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Obtaining a personal and confidential history from adolescents
J O U R N A L OF A D O L E S C E N T H E A L T H CARE 1986;7:118-122
Obtaining a Personal and Confidential History from Adolescents An Opportunity for Prevention ROBERT M. C A V A N A U G H
JR. 1 M . D .
Fifty adolescent girls ages 12-18 years (mean 14.9 years) were asked to complete a confidential questionnaire exploring many important issues of adolescence. The responses included the following: 38 (76%) girls did not wear seatbelts while riding in a car, 23 (46%) had used alcoholic beverages (10 at age -< 13 years), 17 (34%) had experience with marijuana, four (8%) had used other psychoactive drugs, and 14 (28%) were having sexual intercourse, while only eight were using contraception. Of the 16 (32%) girls w h o smoked cigarettes ten did not want to quit. Twenty-two (44%) girls had dysmenorrhea but only four had sought medical attention for the problem. This study suggests the usefulness of a questionnaire to identify individual health care needs for which preventive counseling may be offered. KEY WORDS:
Confidential history Personal history Preventive pediatrics A comprehensive medical assessment of adolescents should optimally include discussions regarding preventive health concerns such as safety, alcohol, substance abuse, smoking, and sexual activity. Accidents, the majority of which are automotive, are the leading cause of death among adolescents in the United States (1,2). Alcohol and marijuana are factors in many of these fatalities From the State University Hospital, Upstate Medical Center, Syracuse, New York. Address correspondence to: Robert M. Cavanaugh Jr., M.D., State University Hospital, Upstate Medical Center, 750 East Adams Street, Syracuse, NY 13210. Manuscript accepted April 18, 1985. 118 0197-0070/86/$3.50
(2,3). More than 90% of high school seniors have used alcohol and over 50% have used marijuana (3). Nearly 20% of youths are said to be problem drinkers (4). Many teenagers have used barbiturates, hallucinogens, inhalants, opiates, amphetamines, and other psychoactive drugs (5). Twenty to thirty percent of all teenagers become regular cigarette smokers by 18 years of age, while over 80% experiment with cigarettes at some time (6,7). The use of tobacco has been linked to 30% of all cancer deaths in the United States (8) as well as to cardiovascular disease, emphysema, and other sources of morbidity and death. There are nearly 1,000,000 pregnancies among American w o m e n -< 19 years of age, with approximately 600,000 live births and 400,000 abortions (9). Twenty percent of adolescent pregnancies occur within one month of the first intercourse and 50% occur within six months (10). Recent data suggest that there are 5000 adolescent suicides per year with 50-200 attempts for every death (11). Health care providers are in a unique position to establish a trusting relationship with adolescents and to confidentially explore these issues. Clinicians should have an organized approach for data collection and information dissemination to the adolescent patient. This article discusses the usefulness of a personal and confidential questionnaire as an adjunct to the traditional history interview and counseling.
Procedures and Methods Fifty consecutive girls ages 12-18 years (mean 14.9) were surveyed during their visit to the Adolescent
© Society for Adolescent Medicine, 1986 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017
MARCH 1986
OBTAININGA PERSONALAND CONFIDENTIALHISTORY
Clinic at the Upstate Medical Center. The patient population consisted of 15 Black, one Hispanic, and 34 White girls. Classification by economic status revealed patients from eight upper-, 24 middle-, and 18 lower-income families. Twenty-six patients lived in the city, 19 in the suburbs, and five in rural areas. Following the general medical history and a complete physical examination, patients were given a personal and confidential questionnaire (see Appendix) to privately complete. This questionnaire has been used in our clinic for seven years and addresses m a n y important issues that have been traditionally incorporated into the standard adolescent interview. The patients were asked if they wished to have their responses placed in the medical record or filed separately and secured. All requests were honored. The patients were personally assured that the information provided would remain confidential and that reports using this information would only contain statistical data. The responses to all questions were confidentially reviewed with the patient. No attempt was made to validate the data beyond relying on the written and verbal report of the patient.
