al. U.S. adolescents receive suboptimal preventive counseling during ambulatory care. J Adolesc Health. 2005;36(5):441. [PubMed] [Google Scholar]
27. Brittain AW, et al. Youth-friendly family planning services for young people: a systematic review. Am J Prev Med. 2015;49(2 Suppl 1):S73–S84. [PMC free article] [PubMed] [Google Scholar]
28. Kuzma EK, Peters RM. Adolescent vulnerability, sexual health, and the NP’s role in health advocacy. J Am Assoc Nurse Pract. 2016;28(7):353–61. [PubMed] [Google Scholar]
29. Divecha Z, et al. Tweeting about testing: do low-income, parenting adolescents and young adults use new media technologies to communicate about sexual health? Perspect Sex Reprod Health. 2012;44(3):176–83. [PMC free article] [PubMed] [Google Scholar]
30. Miller MK, et al. Brief behavioral intervention to improve adolescent sexual health: a feasibility study in the Emergency Department. Pediatr Emerg Care. 2016;32(1):17–9. [PMC free article] [PubMed] [Google Scholar]
31. Catalano RF, et al. Worldwide application of prevention science in adolescent health. Lancet. 2012;379(9826):1653–64. [PMC free article] [PubMed] [Google Scholar]
32. Ralph LJ, Brindis CD. Access to reproductive healthcare for adolescents: establishing healthy behaviors at a critical juncture in the lifecourse. Curr Opin Obstet Gynecol. 2010;22(5):369–74. [PubMed] [Google Scholar]
33. Resnick MD, et al. Seizing the opportunities of adolescent health. Lancet. 2012;379(9826):1564–7. [PubMed] [Google Scholar]
34. Coker TR, et al. Improving access to and utilization of adolescent preventive health care: the perspectives of adolescents and parents. J Adolesc Health. 2010;47(2):133–42. [PubMed] [Google Scholar]
35. Ambresin AE, et al. Assessment of youth-friendly health care: a systematic review of indicators drawn from young people’s perspectives. J Adolesc Health. 2013;52(6):670–81. [PubMed] [Google Scholar]
36. Haller DM, et al. YFHS-WHO+ questionnaire: validation of a measure of youth-friendly primary care services. J Adolesc Health. 2012;51(5):422–30. [PubMed] [Google Scholar]
37. Antonishak J, et al. Impact of an online birth control support network on unintended pregnancy. Soc Mar Q. 2015;21(1):23–36. [Google Scholar]
38. Ford C, et al. Confidential health care for adolescents: position paper for the Society for Adolescent Medicine. J Adolesc Health. 2004;35(2):160–7. [PubMed] [Google Scholar]
39. Sedlander E, et al. Options for assuring access to confidential care for adolescents and young adults in an explanation of benefits environment. J Adolesc Health. 2015;56(1):7–9. [PubMed] [Google Scholar]
40. Gilbert AL, et al. Clinical conversations about health: the impact of confidentiality in preventive adolescent care. J Adolesc Health. 2014;55(5):672–7. [PubMed] [Google Scholar]
41. Lehrer JA, et al. Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern. J Adolesc Health. 2007;40(3):218–26. [PubMed] [Google Scholar]
42. Franzini L, et al. Projected economic costs due to health consequences of teenagers’ loss of confidentiality in obtaining reproductive health care services in Texas. Arch Pediatr Adolesc Med. 2004;158(12):1140–6. [PubMed] [Google Scholar]
43. Colman S, et al. Do parental involvement laws deter risky teen sex? J Health Econ. 2013;32(5):873–80. [PubMed] [Google Scholar]
44. Dempsey AF, et al. Adolescent preventive health care: what do parents want? J Pediatr. 2009;155(5):689–94. e1. [PubMed] [Google Scholar]
45. Ackard DM, Neumark-Sztainer D. Health care information sources for adolescents: age and gender differences on use, concerns, and needs. J Adolesc Health. 2001;29(3):170–6. [PubMed] [Google Scholar]
