Abstract
Purpose
To increase understanding of parental perspectives on time alone and of factors that influence adolescent communication with physicians in a pediatric clinic.
Methods
The sample consisted of 91 parents of adolescents aged 14–17 years who attended a well child visit at one primary care pediatric practice and completed a 2-week follow-up phone call as part of a larger study on adolescent health and communication. Parents reported whether their child met alone with the pediatrician, rated the importance of him or her having time alone with the physician, and responded to open-ended questions regarding barriers and facilitators of adolescent-physician communication. Bivariate and multivariate analyses tested associations of parent and adolescent characteristics with perceived parental importance of time alone. We conducted content analyses of responses to open-ended questions.
Results
Slightly more than half of parents (n = 53, 58%) indicated that it was “a lot” important for their adolescents to meet alone with the pediatrician; parents of males were more likely than parents of females to select this highest rating (73% vs. 43%, χ2(1) = 8.34, p = .004; adjusted odds ratio 4.88, 95% confidence interval 1.84–12.96). Responses to open-ended questions identified numerous adolescent, parent, and provider factors that parents perceived to influence adolescent-physician communication during well child visits, such as preparation for visit, rapport and familiarity with the pediatrician, privacy concerns, time alone with the pediatrician, emotional comfort, trust, and support.
Conclusions
Most parents thought time alone was highly important for their own adolescent in a primary care setting, and parents described additional strategies to facilitate adolescent communication.
Keywords
See Related Editorial on p. 265
Implications and Contribution
The majority of parents perceived time alone for their own adolescent in a pediatric setting as important, and described multiple additional adolescent, parent, and provider factors that may influence adolescent communication with physicians during well child visits. Future research is needed to reduce barriers to time alone and to enhance communication.
Professional organizations have supported developmentally appropriate confidential adolescent health care within ethical and legal guidelines for more than 25 years [
1
, 2
, 3
, 4
]. The rationale for adolescents having access to time alone with physicians includes supporting adolescents' emerging autonomy, facilitating the development of the adolescents' skills to manage their own health, and increasing physician-adolescent communication about sensitive health topics [[5]
]. Research has shown that adolescents are more likely to seek health care and openly talk to physicians when they are assured of privacy, particularly for issues related to sexual behaviors, substance use, and mental health [6
, 7
, 8
].Despite recommendations, less than half of adolescents report time alone with clinicians during preventive visits [
8
, 9
]. Managing parental expectations is one challenge that clinicians face with respect to time alone with adolescents, particularly in primary care settings [[10]
]. Prior research on parental perspectives regarding confidential adolescent health care has found that parents have conflicting attitudes. For example, in a nationally representative survey in the United States, 61% of parents of adolescents 13–17 years old preferred to be in the examination room the entire time their adolescent was being seen for a preventive visit; at the same time, 89% of parents believed that adolescents should be able to speak alone with providers [[8]
]. Another study found that parents were able to identify benefits associated with confidential care yet also believed they should be informed about a wide range of topics, even if their children did not want them to know [[11]
]. One qualitative study found that mothers had substantial concerns about clinicians having confidential discussions about sex with their daughters [[12]
].Recommendations for time alone must be placed within a broader context that recognizes the rationale for supporting multiple strategies for facilitating adolescent-physician communication. Effective communication with adolescents is important with respect to visit satisfaction [
[13]
], adherence to treatment recommendations [14
, 15
], perceptions of control and competence [[16]
], and decisions to seek future health care [[17]
]. However, communicating with adolescents may be challenging for multiple reasons, including perceived adolescent lack of interest [[18]
], a longstanding pattern of parents as the primary focus of communication [[18]
], and physician self-efficacy regarding effectively engaging adolescents [[18]
].Most adolescents are seen for preventive care in primary care clinics, with parents present, and efforts to improve population-based adolescent health through clinical service delivery must include efforts to assure high-quality adolescent-physician communication and developmentally appropriate confidential care [
[19]
]. To date, parent-focused research on this topic has been conducted outside of the clinical context or in highly specialized clinics [8
, 9
, 11
, 20
]; the few pertinent studies in primary care settings have involved focus groups and were not conducted in the context of actual well-child care [[12]
]. As part of a larger study on parent-teen communication and adolescent health, we explored parents' perspectives of their own adolescents spending time alone with pediatricians in a primary care practice as part of routine well child visits (WCVs). Our goals were to examine (1) whether time alone and perceived importance of time alone were associated with the adolescents' age, race, and sex and parental education; (2) parents' perceptions of factors that hinder or facilitate their adolescent's communication with the pediatrician during WCVs.Methods
Overview
This study used data from a randomized controlled trial (NCT02554682) examining a parent-directed intervention to improve parent-adolescent communication about sexual health, alcohol use, or teen driving in adolescents aged 14–17 years. Specifically, participants in Arm 1 were ages 14–15 years old and were randomly assigned to receive usual care (control), the sexual health intervention, or the alcohol intervention. Participants in Arm 2 were ages 16–17 years and planning to apply for their driver's permit; these participants were randomized to receive usual care (control) or the teen driving intervention. All intervention participants received a general handbook related to adolescent development and parent-adolescent communication, as well as materials specific to their intervention group. Intervention content did not focus on confidential care or physician discussion of sensitive health topics with adolescents. For this analysis, we used 2-week follow-up data collected from parents who were assigned to one of the intervention groups.