Results These questionnaires revealed that 38 (76%) patients did not wear seatbelts while riding in a car, 16 (32%) reported that they currently smoked, with 11 beginning -< 13 years of age, and ten were unwilling to quit. Seventeen (34%) girls had u s e d marijuana, and four (8%) reported using other psychoactive drugs including amphetamines (1), LSD (1), barbiturates (1), and cocaine (1). Two stated that they wanted to quit their drug use. Twenty-three (46%) patients had used alcoholic beverages, with ten beginning age 13 years. Most drank w h e n they were h a p p y (7), and in a group (12), but some drank w h e n they were sad (5), worried (3), or alone (2). Twenty (40%) girls wanted to break a habit, the most frequent being biting their fingernails (9), overeating (2), and smoking (2). Forty-six (92%) girls were postmenarchal, of w h o m 24 (52%) were menstruating regularly. Menses lasted from three to seven days for 39 (85%) patients. Twenty-two (44%) girls noted pain associated with menstruation although only four had sought medical care for the symptom. Thirty (60%) girls had boyfriends, and 14 (28%) were having sexual intercourse. Only eight Of the 14 were currently using contraception (7 condoms, 1 birth control pills, and 1 both). Of the total study
119
sample seven (14%) patients were concerned that they would never be able to get pregnant. Of this number five were sexually active, but only one was using birth control. Five (10%) girls felt that they were pressured into sexual relations w h e n they were not ready. Three (6%) patients had already been pregnant, and two had had an abortion. Only one patient reported a history of venereal disease. Forty-eight (96%) girls stated that they had a close friend to talk to about anything they wished. The two (4%) girls w h o did not have such friends had diagnoses of anorexia nervosa and depression. Sixteen (32%) patients did not know what masturbation was. Twenty-four (48%) reported that they had at times worried about their health. No patient refused to complete the questionnaire. It was estimated that all girls were able to complete the form within 5-10 min. In general the examiner required between 10 and 15 min to review this information and offer preventive counseling w h e n appropriate.
Discussion The author considers a personal and confidential history to be an integral part of a comprehensive medical evaluation of an adolescent. This information enhances the clinician's ability to recognize disorders for which the patient is at risk. Properly obtained, such a history also provides an opportunity to appreciate the strengths as well as the weaknesses of the individual, thus promoting a positive physician-patient relationship. I believe performing the physical examination prior to obtaining personal and confidential information may lessen anxiety and promote rapport and trust. Completion of the questionnaire is time efficient for the practitioner and allows the patients an opportunity to indirectly express their feelings. I have used this approach for seven years and believe that adolescents are more likely to reveal sensitive information u n d e r these circumstances. I address hobbies, interests, career goals, etc. first to help the patient understand that I am interested in them as a whole person. The clinician's thoughtful review of the questionnaire with the patient allows individual strengths to be acknowledged while addressing some of the important issues of adolescence (9) and offers an opportunity for preventive counseling w h e n indicated. Our results reinforce the importance of taking an alcohol and substance abuse history from adolescents. An attempt should be made to determine the
120
CAVANAUGH
frequency, amount, and circumstances under which these substances are used. An appropriate evaluation and treatment plan can be carefully formulated in accordance with the pattern of use. In addition, health care providers have an opportunity to provide factual information on alcohol and substance abuse. The fact that 38 (76%) girls did not wear seatbelts is significant because motor vehicle accidents are a leading cause of adolescent deaths (1,2). The office visit can provide an opportunity to stress highway safety including the use of seatbelts and the avoidance of alcohol, marijuana, and other psychoactive drugs w h e n driving. The examiner's review of the menstrual and sexual history should reflect an appreciation of the profound impact this may have on y o u n g women. There are helpful guides for discussing menstruation with teenagers (12,13). An attempt should be made to uncover fears, concerns, or misconceptions as well as symptoms associated with menses. Of the 46 (92%) girls in the study w h o were menstruating 22 experienced dysmenorrhea but only four had sought treatment. The remaining 18 patients were identified from the personal and confidential history and given the opportunity for an appropriate medical evaluation and treatment if indicated. Of this group 14 considered the pain to be a problem, but only three were incapacitated to some degree by their symptoms. After the completion of the menstrual