Background

Most adult health problems have their origins in childhood or adolescence. Numerous sources, such as the CDC Youth Risk Behavioral Survey, the Monitoring the Future survey, the National Longitudinal Study of Adolescent Health, the Growing Up Today Study, and the Commonwealth Fund Surveys of youth, have documented high levels of intentional and non–intentional injuries, depression, substance abuse, sexually transmitted diseases (STDs), obesity, asthma, and pregnancies. The top three causes of death in adolescent and young adult males, age 15–24 years, are unintentional accidents, homicide, and suicide ^1,2 with notable gender disparities. Boys are 3 times more likely to die of unintentional injury and 6.7 times more likely to die of homicide than females in this age group. Although females report a higher rate of depression and suicidal thoughts, males commit suicide 5.3 times ¹ more often than females. Given that much of adolescent morbidity and mortality is preventable, an infrastructure of trained health professional leaders uniquely qualified to partner with public health agencies, schools, and community organizations is needed to provide health promotion and prevention for both boys and girls. In the past decade, there has been a growing interest in the utilization of medical and mental health services by adolescent boys and young men. When boys reach mid–adolescence, they do not utilize health services at the same rate as adolescent girls and young women, a trend that continues into adulthood. ³ Adolescent boys and men often receive much of their care in emergency departments, rather than in primary care practices. ⁴ Although there is variation in their willingness and capacity to seek help and articulate concerns, some will ignore medical symptoms or try home remedies before seeking medical care and others will seek advice on the internet rather than making an appointment with their health care provider.

Strategies to better engage boys in their own health care include offering health care in alternative settings, such as school–based clinics, creating male–friendly environments in medical clinics, and using health care visits as opportunities to teach boys about how to participate more actively in their own health care. ³ Improving interview skills of providers also has the potential to enhance communication. Boys may have preferences about how providers look, act, and speak during visits. ³ For example, providers who greet patients warmly and express a genuine interest in them by inquiring about their interests and daily activities before asking about medical information may facilitate a more positive view of the clinical encounter. Interestingly, the gender of the provider has not been found to be an issue for boys in a uniform way. ^3,5,6 However, some female providers may feel that boys are more comfortable with male providers, and this may affect their own comfort during the visit. Awareness of these issues can be a first step toward improving communication during the visit.

Several mnemonics are used as reminders or frameworks for adolescent preventive services. The HEADSS interview is familiar to most medical clinicians (HEADSS: Home, Education, Activities, Drugs/Depression, Safety/Suicide/Sexuality) (see handout 1). The SSHADESS mnemonic (Strengths, School, Home, Activities, Drugs, Emotions, Sexuality, and Safety) adds to the traditional HEADSS questions by eliciting strengths first and then progressing towards a more comprehensive psychosocial assessment. ⁷ The CRAFFT questions are an evidence–based screen for substance abuse ⁸ (see handout 2).

Both the SSHADESS and the HEADSS questions can be improved by asking about activities and school first, starting with action–oriented questions before asking about more emotionally loaded topics such as family life. Mental health clinicians typically use a standard assessment framework for new patients, and in depth questions about present concerns, substance use, family, social and educational background, history of past emotional problems and therapeutic intervention, and mental status. Similar to the HEADSS assessment, this format can be improved upon for many adolescent and young adult males by asking them general questions about interests, activities, and school before delving into discussing their emotional state. The importance of alliance–building ⁶ and engaging youth in care is also underscored by the framework from the Kalamazoo Project ⁹ (see handout 3). All these guidelines can be applied in training programs, but teachers should also outline some of the ways providers can be sensitive to and respond to the differences of adolescent boys and girls in preventive care visits. Every patient deserves a unique approach, and it is important not to generalize traits to all adolescent boys or all girls, but some general themes have been suggested that can influence the interviewing approach. Many adolescent boys are acculturated to be strong and self–reliant and may be afraid to feel and appear weak and vulnerable. ^10,11 They may adopt a “mask” to appear as though everything is fine, even though they may be frightened, worried, depressed or anxious ¹⁰ (see handout 4). In medical and mental health assessments, boys may give minimal answers to exploratory questions and give no evidence that they have concerns about their health or are suffering emotionally. Consequently, assessing adolescent boys in office visits can be challenging for providers. Providers may miss subtle verbal or non–verbal cues that boys are harboring concerns. As one medical provider noted, “The way I was taught to interview is to ask all the questions and if they say ‘no’ or ‘ok’ then to move on”. Although adolescent boys may present as guarded and minimally verbal, they do hope to have questions answered and to form a comfortable relationship with their providers.