Recruitment and participants
Participants were recruited from January 2016 to September 2016 from one urban primary care practice in the Pediatrics Research Consortium at Children's Hospital of Philadelphia (CHOP). The practice has 13,411 enrolled patients (7,201 [54%] ages 0–9 and 6,210 [46%] ages 10+) and provided 27,635 visits in the last year (13,207 [48%] WCVs and 14,428 [52%] acute visits). Providers see 11–12 patients per half-day clinic session and are allotted 15 minutes for WCVs. Eligible participants included adolescents between 14 and 17 years with a scheduled WCV, identified from CHOP's electronic medical record system, and one parent or legal guardian. Adolescents who were pregnant, were not an established patient, or had a developmental delay or pervasive developmental disorder that would prevent him or her from completing study procedures were ineligible. Letters were mailed to parents 1–2 months before the scheduled WCV and directed parents to contact the study team. Phone calls were placed to all parents who did not contact the study team.
A total of 425 parent-adolescent dyads were contacted and screened. Of these, 188 (44%) did not meet eligibility criteria, 26 (6%) declined, and 37 (9%) could not be scheduled or reached again. The final enrolled sample consisted of 174 participant dyads. A comparison of this sample with those who were contacted but did not participate showed that they did not differ with respect to adolescent age, sex, race, or ethnicity (ps > .10). Of the 174 enrolled dyads, 108 were assigned to one of the intervention groups and eligible to complete the 2-week follow-up (parents in the control groups did not complete the 2-week follow-up assessment). Of these, 91 (84%) parents completed the follow-up. Those who completed the 2-week follow-up were not different from those who did not with respect to intervention arm or adolescent age, sex, race, or ethnicity (ps > .10).
Procedures
The institutional review board at CHOP approved the study protocol. During the recruitment call, study personnel explained the study to the parent and adolescent, and obtained parental consent and adolescent assent. Dyads were randomized into study groups, completed a baseline assessment, and attended the adolescent's WCV. For the present analysis, we focused on data obtained from parents at the 2-week follow-up call. Responses were entered directly into Research Electronic Data Capture [
[21]
], a secure, web-based application designed to support research data capture. Parents received $5 for completing the 2-week follow-up.Measures
At baseline, parents completed a demographic questionnaire that assessed parent age, sex, race, ethnicity, marital status, and highest level of education. Adolescents also completed a demographic questionnaire that assessed sex at birth, race, and ethnicity.
At the 2-week follow-up, parents indicated whether the adolescent met alone with the pediatrician during the prior WCV (yes/no), and if yes, for how long (write-in). Parents also responded to one item assessing how important they think it is for their adolescent to meet alone with the pediatrician during WCVs. Responses were selected from a four-point Likert-like scale (not at all, a little bit, quite a bit, a lot). For analyses, response categories were collapsed into the lowest rating (not at all), intermediate ratings (a little bit or quite a bit), and the highest rating (a lot) based on the conceptual differences. Finally, parents responded to two open-ended questions: “What makes it hard for your teen to talk to the doctor during clinic visits?” and “What might make it easier for your teen to talk to the doctor during clinic visits?” Initial responses were recorded by the interviewer. Prompts were only used to clarify participant responses.