history a brief explanation of normal sexual development may be useful as a lead into the sexual history. Those patients w h o are sexually active should be questioned about t h e frequency of intercourse and the use of birth control. Of the 30 (60%) girls in my study w h o had boyfriends, 14 were having sexual intercourse, but only eight were using contraception. C o n c e r n s and misconceptions about fertility were present in seven (14%) w h o expressed an unrealistic fear that they might be infertile. Of this number five were sexually active and only one was using birth control. An awareness of the importance that adolescents give to sexual issues, including homosexuality, should be coupled with the clinician's preventive counseling on contraception and venereal disease. Self-manipulation of the genitalia is frequently a source of concern to y o u n g w o m e n as wel ! as y o u n g men (14). Sixteen (32%) of the girls in my study did not know the meaning of the term masturbation. In the authors opinion, this topic should be reviewed with all adolescents to enhance understanding, re-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
move guilt, correct misconceptions, and provide reassurance that it is a common and usually harmless form of sexual activity. Feelings of sadness, depression, and suicidal ideation detected during the history and physical should always be addressed. Although not specifically evaluated in this study, inclusion of these issues on a personal and confidential questionnaire may be a valuable adjunct to the standard interview of adolescents. Serious thoughts of suicide or homicide may force the physician to violate confidentiality in an effort to protect the life of the patient and/or others. My data describe the responses of 50 consecutive young w o m e n concerning some of the important issues of adolescence. The demographic breakdown of our patient population suggests that the data may be generalizable to other populations of adolescent women. Similar information from questionnaires completed by young men is also routinely obtained in our clinic but was not analyzed in this study. No attempt was made to validate the data beyond directly reviewing the information with the patients; therefore, our numbers may under- or overestimate the prevelance of the issues discussed. Although not quantitated, there were very few positive responses on the questionnaire that appeared misleading when the item was discussed with the patient. It seems evident that a clinical encounter offers an excellent opportunity to explore many issues and provide appropriate preventive counseling. A personal and confidential questionnaire appears to offer another useful technique by which important information can be obtained from the adolescent.
Summary This article illustrates h o w data collected from a sample of adolescent females may be used to promote preventive medicine counseling in the clinical setting. My data suggest that a personal and confidential questionnaire may augment the verbal interview in identifying individuals at risk for the adverse consequences of alcohol and substance abuse, cigarette smoking, and sexual intercourse, as well as other important issues of adolescence. Appropriate counseling can be offered. The use of such a questionnaire appears to be an efficient and effective way o f maximizing the time spent during an office visit as well as an effective method of uncovering significant problems not easily revealed in an initial face-to-face interview.
MARCH 1986
OBTAINING A PERSONAL AND CONFIDENTIAL HISTORY
References
7. Palmer AB. Some variables contributing to the onset of cigarette smoking among junior high school students. Soc Sci Med 1970;4:359-60. 8. Morbidity and Mortality Weekly Report: Smoking and cancer. Center for Disease Control 1982;31:77-80. 9. Cohen MI. Adolescent health: Concerns for the eighties. Pediatr Rev 1982;4:3-6. 10. Duke PM. Adolescent sexuality. Pediatr Rev 1982;4:44-51. 11. Cohen MI. The society for Behavioral Pediatrics: A new portal in a rapidly moving boundry. Pediatrics 1984;73:791-8. 12. Planned Parenthood of Minnesota. Menstruation. Planned Parenthood of'Minnesota, 1979. 13. American Academy of Pediatrics. Committee on adolescence: Sex education for adolescents: A bibliography of low cost materials, 1984. 14.' Gordon S, Dickman I. Sex Education: The parents role. New York, Public Affairs Pamphlet No. 549, 1981;16-17.
1. Daniel WA, Jr. Adolescents in health and disease. St. Louis: The C. V. Mosby CO., 1977;8. 2. Coupey SM, Schonberg SK. Evaluation and management of drug problems in adolescents. Pediatr Annals 1982;11:653-8. 3. Long WA, Brown RC, Jenkins RR, et al. The role of the pediatrician in substance abuse counseling. Pediatrics 1983;72:251-2. 4. Eckardt MJ, Harford TC, Kaelber CT, et al. Health hazards associated with alcohol consumption. JAMA 1981;246:64861. 5. Hein K, Cohen MI, Litt IF. Illicit drug use among urban adolescents: A decade in retrospect. Am J Dis Child 1979;133:3840. 6. McKennell AC, Thomas RK. Adult's and adolescent's smoking habits and attitudes. Government Social Survey, London, HMSO, 1967.
