1With contributions from David Sorenson, M.D., and Alan Lyman, M.D.
Essential Concepts
Don’t laugh at a youth for his affectations; he is only trying on one face after another to find his own.
Logan Pearsall Smith
There are three reasons to include a chapter on adolescents in a book otherwise devoted to adult psychopathology: (a) Child and adolescent treatment is a part of most general training programs; (b) many primarily “adult” clinicians are called on to evaluate adolescents; and (c) many “adult” patients are still struggling through late adolescence, which begins during the later teen years and extends to the early 20s. If you can master the techniques of evaluating adolescents, you will find yourself using these same techniques for many of your adult patients, of any age.
Your initial interview with an adolescent will usually include family members for at least part of, and sometimes all of, the session. Adolescents are great minimizers and deniers, and you often will need to interview the family separately to ascertain the presence of any problem at all. In addition, many psychiatric disorders in adolescents are strongly related to family issues, with family dynamics sometimes contributing significantly to them (e.g., oppositional defiant disorder, depression) and at other times being the cause of family strife (e.g., attention deficit hyperactivity disorder [ADHD]). Finally, treatment can rarely happen without the consent and cooperation of family members.
Thus, for the first appointment, plan to invite the entire family into your office. Usually, I walk out to the waiting room and greet the patient with an introduction and handshake and then face the family, saying, “Why don’t we all go in for the first part of the hour, then maybe I can have some time to chat with _____ afterward.”
Once in the office, allow the family to decide where to sit, and then shut up and listen for a while, just as you would with your adult patients. If there is some initial silence, you can get things going with questions such as
What brings us all together today?
What sort of issues have been coming up?
or, more simply,
Okay, who wants to do the talking?
A parent usually begins, and it is important that you listen closely, because a family’s desires may be quite different from what you suspected or from what you can provide.
CLINICAL VIGNETTE
Two parents brought in their 17-year-old son for an evaluation. Once in the office, the mother’s first words were, “I want you to commit my son for his drug addiction.”
The son, taken aback, turned to her and said, “Are you crazy?”
What developed was that the parents had suspected the son of drug use but had told him that this was a family therapy meeting to “work out some family issues.” The mother’s expectation was that the clinician would immediately have a police officer escort the patient from the office to a substance abuse treatment facility. The clinician explained that this was not possible and went on to explain the state’s legal criteria for involuntary commitment. Eventually, the adolescent agreed to outpatient treatment of substance abuse and depression.
Allow at least 5 minutes of free speech, in which you simply listen to family members discussing the perceived problem. Aside from clueing you into diagnostic possibilities, this will allow you to understand the communication style and family dynamics. After listening for a few minutes, you will want to jump in with various questions to ascertain elements of the psychiatric and social history. It is important to adopt a neutral attitude so as not to appear that you are taking the parents’ side. If the parents constantly speak over the patient (or vice versa), make a corrective comment, such as
Everyone obviously has a lot of feelings about this issue, but it is important that I get a chance to hear everyone’s viewpoint without too much interrupting.
After a period of time, you will want to talk to the adolescent alone.
I enjoyed meeting you, and now, I’d like to talk about some things with Matthew. Afterward, we’ll get back together and discuss what we’ve talked about.
How much time should you devote to the individual interview? There are no hard-and-fast rules. A full hour of individual discussion may be appropriate for a sensitive and sophisticated 14-year-old adolescent with depression, whereas an angry and involuntary 17-year-old adolescent with conduct disorder may be able to tolerate no more than 5 minutes alone with you. The more verbal and engaged the patient seems, the more time you will want to allot for your individual interview with her.
So there you are, in the room alone with your adolescent patient. Clinicians who spend most of their time with adults often freeze at this point. What do you say to a 15-year-old, who may feel quite awkward and embarrassed, especially now that his parents have left the room?
You want to avoid awkward gaps in the conversation as much as possible, which may involve doing more talking than you normally do. Some degree of self-disclosure may be acceptable too, to build rapport. You can start with some tension-relieving statements such as:
Okay. Now I get to hear your side of the story.
We have a half hour or so to talk confidentially now. I hope you’ll feel comfortable telling me your side of what’s been going on at home.
If the family discussion was heated, react to that in some way:
Whew, things got pretty hot there; what do you think?
Remember that adolescents may have had no prior experience with a professional who asks very personal questions. Thus, it may be helpful to begin with a comment such as
Do you mind if I ask you some personal questions?
I may ask some questions that you’re uncomfortable answering, and you don’t have to answer if you don’t want to.
At some point during the interview, say something about the limits of confidentiality. Relay the statement with terms such as “worry”:
I won’t tell your parents about anything you say unless I’m really worried that your life might be in danger.
Later, before you bring the family back in, ask
Is there anything you don’t want me to tell your parents?
Is it okay if I tell your parents about these things?
If they say “yes,” follow up with
Do you want to tell them or do you want me to?
This way, you’re maximizing your patient’s sense of control.
Adolescents tend to have difficulty describing their internal emotional state. Sometimes, this is because they don’t want to seem vulnerable; other times it’s because their emotional vocabulary is underdeveloped. Thus, asking direct questions about feelings is likely to lead to the following type of exchange:
Interviewer: Have you been feeling depressed?
Patient: I don’t know.
Interviewer: Have you been feeling angry?
Patient: I don’t know.
Interviewer: How have you been feeling?
Patient: Okay, I guess.
How does one get beyond the “I don’t know” syndrome? One way is to give the patient permission to plead the fifth:
Look, if you really don’t know something, that’s fine. But if you don’t want to tell me something, that’s okay too. Just say, “I don’t want to say.”
