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Time Alone for Adolescents With Their Providers During Clinical Encounters: It Is Not That Simple!

      See Related Article on pgs. 280 and 357
      For 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 [
      • Elster AB
      • Kuznets NJ
      The American Medical Association Guidelines for Adolescent Preventive Services (GAPS): Recommendations and rationale.
      ,
      • Hagan J
      • Shaw JS
      • Duncan PM
      Bright futures: Guidelines for health supervision of infants, children and adolescents.
      ,
      • Ford C
      • English A
      • Sigman G
      Confidential health care for adolescents: Position paper of the Society for Adolescent Medicine.
      ]. 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. Many of us who have advocated for time alone in the clinical setting have based our advocacy on evidence for the importance of confidential care, but very little of the evidence behind the guidelines comes from the perspective of parents. We often equate confidentiality with time alone, but these may represent overlapping and yet separate phenomena. We do have documentation that some young people will forgo care and not disclose their risky behaviors to clinicians if they do not have access to confidential care [
      • Ford CA
      • Millstein SG
      • Halpern-Felsher BL
      • Irwin CE., Jr
      Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future care: A randomized control trial.
      ,
      • Ford CA
      • Bearman PS
      • Moody J
      Foregone health care among adolescents.
      ]. But we also have an emerging body of work that highlights the critical importance of family engagement in assisting adolescents with health over the second decade of life [
      • Kim BKE
      • Oesterle S
      • Catalano RF
      • Hawkins JD
      Change in protective factors across adolescent development.
      ]. The question for clinicians remains: how do we develop health care delivery systems that accommodate family interdependencies while also encouraging young people to assume increasing responsibility for their own health? In other words, how can we enable young people to thrive, but with support as needed?
      In the current issue of the Journal of Adolescent Health, two articles, both based on the rarely queried perspective of parents, further our understanding of the role that parents play in supporting time alone in clinical encounters [
      • Miller VA
      • Friedrich E
      • Garcia-Espana JF
      • et al.
      Adolescents spending time alone with pediatricians during routine visits: Perspectives of the parents.
      ,
      • Butler P
      • Middleman AB
      Protecting adolescent confidentiality: A response to one state's “Parents Bill of Rights”.
      ]. This work is critically important. The U.S. National Medical Expenditure Survey (MEPS) Data documents that only 33% of children over 12 years of age had any time alone with clinicians at their most recent healthcare visit over the past year [
      • Adams SH
      • Park MJ
      • Tweitmeyer L
      • et al.
      Increasing delivery of preventive services in adolescents and young adults: Does the preventive visit help?.
      ]. In this issue, Miller et al. report on parental perceptions of the importance of time alone. Most parents want their sons and daughters to have time alone with their provider, with 58% of them indicating that it was “a lot” important for their adolescents to meet alone with the pediatrician [
      • Miller VA
      • Friedrich E
      • Garcia-Espana JF
      • et al.
      Adolescents spending time alone with pediatricians during routine visits: Perspectives of the parents.
      ]. In addition, parents of males were far more likely than parents of females to endorse this high rating. Older age of patient and higher parental-perceived importance of time alone were independently associated with both time alone and amount of time alone. In a series of qualitative questions, parents identified a number of factors having to do with structural issues of the practice; clinician factors, such as cues from the parent and adolescent about whether to offer time alone; adolescent factors, such as anxiety and early adolescence; and parental factors, including preparing their son or daughter for the visit. These findings, from a practice where 79% of adolescents had some time alone, clearly represent a rare opportunity to understand the “time alone” construct from the perspective of the parents where it is the norm. It is not clear whether parents would support time alone in a practice where norms are more consistent with national attitudes toward confidential care for adolescents.
      Also in this issue, Butler and Middleman describe a study in which they sought parental input on the “Parents’ Bill of Rights” law, recently enacted in the state of Oklahoma [
      • Butler P
      • Middleman AB
      Protecting adolescent confidentiality: A response to one state's “Parents Bill of Rights”.
      ]. The law prohibits clinicians from providing conditional confidential pediatric care. In the study, parents were asked to waive their rights to be present for their child's physical examination, to be present for discussions of risk behaviors, and to consent to hormonal therapy, if indicated. Over 95% of the 269 parents presenting to the clinic waived their rights. These findings lend further support to the idea that families are committed to enabling their adolescents to obtain high quality care with their support and guidance. Similar to Miller et al., this study takes place in an uncommon clinical setting: a referral adolescent medicine practice at the University of Oklahoma.
      Two relatively recent studies, one by Gilbert et al. and another by the Unity Consortium, provide a more nuanced view of time alone from both adolescent and parental perspectives [
      • Gilbert AL
      • Rickert VI
      • Asalma MC
      Clinical conversations about health: The impact of confidentiality in preventive care.