APPENDIX 1
(Adolescent) UPSTATE NEDICAL CENTER ADOLESCENT PROGRAM CONFIDENTIAL INFORMATION FOR ADOLESCENT GIRLS Please
list
your hobbies
Please
list
sports
What a r e y o u r c a r e e r television
Favorite
type of music:
Please
in:
goals?
Favorite
Favorite
and i n t e r e s t s :
you participate
show:
musica I group: list
closest
friends:
Name o r I n i t i a 1 s
Do y o u h a v e a f r i e n d Is there Yes _ _
Age
you can talk
Sex
to about anything
Do y o u g e t
along ~rfth your parents?
Yes ~
No
DO y o u g e t
along with
Yes
No
Is there
at all?
anyone in the family or a friend whose health No If yes, please explain:
a conflict
other
kids?
i n y o u r home?
Do y o u w o r r y a b o u t y o u r p a r e n t s ' please explain: Are there any habits please list:
you vould
No
Yes ~ relationship?
like
Yes _ _
worries
If yes, Yes
to break?
Yes
No I No
No
you?
please f
explain yes,
If
yes,
Do y o u s m o k e y Yes No I f y e s - how many e a - ~ day? ~ E v e r smoke m a r i J , ~ n m ? If yes, do y o u e v e r d r i v e • c a r o r m o t o r c y c l e a f t e r s m o k i n g ? ~ old w e r e y o u w h e n y o u f i r s t b e g a n t o 8make? Do y o u w a n t t o q u i t ? Do 7 o u u s e druK8 s u c h a s FCP, T ' s & B's, a m p h e t a m i n e s o r o t h e r s t r e e t druKs? Yes
~ '
barbiturates, cocaine, No _ _ If yes, which
types? How o f t e n ? •
How o l d w e r e y o u w h e n y o u £ 1 r a t b e g a n t h e s e d r u g s ? DO y o u w a n t t o q u i t ? DO y o u d ~ i v e • e a r o r m o t o r c y c l e ~
I~tk:Lng t h e s e druKs?
121
122
CAVANAUGH
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2
APPENDIX Continued
2 (Adolescent) DO you d r i n k a l c o h o l - c o n t a i n i n g b e v e r a g e s ? Yes No If yes, type - beer. wine, whiskey? ~wmuc-~'~ch day? How much each week? Row old were you when ~-it-~gan to drink? Do y o u d r i ~ k w h e n you h a p p y , s a d , a l o n e , w o r r i e d , i n a g r o u p ( c i r c l e a l l t h a t a p p l y ) . Do you • car or motorcycle after drinking? Do you drive a car? or driving a car?
what you are: drive
Do you wear a seatbelt when riding in
Have you begun to menstruate? Yes No If yes, state age you began: How often do periodso-'o'c~r? Are periods regular or irregular? How long do. they last--~'~--Is there associated pain? When did your last period start? When did your last period e n d ? - ROw old were you when you first noticed breast development? Hair development? Do you have any boyfriends? Y e s No If yes - are you sexually active? Yes No If you are se~-----T~ actlve, do you or your partner use contracept--~l~n? ~ No If yes, please explain method used:
Are you w o r r i e d t h a t you may become p r e g n a n t ? Yes No Are you worried that you may not be able to get p r e g n a n t ? ~ So Are you being pressured for sex, but feel you are not r e a d y - ' / - - Y e s N o Have you ever used birth control pills or other contraceptives? NO ~ y e s , please explain:
Yes _
_
No Have you e v e r had a m i s c a r r i a g e Have y o u e v e r b e e n p r e g n a n t ? Yes ever had s y p h i l i s , gonorrhea or o r a b o r t i o n ? Yes No H a v - - Q ~ - ~ o u Other venereal dt~? Yes N o _ _ If yes, please explain: Do you know what m a s t u r b a t i o n
i s ? Yes
Do y o u e v e r w o r r y a b o u t y o u r h e a l t h ? explain:
No Yes
- -
Do you have any o t h e r p r o b l e m s you would l l k e b u t w o u l d r a t h e r n o t w r i t e them down? Yes
No
If
yes,
please
to d i s c u s s w i t h the d o c t o r , No
Name : ~ a n k you, R o b e r t M Cavanaugh, J r . , Adolescent Medicine
M.D.
