COMMENTARY

Earning a Teenager's Trust

Kenneth R. Ginsburg, MD

Disclosures

April 01, 2013

Editorial Collaboration

Medscape &

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Hello. My name is Ken Ginsburg. I am an adolescent medicine specialist at the Children's Hospital of Philadelphia. Adolescence is an amazing time. If we can work with adolescents, we can affect their health over a lifetime. It is during adolescence that so many behaviors are initiated that are going to make a difference for decades to come. Whether we're talking about substances, exercise, or nutrition, we can make a difference now.

The other thing to remember about adolescence is that it is also a time filled with risk. In fact, if we talk about what really hurts or kills kids, nearly 80% is entirely preventable. It starts with car crashes, followed by suicide, followed by homicide. What that means is that the reactive paradigm of medicine, where we say "tell us what you want us to deal with today," is not going to cut it. It means that it is about prevention. But if we are going to do prevention right and avert crises before they ever happen, kids need to know that we are worthy of their trust.

What do they need to know? The first thing they need to know is why we are asking these questions. "I came to you for a headache; why are you asking me about school? Why are you asking me about stress? Why are you asking me about sex?"

The next thing they need to know is that we are asking them to be honest, and we intend to be honest with them. When they know that the healthcare setting is a place for an honest interchange of information, powerful things can happen.

Next, they need to know that we are not about judgment. We are about service. When they tell us what is going on in their lives, we respect them because we know that they want to move forward.

Perhaps most important is confidentiality. It is widely accepted that a confidential relationship with a healthcare professional during adolescence is key. So how do we talk about this? The way that we were all taught to talk about this is to say, "I want you to know that we are going to have a confidential relationship. Everything will be kept confidential unless I'm worried that you are going to hurt yourself, hurt someone else, or that someone else is hurting you." The problem is that when we say that, kids have no idea what we're talking about, and they shut down and withhold information. Why?

Kids don't know what the word "confidentiality" means. Ask kids, and what they will say to you is: "Thank you, Doctor. I am going to try to have confidence in you, too." So we have to choose a different word. We have to choose a word like "privacy." "Your information is important and for that reason I promise you privacy." In medicine we call that confidentiality. Don't use the word "secret" because secret is shameful.

Next, don't tell kids, "I am worried that you are going to hurt yourself or hurt someone else or someone is hurting you; I'm going to have to tell someone." Why? Think about it from a 16-year-old's perspective. Does a 16-year-old think that you think doing drugs hurts them? Yes, they do. Does a 16-year-old think that you think that having sex without a condom hurts them? Yes, they do. So what they hear is entirely different from what we intended. If we want to build trust and create an opportunity for them to disclose the kind of information we need to hear, we need to be explicit. Instead, say:

"I am going to keep your information private because I know how important it is, and I need for you to know that this is a place to learn and it is worthy of your trust. I also need you to know that I would need to break privacy, because I would need to support you to get help, only under 3 conditions: if I was so worried about you that I thought your life was in danger, meaning that you were going to kill yourself or you were going to kill somebody else or if there was an adult that was abusing you in any way. Then I would need to get you help right away. But everything else, whether we are talking about stress or feelings or sadness, whether we are talking about drugs or sex -- that is stuff where I am going to honor your privacy so that this place is a safe place for you to move forward and for you to learn and to make wise decisions."

At the same time, we can share with them that we know that their parents are the most important people in their lives, and we don't want them to be angry at us when we suggest that we talk to their parents together. They are in control of that decision.

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