46. Wakley G. Helping parents with sex education. J Fam Health Care. 2011;21(2):30–3. [PubMed] [Google Scholar]
47. Sochalski J, Weiner J. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, editor. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011. Health care system reform and the nursing workforce: matching nursing practice and skills to future needs, not past demands; pp. 375–400. [Google Scholar]
48. Santa Maria D, et al. Preparing student nurses as parent-based adolescent sexual health educators: results of a pilot study. Public Health Nurs. 2016 Mar 31; Epub ahead of print. [PubMed] [Google Scholar]
49. Kurth AE, et al. A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history. Sex Transm Dis. 2004;31(12):719–26. [PubMed] [Google Scholar]
50. Eade DM, Henning D. Chlamydia screening in young people as an outcome of a HEADSS; Home, Education, Activities, Drug and alcohol use, Sexuality and Suicide youth psychosocial assessment tool. J Clin Nurs. 2013;22(23–24):3280–8. [PubMed] [Google Scholar]
51. Guilamo-Ramos V, et al., editors. Parental monitoring of adolescents: current perspectives for researchers and practitioners. New York: Columbia University Press; 2010. [Google Scholar]
52. Guilamo-Ramos V, et al. Parent-adolescent communication about contraception and condom use. JAMA Pediatr. 2016;170(1):14–6. [PMC free article] [PubMed] [Google Scholar]
53. Santa Maria D, et al. Does parental monitoring moderate the relation between parent-child communication and pre-coital sexual behaviours among urban, minority early adolescents? Sex Educ. 2014;14(3):286–98. [Google Scholar]
54. Wight D, Fullerton D. A review of interventions with parents to promote the sexual health of their children. J Adolesc Health. 2013;52(1):4–27. [PubMed] [Google Scholar]
55. Dittus PJ, et al. Parental monitoring and its associations with adolescent sexual risk behavior: a meta-analysis. Pediatrics. 2015;136(6):e1587–e1599. [PMC free article] [PubMed] [Google Scholar]
56. Jaccard J, et al. Parent-adolescent communication about sex and birth control: a conceptual framework. New Dir Child Adolesc Dev. 2002;(97):9–41. [PubMed] [Google Scholar]
57. Wilson EK, Koo HP. Mothers, fathers, sons, and daughters: gender differences in factors associated with parent-child communication about sexual topics. Reprod Health. 2010;7:31. [PMC free article] [PubMed] [Google Scholar]
58. Guilamo-Ramos V, et al. A comparative study of interventions for delaying the initiation of sexual intercourse among Latino and black youth. Perspect Sex Reprod Health. 2011;43(4):247–54. [PubMed] [Google Scholar]
59. Santa Maria D, et al. Parent-based adolescent sexual health interventions and effect on communication outcomes: a systematic review and meta-analyses. Perspect Sex Reprod Health. 2015;47(1):37–50. [PMC free article] [PubMed] [Google Scholar]
60. DiIorio C, et al. REAL men: a group-randomized trial of an HIV prevention intervention for adolescent boys. Am J Public Health. 2007;97(6):1084–9. [PMC free article] [PubMed] [Google Scholar]
61. DiIorio C, et al. Keepin’ it R.E.A.L. !: results of a mother- adolescent HIV prevention program. Nurs Res. 2006;55(1):43–51. [PubMed] [Google Scholar]
62. Villarruel AM, et al. Testing the efficacy of a computer-based parent-adolescent sexual communication intervention for Latino parents. Fam Relat. 2010;59(5):533–43. [PMC free article] [PubMed] [Google Scholar]
63. D’Cruz J, et al. Promoting parent-child sexual health dialogue with an intergenerational game: parent and youth perspectives. Games Health J. 2015;4(2):113–22. [PMC free article] [PubMed] [Google Scholar]