Data analytic plan
We used ordinal logistic regression to examine bivariate associations of perceived importance of time alone with adolescent sex, age, race (white vs. non-white), parental education (college degree or more vs. others), parental age, parental sex, parental marital status (married vs. others), and intervention arm. In all analyses age was entered as a continuous variable; for ease of presentation in tables, age is presented as a categorical variable. There were no significant differences in perceived importance by intervention arm, so participants from different arms were collapsed for analyses. We also evaluated the association between perceived importance of time alone and actual time, in minutes, spent alone in WCV.
Demographic factors associated with perceived importance of time alone at the p ≤ .20 level, as well as time spent alone (p = .002), were retained for multivariate analyses. Multivariable ordinal logistic regression was used to estimate ordinal odds ratios (OR) with 95% confidence intervals (CI) for associations with perceived importance of time alone. The model met the proportionality of odds assumption (score test for the multivariable proportional odds assumption: chi-square = 8.26; df 5; p = .142).
We conducted a post hoc analysis evaluating associations of parents' perceived importance of time alone and amount of reported time spent alone in minutes. A multivariable negative binomial model, to account for the number of excess zeros, was fitted to the time (in minutes) that adolescents talked alone with their health-care providers. Teens who did not meet alone with their health-care providers were coded as zeros (0). Independent variables selected via bivariate analyses were teen age, teen sex, and perceived importance of time alone. Because parents valued time alone more for their sons than their daughters, an interaction between child gender and parent perceived importance of time alone was included.
Using conventional content analysis [
[22]
], two research personnel independently read all participant responses to the open-ended items, identified overarching themes, and developed a coding scheme. Codes were then independently assigned to each response, and discrepant coding was discussed between the two coders until consensus was reached. For five responses, consensus could not be reached, and the first author made the final decision. We then summarized the frequencies and percentages for each code.Results
Descriptive findings
Demographic characteristics of the 91 parent-adolescent dyads with 2-week follow-up data are shown in Table 1. One-half of adolescents were female (n = 46, 51%), and almost all parents were female (n = 88, 97%). Participant race reflected that of the practice (62% black, 31% white, 8% other). Most parents were married (n = 63, 69%) and had at least a 4-year educational degree (n = 66, 72%).
Table 1Participant demographics (N = 91 dyads)
| n (%) | |
|---|---|
| Adolescent age (y) | |
| 14–15 | 67 (74) |
| 16–17 | 24 (26) |
| Adolescent sex | |
| Female | 46 (51) |
| Adolescent race | |
| Black | 56 (62) |
| White | 28 (31) |
| Other | 7 (8) |
| Parent age (y) | |
| 30–40 | 22 (24) |
| 41–50 | 43 (47) |
| 51–71 | 26 (29) |
| Parent sex | |
| Female | 88 (97) |
| Parent marital status | |
| Married | 63 (69) |
| Never married | 9 (10) |
| Divorced | 8 (9) |
| Separated | 5 (6) |
| Living with partner | 3 (3) |
| Refused | 2 (2) |
| Widowed | 1 (1) |
| Parent educational attainment | |
| High school/GED | 6 (7) |
| Some college/Associates | 19 (21) |
| Four-year degree | 26 (29) |
| Master's degree | 35 (38) |
| Doctoral degree | 5 (5) |
The majority of parents (n = 78, 86%) reported that their adolescents had time alone for part of the WCV. Duration of time alone ranged from 5 to 30 minutes (M = 12.7, SD = 6.4). More than half of parents (n = 53, 58%) indicated that it was “a lot” important for their adolescent to meet alone with the pediatrician; 27% (n = 25) indicated that it was “quite a bit” important, 8% (N = 7) indicated that it was “a little bit” important, and 7% (n = 6) indicated it was “not at all” important. Among the 15 parents of teens who did not spend time alone with a pediatrician, four (27%) reported it was “a lot” important and six (40%) reported it was “quite a bit or a little important” for their teen to spend time alone with a pediatrician.