Obtaining a Personal and Confidential History from Adolescents An Opportunity for Prevention ROBERT M. C A V A N A U G H
JR. 1 M . D .
Fifty adolescent girls ages 12-18 years (mean 14.9 years) were asked to complete a confidential questionnaire exploring many important issues of adolescence. The responses included the following: 38 (76%) girls did not wear seatbelts while riding in a car, 23 (46%) had used alcoholic beverages (10 at age -< 13 years), 17 (34%) had experience with marijuana, four (8%) had used other psychoactive drugs, and 14 (28%) were having sexual intercourse, while only eight were using contraception. Of the 16 (32%) girls w h o smoked cigarettes ten did not want to quit. Twenty-two (44%) girls had dysmenorrhea but only four had sought medical attention for the problem. This study suggests the usefulness of a questionnaire to identify individual health care needs for which preventive counseling may be offered. KEY WORDS:
Confidential history Personal history Preventive pediatrics A comprehensive medical assessment of adolescents should optimally include discussions regarding preventive health concerns such as safety, alcohol, substance abuse, smoking, and sexual activity. Accidents, the majority of which are automotive, are the leading cause of death among adolescents in the United States (1,2). Alcohol and marijuana are factors in many of these fatalities From the State University Hospital, Upstate Medical Center, Syracuse, New York. Address correspondence to: Robert M. Cavanaugh Jr., M.D., State University Hospital, Upstate Medical Center, 750 East Adams Street, Syracuse, NY 13210. Manuscript accepted April 18, 1985. 118 0197-0070/86/$3.50
(2,3). More than 90% of high school seniors have used alcohol and over 50% have used marijuana (3). Nearly 20% of youths are said to be problem drinkers (4). Many teenagers have used barbiturates, hallucinogens, inhalants, opiates, amphetamines, and other psychoactive drugs (5). Twenty to thirty percent of all teenagers become regular cigarette smokers by 18 years of age, while over 80% experiment with cigarettes at some time (6,7). The use of tobacco has been linked to 30% of all cancer deaths in the United States (8) as well as to cardiovascular disease, emphysema, and other sources of morbidity and death. There are nearly 1,000,000 pregnancies among American w o m e n -< 19 years of age, with approximately 600,000 live births and 400,000 abortions (9). Twenty percent of adolescent pregnancies occur within one month of the first intercourse and 50% occur within six months (10). Recent data suggest that there are 5000 adolescent suicides per year with 50-200 attempts for every death (11). Health care providers are in a unique position to establish a trusting relationship with adolescents and to confidentially explore these issues. Clinicians should have an organized approach for data collection and information dissemination to the adolescent patient. This article discusses the usefulness of a personal and confidential questionnaire as an adjunct to the traditional history interview and counseling.
Procedures and Methods Fifty consecutive girls ages 12-18 years (mean 14.9) were surveyed during their visit to the Adolescent
© Society for Adolescent Medicine, 1986 Published by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017
MARCH 1986
OBTAININGA PERSONALAND CONFIDENTIALHISTORY
Clinic at the Upstate Medical Center. The patient population consisted of 15 Black, one Hispanic, and 34 White girls. Classification by economic status revealed patients from eight upper-, 24 middle-, and 18 lower-income families. Twenty-six patients lived in the city, 19 in the suburbs, and five in rural areas. Following the general medical history and a complete physical examination, patients were given a personal and confidential questionnaire (see Appendix) to privately complete. This questionnaire has been used in our clinic for seven years and addresses m a n y important issues that have been traditionally incorporated into the standard adolescent interview. The patients were asked if they wished to have their responses placed in the medical record or filed separately and secured. All requests were honored. The patients were personally assured that the information provided would remain confidential and that reports using this information would only contain statistical data. The responses to all questions were confidentially reviewed with the patient. No attempt was made to validate the data beyond relying on the written and verbal report of the patient.