The reluctance of adolescent males to visit health care providers and to disclose their concerns results in missed opportunities for boys to become comfortable with medical and mental health providers, to receive help for treatable problems, and to receive guidance about health behaviors and risks. This is especially pertinent in the area of emotional health. Providers need to know that males may have symptoms that they do not report and that their symptoms may differ from those reported by females. For example, females report symptoms, thoughts, and feelings of depression and suicidal ideation much more frequently than males, yet the completed suicide rate is higher for males. Of importance, many adolescent boys indicate that they would like to be able to raise concerns with their providers and would do so if approached in ways that help them feel comfortable. ¹² Provider training on how to obtain comprehensive information about their concerns, read non–verbal cues, and encourage adolescent boys to talk will increase the likelihood of providers learning important information about how adolescent boys think and feel. Recognizing non–verbal communication is an area of needed improvement for medical providers and is particularly important in clinical visits with adolescent boys. Providers who are skilled at non–verbal communication are recognized by patients with higher satisfaction and lower cancellation rates. ¹³ In addition, a better understanding of the elements of a successful interview has the potential to teach the adolescent boys how to use better communication skills themselves.

Focus Groups 2012: Perspectives from Adolescent and Young Adult Males

In order to explore adolescent boys’ attitudes and perspectives about health care providers, we convened focus groups of adolescent boys and young men, ages 15–22. We asked them what was important to them about the approach of their medical and mental health providers and what made them react either positively or negatively to the clinical encounter or provider. Participants identified certain provider behaviors that encouraged or discouraged their engagement, confidence, and trust. The routine preventive services visit includes areas of questioning that were uncomfortable for many boys, but also many opportunities for alliance building and health education. Adolescent boys expressed feeling particularly uneasy discussing sexual health concerns, drug and alcohol use, and emotional health issues; the issues for which they are at greatest risk and need the most guidance. In addition to their difficulty articulating these concerns, they also worried about confidentiality, particularly as it relates to their parents’ finding out about certain behaviors. Mental health and medical assessments were similarly challenging. One young man stated, “I would have to be on my deathbed before going to the doctor”. ¹² The young men also identified wording in the assessments and techniques used as being barriers to connection between patient and provider and causing confusion or reluctance to share their concerns.

Focus group participants clearly indicated that they wanted to have positive relationships with their providers and would be able to talk about what is on their minds if asked in ways that put them at ease. They wanted providers to communicate to adolescent boys, verbally and non–verbally, in a setting that was safe, friendly, and confidential. They also wanted their providers to get to know them as people and not just as patients.

Provider behaviors that male participants identified as positive:

• A smile and a handshake
• Inquiring in the beginning about their interests
• Showing genuine interest in them
• Assurance about confidentiality, particularly regarding issues of sexual activity and substance use
• A confident but relaxed demeanor
• Casual, yet professional
• Plain, easily understandable language

Provider behaviors that male participants identified as negative:

• Stiff posture or presentation
• Checklist approach
• Blunt presentation or language
• Not remembering their information from the last appointment
• Turning their attention to type on the computer

The following skills were identified by male participants as essential for effective interviews:

• Ability to read non–verbal cues
• Understanding that boys may have trouble articulating concerns
• Understanding that symptom experience and expression may be different than for females
• Comfort with asking open–ended questions and encouraging self–reflection
• Encouraging boys’ participation in their own health care