Another strategy is to ask the “fly on the wall” question:
If I were a fly on the wall when you get into one of your moods, what would I see?
or, a slight variation,
What would your friend look like if he looked like you in one of your moods?
These questions invite the patient to describe his behavior, a less threatening proposition than describing a subjective state.
A third strategy is to rely on the defense mechanism of displacement. Ask your patient if he has any friends with problems:
Do you have any friends who are in trouble? What’s going on with them?
This might lead into an elaborate discussion of a friend’s antisocial or suicidal behavior, which may actually be autobiographical.
Often, the trick with adolescents is to get them talking, much less getting them to reveal personal information. The best strategy is to adopt an attitude of curiosity and respect; a sense of humor is always a plus.
Most adolescents are interested in music, so this is as good a place to start as any.
Do you like music? Who do you like?
Chances are that you will have never heard of their favorite group. You could respond with
I have no idea what kind of music that is. Me, I like jazz and, I’m ashamed to admit, Barry Manilow.
If you’re square and goofy, and most of us over 30 are, admit it. This is disarming to most adolescents and is better than trying to pose as “cool.”
Other questions that help open up a shut-down adolescent include questions about school, friends, and interests. Each line of inquiry can also serve as a jumping-off point for diagnostic questions.
Where do you go to school?
What’s that school like?
Is it fun?
Is it easy?
What are the other kids like there?
Who do you hang out with?
After asking these nonthreatening questions, ask about grades. If his grades are low or if he looks disappointed in his grades, follow up with
Is that the same as you’ve always done, or have your grades changed recently?
A change in grades may signal the onset of depression or involvement with substance abuse. You might also ask
Are there any particular subjects that are hard?
The DSM-5 classifies learning disorders under the traditional categories of reading, writing, and arithmetic, and you can pick up a hint of a learning disorder by asking this question. However, children are usually diagnosed with a learning disability long before their teenage years.
What do you do with your time after school?
Are you involved in any extracurricular activities, like sports or clubs?
What do you enjoy doing the most?
Besides being good questions for opening up your patient and establishing rapport, these are good screening questions for depression. Withdrawal from social activities is a common feature of teenage depression. Conversely, the patient who expresses clear interest and excitement in any activity is less likely to be depressed.
How many hours of TV do you watch on the average school night?
How many hours do you spend on the computer?
This gives another indication of how socially involved your patient is.
Using the techniques discussed in Chapter 4 is helpful in communicating a nonjudgmental attitude when asking about drug use. Thus, you can use normalization:
I hear there’s a lot of drinking and drug use at your school. Do you know anyone who uses drugs?
You read in the paper that 90% of kids use drugs these days. Do you ever use drugs?
or symptom expectation:
How often do you have a drink?
What drugs do you use?
Other patients respond quite well to a direct query:
Do you drink or use drugs?
Although asking about sex is important when interviewing adolescents, use judgment and common sense in determining when such questions are appropriate. If your rapport is shaky, you may want to delay such questions for follow-up visits, or you may decide not to raise the questions at all. It’s vitally important that any questions about sex not be seen by your patient as idle or lurid interest, but rather that they are seen as an essential component of your psychiatric evaluation. A sexual history is important for a variety of psychiatric and medical issues, including assessing risk for AIDS, discovering a history of sexual abuse, and assessing the presence of sexual acting-out as a symptom of depression, mania, substance abuse, or other disorder.
A good way to approach this uncomfortable topic is to begin talking about “romance” rather than “sex.”
Do you have any romantic relationships?
How long have you been seeing this person?
What’s his/her name?
What do you like about_____?
Now that you’ve given a human face to the relationship, you can introduce the topic of sex:
Would you feel comfortable if we talked about your sex life?
Are you sexually active?
Are you using protection?
Do you know about AIDS?
Do you ever do things sexually that you later regret, like not using protection or having sex with people you don’t know very well?
You can also approach sexuality by embedding it in a list of health-related questions:
I want to ask a few questions about your health:
Do you get headaches?
Stomachaches?
Do you have sexual problems?
Are you sexually active?
Do you smoke?
Do you use drugs or alcohol?
If it seems appropriate, ask about sexual orientation:
Have you ever wondered whether your sexual feelings are normal?
Do you ever think that your feelings about sex are different from other kids’ feelings?
Note that neither of these questions uses terms such as sexual orientation and sexual identity, either of which may confuse or alienate adolescents.
Conduct disorder and oppositional defiant disorder are common reasons for referral, and you’ll often be faced with the task of getting patients to admit to illegal behavior. Usually, the parents will have disclosed such behavior during the family meeting. A good way to begin a private interview in such circumstances is as follows:
It looks like your mom feels there’s been a lot of stealing (or whatever alleged behavior), and I have no way of knowing if it’s true, but if you were stealing, I’m sure there was a good reason for it. Maybe it was the only way you could get something? Or maybe your friends challenged you to do it?
or, more simply,
Do you know what your parents are saying about what you’ve been doing?
If the rapport is good, and you don’t mind using some humor, use the “inducing to brag” approach:
So, I hear you’re an excellent thief. What’s the best thing you’ve stolen?
Remember that you aren’t asking these questions just to get your patient to confess to bad behaviors; rather, you’re primarily interested in finding out why he does these things. Is it peer pressure? A way of expressing anger toward his parents? A symptom of a manic episode? Follow up on an admission of antisocial behaviors with questions designed to address these topics.