Results These questionnaires revealed that 38 (76%) patients did not wear seatbelts while riding in a car, 16 (32%) reported that they currently smoked, with 11 beginning -< 13 years of age, and ten were unwilling to quit. Seventeen (34%) girls had u s e d marijuana, and four (8%) reported using other psychoactive drugs including amphetamines (1), LSD (1), barbiturates (1), and cocaine (1). Two stated that they wanted to quit their drug use. Twenty-three (46%) patients had used alcoholic beverages, with ten beginning age 13 years. Most drank w h e n they were h a p p y (7), and in a group (12), but some drank w h e n they were sad (5), worried (3), or alone (2). Twenty (40%) girls wanted to break a habit, the most frequent being biting their fingernails (9), overeating (2), and smoking (2). Forty-six (92%) girls were postmenarchal, of w h o m 24 (52%) were menstruating regularly. Menses lasted from three to seven days for 39 (85%) patients. Twenty-two (44%) girls noted pain associated with menstruation although only four had sought medical care for the symptom. Thirty (60%) girls had boyfriends, and 14 (28%) were having sexual intercourse. Only eight Of the 14 were currently using contraception (7 condoms, 1 birth control pills, and 1 both). Of the total study
119
sample seven (14%) patients were concerned that they would never be able to get pregnant. Of this number five were sexually active, but only one was using birth control. Five (10%) girls felt that they were pressured into sexual relations w h e n they were not ready. Three (6%) patients had already been pregnant, and two had had an abortion. Only one patient reported a history of venereal disease. Forty-eight (96%) girls stated that they had a close friend to talk to about anything they wished. The two (4%) girls w h o did not have such friends had diagnoses of anorexia nervosa and depression. Sixteen (32%) patients did not know what masturbation was. Twenty-four (48%) reported that they had at times worried about their health. No patient refused to complete the questionnaire. It was estimated that all girls were able to complete the form within 5-10 min. In general the examiner required between 10 and 15 min to review this information and offer preventive counseling w h e n appropriate.
Discussion The author considers a personal and confidential history to be an integral part of a comprehensive medical evaluation of an adolescent. This information enhances the clinician's ability to recognize disorders for which the patient is at risk. Properly obtained, such a history also provides an opportunity to appreciate the strengths as well as the weaknesses of the individual, thus promoting a positive physician-patient relationship. I believe performing the physical examination prior to obtaining personal and confidential information may lessen anxiety and promote rapport and trust. Completion of the questionnaire is time efficient for the practitioner and allows the patients an opportunity to indirectly express their feelings. I have used this approach for seven years and believe that adolescents are more likely to reveal sensitive information u n d e r these circumstances. I address hobbies, interests, career goals, etc. first to help the patient understand that I am interested in them as a whole person. The clinician's thoughtful review of the questionnaire with the patient allows individual strengths to be acknowledged while addressing some of the important issues of adolescence (9) and offers an opportunity for preventive counseling w h e n indicated. Our results reinforce the importance of taking an alcohol and substance abuse history from adolescents. An attempt should be made to determine the
120
CAVANAUGH
frequency, amount, and circumstances under which these substances are used. An appropriate evaluation and treatment plan can be carefully formulated in accordance with the pattern of use. In addition, health care providers have an opportunity to provide factual information on alcohol and substance abuse. The fact that 38 (76%) girls did not wear seatbelts is significant because motor vehicle accidents are a leading cause of adolescent deaths (1,2). The office visit can provide an opportunity to stress highway safety including the use of seatbelts and the avoidance of alcohol, marijuana, and other psychoactive drugs w h e n driving. The examiner's review of the menstrual and sexual history should reflect an appreciation of the profound impact this may have on y o u n g women. There are helpful guides for discussing menstruation with teenagers (12,13). An attempt should be made to uncover fears, concerns, or misconceptions as well as symptoms associated with menses. Of the 46 (92%) girls in the study w h o were menstruating 22 experienced dysmenorrhea but only four had sought treatment. The remaining 18 patients were identified from the personal and confidential history and given the opportunity for an appropriate medical evaluation and treatment if indicated. Of this group 14 considered the pain to be a problem, but only three were incapacitated to some degree by their symptoms. After the completion of the