      ,
      Unity Consortium
      Beliefs on adolescent health and vaccination: Results from a Unity U.S. Survey.
      ]. In Gilbert's work, 89% of parents believed adolescents should be able to speak with their providers alone, but 61% preferred to be in the examination room for the entire visit [
      • Gilbert AL
      • Rickert VI
      • Asalma MC
      Clinical conversations about health: The impact of confidentiality in preventive care.
      ]. In addition, adolescents reported comfort discussing a much broader range of topics—including nutrition, issues at home, sexual health, substance use, and mental health—with their provider when the visit was even partially confidential. These findings on confidential care support previous work and show that discussions are not limited to so-called “risky behaviors” [
      • Ford CA
      • Millstein SG
      • Halpern-Felsher BL
      • Irwin CE., Jr
      Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future care: A randomized control trial.
      ,
      • Ford CA
      • Bearman PS
      • Moody J
      Foregone health care among adolescents.
      ].
      A 2016 survey by the Unity Consortium brings further understanding of these divergent views. Adolescents, parents, and health care providers were queried about their attitudes toward adolescent preventive care, roles and responsibilities in adolescent health, and vaccinations [
      Unity Consortium
      Beliefs on adolescent health and vaccination: Results from a Unity U.S. Survey.
      ]. Parents and adolescents were not matched dyads in this survey. Sixty-one percent of adolescents reported that their parents were in the room for the full visit the last time they visited a heath care provider; parents reported that they were only present 49% of the time. When parents were in the room, 89% of teens felt it was reassuring and 53% of the parents insisted on being in the room for the entire visit. And yet, in spite this, 67% of parents, 84% of adolescents, and 97% of physicians thought it was important for the adolescent to have time to speak with the clinician alone. And when adolescents spent time alone with the provider, 78% of teens, 80% of parents, and 96% of physicians agreed that, “Spending time alone with the doctor makes me/teens feel more responsible for their health.” The survey also provides support for parental engagement, with only 40% of teens feeling comfortable without their parent in the room, 87% of adolescents wanted their parents engaged in decisions about their heath, and physicians stated that one-third of early adolescents and slightly over half of older adolescents are not engaged in the visit without their parents present.
      The approach to providing clinical care in the second decade of life appears to bit more nuanced than what our professional recommendations have outlined [
      • Elster AB
      • Kuznets NJ
      The American Medical Association Guidelines for Adolescent Preventive Services (GAPS): Recommendations and rationale.
      ,
      • Hagan J
      • Shaw JS
      • Duncan PM
      Bright futures: Guidelines for health supervision of infants, children and adolescents.
      ,
      • Ford C
      • English A
      • Sigman G
      Confidential health care for adolescents: Position paper of the Society for Adolescent Medicine.
      ]. First and foremost, we still need to develop systems that support some time alone for adolescents. Second, we need to articulate the way in which we develop systems for clinical care so that parents and adolescents can understand the guidelines and reasons for adding confidential care as they are entering adolescence. It may be helpful to clarify what constitutes confidential care, as Butler and Middleman did [
      • Butler P
      • Middleman AB
      Protecting adolescent confidentiality: A response to one state's “Parents Bill of Rights”.
      ]. In Miller et al., parents were overwhelmingly supportive of time alone when the practice was built around that concept, though we know that not all parents fully endorse the concept of time alone for the entire clinical encounter [
      • Miller VA
      • Friedrich E
      • Garcia-Espana JF
      • et al.
      Adolescents spending time alone with pediatricians during routine visits: Perspectives of the parents.
      ]. In Gilbert's article, parents endorsed time alone, but they also expressed interest in being in the room all the time; and adolescents reported that they were more likely to disclose information about a wide range of topics if the parents were not present [
      • Gilbert AL
      • Rickert VI
      • Asalma MC
      Clinical conversations about health: The impact of confidentiality in preventive care.
      ]. Finally, in the Unity survey, adolescents expressed much more desire for family engagement than previous work has demonstrated.
      Some of these results are clearly linked to how the questions are asked, who is being asked, and the sociodemographics of the population being studied. In Butler and Middleman's article, we see parents opting for confidential care that is focused on specific areas, including reproductive health. Perhaps, the message from all of this work is that we must find language that brings greater clarity to the foundations of adolescent care. “Adolescent-Centric and Family Engaged Care” places the adolescent in the center of care, but surrounds them with the support and guidance of the family. The most important factor is to increase the competence of our young people to make good choices about their health and well-being and to negotiate a very complicated health care system with the support of their families and communities [
      • Kim BKE
      • Oesterle S
      • Catalano RF
      • Hawkins JD
      Change in protective factors across adolescent development.
      ].

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