Associations with perceived importance of time alone
Relationships between parental perceptions of the importance of time alone, adolescent and parent sociodemographic factors, and time spent alone are shown in Table 2. In bivariate analyses, parents of male adolescents reported significantly higher ratings of level of importance of time alone as compared with parents of female adolescents (p = .001), and parents of adolescents who spent increasing amounts of time alone with a provider reported significantly higher ratings of importance of time alone as compared with parents of adolescents who spent less or no time alone (p = .002). Married parents reported higher levels of importance of time alone, but this did not reach standard thresholds for statistical significance (p = .07). Adolescent age, race, parent age, parent sex, and parental education were not associated with reported parental importance of time alone.
Table 2Associations between parental perceptions of the importance of time alone, adolescent and parent sociodemographic factors, and time spent alone (N = 91 dyads)
| How important is it for your adolescent to meet alone with the pediatrician during well child visits (WCVs)? | ||||||
|---|---|---|---|---|---|---|
| A lot | Quite a bit/A little bit | Not at all | p | Adjusted OR [95% CI] | p | |
| Overall | 53 (58.2%) | 32 (35.2%) | 6 (6.6%) | |||
| Adolescent | ||||||
| Age | ||||||
| 14–15 | 40 (59.7%) | 22 (32.8%) | 5 (7.5%) | .691 | ||
| 16–17 | 13 (54.2%) | 10 (41.7%) | 1 (4.2%) | |||
| Sex | ||||||
| Female | 20 (43.5%) | 20 (43.5%) | 6 (13.0%) | .001 | Reference | |
| Male | 33 (73.3%) | 12 (26.7%) | 0 (0%) | 4.88 (1.84–12.96) | .001 | |
| Race | ||||||
| White | 20 (71.4%) | 6 (21.4%) | 2 (7.1%) | .122 | Reference | |
| Non-white | 33 (52.4%) | 26 (41.3%) | 4 (6.4%) | .83 (.27–2.62) | .756 | |
| Parent | ||||||
| Education | ||||||
| <college | 14 (56.0%) | 10 (40.0%) | 1 (4.0%) | .908 | ||
| ≥college | 39 (59.1%) | 22 (33.3%) | 5 (7.6%) | |||
| Age | ||||||
| <46 | 20 (46.5%) | 19 (44.2%) | 4 (9.3%) | .147 | 1.05 (.98–1.12) | .151 |
| ≥46 | 33 (68.8%) | 13 (27.1%) | 2 (4.2%) | |||
| Sex | ||||||
| Male | 2 (66.7%) | 1 (33.3%) | 0 (0%) | .723 | ||
| Female | 51 (58.0%) | 31 (35.2%) | 6 (6.8%) | |||
| Marital Status | ||||||
| Married | 41 (65.1%) | 18 (28.6%) | 4 (6.4%) | .072 | 3.60 (1.24–10.47) | .018 |
| Other | 12 (42.9%) | 4 (50.0%) | 2 (7.1%) | Reference | ||
| Teen time alone in WCV (min) | ||||||
| 0 | 4 (26.7%) | 6 (40.0%) | 5 (33.3%) | .002 | 1.13 (1.05–1.21) | .001 |
| <10 | 16 (43.2%) | 15 (40.5%) | 6 (16.2%) | |||
| ≥10 | 37 (68.5%) | 17 (31.5%) | 0 (0%) | |||
a Age presented as categorical variable for ease of presentation in table; in analyses age and time spent alone are included as a continuous variable.
b Results of multivariate analyses controlling for variables significant at p ≤ .20 in bivariate analyses, presented as adjusted odds ratios with 95% confidence intervals.
In multivariate analyses (Table 2), parents of male adolescents (aOR [95% CI]: 4.88 [1.84–12.96]; p = .001) and married parents (aOR [95% CI]: 3.60 [1.24–10.47]; p = .018) were more likely to endorse a higher importance of time alone. Amount of time the adolescent spent alone with a provider during the WCV was positively associated with higher perceived importance of time alone (aOR [95% CI]: 1.13 [1.05–1.21]; p = .001).
Post hoc analyses exploring adolescent sex, parent perceptions, and time spent alone
Factors independently associated with amount of time alone were older age (aOR [95% CI]: 1.20 [1.02–1.41]; p = .025) and higher parent-perceived importance of time alone (OR [95% CI]: 1.72 [1.24–2.39]; p = .001). Teen sex was not associated with amount of time alone (aOR [95% CI]: 1.06 [.74–1.52]; p = .740). In addition, the interaction between parent-perceived importance of time alone and teen sex was not statistically significant (Wald chi-square = .93; p = .331). There were no significant differences in amount of time spent alone with the provider based on race or parental education.