menstrual history a brief explanation of normal sexual development may be useful as a lead into the sexual history. Those patients w h o are sexually active should be questioned about t h e frequency of intercourse and the use of birth control. Of the 30 (60%) girls in my study w h o had boyfriends, 14 were having sexual intercourse, but only eight were using contraception. C o n c e r n s and misconceptions about fertility were present in seven (14%) w h o expressed an unrealistic fear that they might be infertile. Of this number five were sexually active and only one was using birth control. An awareness of the importance that adolescents give to sexual issues, including homosexuality, should be coupled with the clinician's preventive counseling on contraception and venereal disease. Self-manipulation of the genitalia is frequently a source of concern to y o u n g w o m e n as wel ! as y o u n g men (14). Sixteen (32%) of the girls in my study did not know the meaning of the term masturbation. In the authors opinion, this topic should be reviewed with all adolescents to enhance understanding, re-
JOURNALOF ADOLESCENTHEALTHCAREVol. 7, No. 2
move guilt, correct misconceptions, and provide reassurance that it is a common and usually harmless form of sexual activity. Feelings of sadness, depression, and suicidal ideation detected during the history and physical should always be addressed. Although not specifically evaluated in this study, inclusion of these issues on a personal and confidential questionnaire may be a valuable adjunct to the standard interview of adolescents. Serious thoughts of suicide or homicide may force the physician to violate confidentiality in an effort to protect the life of the patient and/or others. My data describe the responses of 50 consecutive young w o m e n concerning some of the important issues of adolescence. The demographic breakdown of our patient population suggests that the data may be generalizable to other populations of adolescent women. Similar information from questionnaires completed by young men is also routinely obtained in our clinic but was not analyzed in this study. No attempt was made to validate the data beyond directly reviewing the information with the patients; therefore, our numbers may under- or overestimate the prevelance of the issues discussed. Although not quantitated, there were very few positive responses on the questionnaire that appeared misleading when the item was discussed with the patient. It seems evident that a clinical encounter offers an excellent opportunity to explore many issues and provide appropriate preventive counseling. A personal and confidential questionnaire appears to offer another useful technique by which important information can be obtained from the adolescent.
Summary This article illustrates h o w data collected from a sample of adolescent females may be used to promote preventive medicine counseling in the clinical setting. My data suggest that a personal and confidential questionnaire may augment the verbal interview in identifying individuals at risk for the adverse consequences of alcohol and substance abuse, cigarette smoking, and sexual intercourse, as well as other important issues of adolescence. Appropriate counseling can be offered. The use of such a questionnaire appears to be an efficient and effective way o f maximizing the time spent during an office visit as well as an effective method of uncovering significant problems not easily revealed in an initial face-to-face interview.
MARCH 1986
OBTAINING A PERSONAL AND CONFIDENTIAL HISTORY
References
7. Palmer AB. Some variables contributing to the onset of cigarette smoking among junior high school students. Soc Sci Med 1970;4:359-60. 8. Morbidity and Mortality Weekly Report: Smoking and cancer. Center for Disease Control 1982;31:77-80. 9. Cohen MI. Adolescent health: Concerns for the eighties. Pediatr Rev 1982;4:3-6. 10. Duke PM. Adolescent sexuality. Pediatr Rev 1982;4:44-51. 11. Cohen MI. The society for Behavioral Pediatrics: A new portal in a rapidly moving boundry. Pediatrics 1984;73:791-8. 12. Planned Parenthood of Minnesota. Menstruation. Planned Parenthood of'Minnesota, 1979. 13. American Academy of Pediatrics. Committee on adolescence: Sex education for adolescents: A bibliography of low cost materials, 1984. 14.' Gordon S, Dickman I. Sex Education: The parents role. New York, Public Affairs Pamphlet No. 549, 1981;16-17.
1. Daniel WA, Jr. Adolescents in health and disease. St. Louis: The C. V. Mosby CO., 1977;8. 2. Coupey SM, Schonberg SK. Evaluation and management of drug problems in adolescents. Pediatr Annals 1982;11:653-8. 3. Long WA, Brown RC, Jenkins RR, et al. The role of the pediatrician in substance abuse counseling. Pediatrics 1983;72:251-2. 4. Eckardt MJ, Harford TC, Kaelber CT, et al. Health hazards associated with alcohol consumption. JAMA 1981;246:64861. 5. Hein K, Cohen MI, Litt IF. Illicit drug use among urban adolescents: A decade in retrospect. Am J Dis Child 1979;133:3840. 6. McKennell AC, Thomas RK. Adult's and adolescent's smoking habits and attitudes. Government Social Survey, London, HMSO, 1967.
