DR. GINSBURG is an associate professor of pediatrics, the Craig-Dalsimer Division of Adolescent Medicine, the Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine. He is also Health Services Director at Covenant House, a shelter for homeless youth in Philadelphia. He is the author of A Parent's Guide to Building Resilience in Children and Teens: Giving Your Child Roots and Wings, published by the American Academy of Pediatrics.
A starting point to effective communication is to take a positive view of our patients, because if we do so, they will be more likely to talk to us and to be receptive to our guidance.
If we focus only on negatives, we put up barriers to an effective relationship, which hurts our ability to engage adolescents in a health promoting process. The risk-based (let me explore what is wrong with you) approach engenders shame, and shame is a barrier to engagement. When teenagers are seen only in the context of their risk behaviors, they are embarrassed and resentful. Moreover, they are not inspired to change or to propel themselves forward equipped only with the knowledge that others think they are doing something wrong.
A first step in contemplating change is to have confidence in the potential to change. That confidence derives from an inherent sense of competence and is undermined by shame or being viewed as a failure. Adolescents live up to—or down to—our expectations of them. If you expect adolescents to have an "attitude," they will. On the other hand, when they know that the interviewer enjoys their thoughtfulness, they will open up and share their thoughts. Finally, adolescents want to be liked, just as we all do. They respond far better and listen more attentively to health messages that are given by someone who genuinely seems to care for and respect them.
Because nearly 80% of deaths among adolescents are related to risk behaviors, avoiding or reducing these behaviors should be a top priority in our clinical encounters. But as we incorporate a positive approach, we need to move beyond the risk-centered approach. Is our ultimate goal really to prevent adolescents from engaging in these behaviors? Or, is it to facilitate the development of youth well-prepared to be creative, responsible, and productive human beings?
If we define success for youth in terms of behaviors they avoid, rather than who they are, or what we hope they might accomplish, we perpetuate lower expectations for them. Imagine if a 17-year-old girl hoping to volunteer in your practice was introduced to you in this manner: "Here's Anna, she's not pregnant, not drug addicted, not depressed, not engaged in violence or self-mutilation, and she's even not sexually active! May she work here?" You would certainly ask, "Who is she, how will she add to the office, what are her capabilities and strengths?"
We must never consider it adequate for our patients to be risk-free; we must search for and promote their strengths. We must hold them to high expectations to reinforce our message that they have the potential of success. Advocates of youth development and resiliency believe that a positive, strength-based approach will produce more successful youth and deserves full consideration as a means to reduce risk.
Setting the stage
To see the best in our adolescent patients, we need to first create a setting in which they are comfortable revealing their thoughts and complex emotions. Adolescents sometimes withhold information or give monosyllabic responses because they are suspicious and self-protective. This creates a barrier to engagement, because we learn from experience that our attempts at connection may be futile. However, we should not expect anybody, including our teenage patients, to reveal himself (herself) unless he grasps both the benefit of doing so and the safety of the setting.