Barriers and facilitators of adolescent communication during WCVs
In response to the question, “What makes it hard for your teen to talk to the doctor during clinic visits?” 91 parents provided 99 responses. The most frequent response was “It's not hard” (n = 36, 36%). The remaining responses were categorized into adolescent, parent, and provider factors. Adolescent factors included the adolescent not wanting to speak up because of being shy or embarrassed (n = 29, 29%) [“He doesn't engage much with other adults”; “He's not a talker and is an introvert”]; concerns about disclosing information to the doctor (n = 6, 6%) [“If she doesn't want to share information”; “He may not want to talk about his problems”]; fear of disapproval or judgment (n = 2, 2%) [“Fear of disapproval by adults”]; and vulnerability when undressed (n = 1, 1%) [“She feels uncomfortable when she isn't dressed and is wearing a paper gown”]. There was only one parent factor, which was parental presence (n = 10, 10%) [“If I'm in the room, can't be open and honest”; “Doesn't want me overhearing things-he's older now”]. Provider factors included poor rapport or unfamiliarity with the pediatrician (n = 11, 11%) [“He doesn't really know the doctor”; “Not comfortable because he doesn't see her all the time”] and sex (n = 4, 4%) [“Female gender of doctor might make it hard”].
In response to the question, “What might make it easier for your teen to talk to the doctor during clinic visits?” 90 parents provided 102 responses. The most frequent response was “It's not hard” (n = 25, 25%). Adolescent patient factors included their preparation for the visit (n = 6, 6%) [“Preparation and knowing things she should be asking doctor”; “Write down what he wants to talk to his doctor about before their appointment”]; personality (n = 1, 1%) [“His comfort with people in general”]; and development (n = 3, 3%) [“Understand that she is responsible for herself”]. Parent factors included parental support (n = 12, 12%), which encompassed responses indicating that parental presence during at least part of the visit was helpful [“Might feel I should be there to initiate conversations”; “If I'm present it makes it easier for him to talk”], as well as discussing the visit with the adolescent in advance and encouraging the adolescent to speak up and ask questions. Provider factors included pediatrician support or communication (n = 19, 19%). Specific responses related to pediatrician support or communication included initiating discussion of specific topics and asking the adolescent questions [“He will talk if he's asked questions”; “Easier if the doctor brought up topics”; “Structured way to have conversations so he doesn't have to bring up uncomfortable topics”] and reassuring adolescent patients that it is okay to speak up [“Doctor letting her know that she is free to say whatever without feeling judged or uncomfortable”]. Other provider factors noted by parents included good rapport and familiarity with pediatrician (n = 18, 18%) [“Same doctor his whole life”; “Knowing the doctor, she feels comfortable with her”], time alone with the pediatrician was helpful (n = 11, 11%) [“It is easier when the doctor talks to the teen one-on-one”], and sex or age of the pediatrician (n = 5, 5%) [“Having a younger doctor-smaller age difference”]. Two additional characteristics that we thought were reflective of the health-care system or specific practice were mentioned: not feeling rushed (n = 1, 1%) and having teen-directed materials in the room (n = 1, 1%).
Discussion
In this primary care pediatric practice, the majority of parents perceived that adolescent time alone with the pediatrician was important. Because physicians may rely on cues from the adolescent or parent when deciding whether to include time alone as part of the WCV [
[10]
], parental attitudes about physicians generally, and time alone specifically, may impact whether adolescents are given time alone with the pediatrician. Nonetheless, 7% of parents rated time alone as not at all important. Potential reasons for low perceived importance include parental worry about topics addressed by pediatricians during time alone, the perception that the adolescent is too young or not mature enough to engage in independent communication with the pediatrician, and discomfort with no longer being the primary focus of communication [[10]
].Parents of male adolescents were more likely than parents of female adolescents to indicate that time alone with the pediatrician was highly important. This finding is consistent with prior qualitative research that found that mothers of adolescent females, but not males, expressed significant uneasiness with confidential care, especially related to provision of developmentally appropriate information related to sexual topics [
12
, 23
]. It is also consistent with national survey results showing male adolescents are more likely to receive time alone during preventive visits than female adolescents [[9]
]. One strategy to address such concerns would be to provide parents with anticipatory guidance regarding the purpose and nature of confidential care, which may enhance parental comfort with time alone, especially for parents of females [[12]
]. Of note, in our post hoc analyses we did not find a significant difference in whether boys or girls actually spent time alone with providers, or the amount of time spent alone, suggesting that factors in addition to parental perceptions of importance of private time based on sex contribute to behaviors in actual clinic settings.Parental responses to the questions about adolescent-physician communication focused on provider, adolescent, and parent factors, and highlighted that efforts to support communication should go beyond an exclusive focus on time alone. The provider factors, including establishing trust with adolescent patients and asking questions to facilitate dialogue, are consistent with prior research [
13
, 17
]. Some adolescent factors mentioned by parents (e.g., adolescent concern about disclosing, fear of judgment, lack of previsit preparation) underscore the importance of adequate education and guidance of adolescents regarding the adolescent-physician relationship, communication skills, and confidential health care. With respect to parental factors, some parents noted that parental presence could inhibit adolescent-physician communication, whereas others indicated that parental presence facilitated adolescents' willingness to speak up. Parental presence during the initial part of the visit might be used to facilitate adolescent comfort with open communication with physicians when they have time alone. Other aspects of parental support noted by parents included preparing the adolescent in advance of the visit and encouraging the adolescent to ask questions. These results underscore that parents have an important role to play in guiding and supporting effective adolescent-physician communication [[24]
].Taken together, our results suggest that ensuring that adolescents receive time alone and effectively communicate with clinicians will require a multilevel approach. Strategies need to address structural issues to providing time alone (time constraints or competing demands), which appear to have been successful in this busy pediatric practice. Strategies are also needed to take into account clinician (e.g., reliance of cues from the adolescent or parent when deciding whether to include time alone), adolescent (e.g., anxiety about talking to clinician alone), and parent (e.g., preparation of adolescent) factors. Additional research is needed to identify the interplay of factors that drives adolescent time alone, as well as strategies to generally enhance effective patient-physician communication.
There are several important limitations to this study, including that participants were primarily mothers from one practice. The findings may not be generalizable to other or larger populations, including parents from other settings or to fathers. Participants were primarily African-American or Caucasian and highly educated. The findings are not generalizable to Hispanic adolescents, who are less likely to get time alone than adolescents from other ethnic groups [
9
, 25
]. Similarly, our participants agreed to enroll in an intervention study related to parent-adolescent communication about health and safety issues and may have been especially likely to place importance on communication. Furthermore, we did not examine adolescent or physician perceptions, which are critical for understanding barriers to and facilitators of both time alone and effective physician-adolescent communication.Despite limitations, this study contributes to the literature by demonstrating that the majority of parents thought time alone was important for their own adolescent in a pediatric primary care practice, and these perceptions were associated with adolescent sex. The findings also suggest that parents may have an important role in facilitating increased adolescent-physician communication. Further research exploring the role of parents in facilitating increased adolescent-physician communication during adolescent preventive visits would be valuable to future interventions.
Acknowledgments
The authors have no conflicts of interest to disclose in relation to this research. This study was funded by The University of Pennsylvania Perelman School of Medicine Department of Pediatrics and The Children's Hospital of Philadelphia. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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Article info
Publication history
Published online: June 07, 2018
Accepted:
January 17,
2018
Received:
May 25,
2017
Footnotes
The authors acknowledge The Children's Hospital of Philadelphia Pediatric Research Consortium (PeRC) and The Children's Hospital of Philadelphia Care Network—Chestnut Hill Practice for their contributions to this project.
Identification
Copyright
© 2018 Society for Adolescent Health and Medicine. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Time Alone for Adolescents With Their Providers During Clinical Encounters: It Is Not That Simple!Journal of Adolescent HealthVol. 63Issue 3
- PreviewFor over two decades, professional organizations have made a strong case for confidential care in adolescents, including time alone without parents or guardians present during at least part of the clinical encounter [1–3]. The premise behind these recommendations was twofold: first, adolescents would be more likely to seek care and disclose risky behaviors such as sexual activity and substance use, and second, adolescents would begin to become more engaged in their own health care, assume increased responsibility for their care, and enter the third decade of life with more competence in health care decision making.
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