APPENDIX 1
(Adolescent) UPSTATE NEDICAL CENTER ADOLESCENT PROGRAM CONFIDENTIAL INFORMATION FOR ADOLESCENT GIRLS Please
list
your hobbies
Please
list
sports
What a r e y o u r c a r e e r television
Favorite
type of music:
Please
in:
goals?
Favorite
Favorite
and i n t e r e s t s :
you participate
show:
musica I group: list
closest
friends:
Name o r I n i t i a 1 s
Do y o u h a v e a f r i e n d Is there Yes _ _
Age
you can talk
Sex
to about anything
Do y o u g e t
along ~rfth your parents?
Yes ~
No
DO y o u g e t
along with
Yes
No
Is there
at all?
anyone in the family or a friend whose health No If yes, please explain:
a conflict
other
kids?
i n y o u r home?
Do y o u w o r r y a b o u t y o u r p a r e n t s ' please explain: Are there any habits please list:
you vould
No
Yes ~ relationship?
like
Yes _ _
worries
If yes, Yes
to break?
Yes
No I No
No
you?
please f
explain yes,
If
yes,
Do y o u s m o k e y Yes No I f y e s - how many e a - ~ day? ~ E v e r smoke m a r i J , ~ n m ? If yes, do y o u e v e r d r i v e • c a r o r m o t o r c y c l e a f t e r s m o k i n g ? ~ old w e r e y o u w h e n y o u f i r s t b e g a n t o 8make? Do y o u w a n t t o q u i t ? Do 7 o u u s e druK8 s u c h a s FCP, T ' s & B's, a m p h e t a m i n e s o r o t h e r s t r e e t druKs? Yes
~ '
barbiturates, cocaine, No _ _ If yes, which
types? How o f t e n ? •
How o l d w e r e y o u w h e n y o u £ 1 r a t b e g a n t h e s e d r u g s ? DO y o u w a n t t o q u i t ? DO y o u d ~ i v e • e a r o r m o t o r c y c l e ~
I~tk:Lng t h e s e druKs?
121
122
CAVANAUGH
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 2
APPENDIX Continued
2 (Adolescent) DO you d r i n k a l c o h o l - c o n t a i n i n g b e v e r a g e s ? Yes No If yes, type - beer. wine, whiskey? ~wmuc-~'~ch day? How much each week? Row old were you when ~-it-~gan to drink? Do y o u d r i ~ k w h e n you h a p p y , s a d , a l o n e , w o r r i e d , i n a g r o u p ( c i r c l e a l l t h a t a p p l y ) . Do you • car or motorcycle after drinking? Do you drive a car? or driving a car?
what you are: drive
Do you wear a seatbelt when riding in
Have you begun to menstruate? Yes No If yes, state age you began: How often do periodso-'o'c~r? Are periods regular or irregular? How long do. they last--~'~--Is there associated pain? When did your last period start? When did your last period e n d ? - ROw old were you when you first noticed breast development? Hair development? Do you have any boyfriends? Y e s No If yes - are you sexually active? Yes No If you are se~-----T~ actlve, do you or your partner use contracept--~l~n? ~ No If yes, please explain method used:
Are you w o r r i e d t h a t you may become p r e g n a n t ? Yes No Are you worried that you may not be able to get p r e g n a n t ? ~ So Are you being pressured for sex, but feel you are not r e a d y - ' / - - Y e s N o Have you ever used birth control pills or other contraceptives? NO ~ y e s , please explain:
Yes _
_
No Have you e v e r had a m i s c a r r i a g e Have y o u e v e r b e e n p r e g n a n t ? Yes ever had s y p h i l i s , gonorrhea or o r a b o r t i o n ? Yes No H a v - - Q ~ - ~ o u Other venereal dt~? Yes N o _ _ If yes, please explain: Do you know what m a s t u r b a t i o n
i s ? Yes
Do y o u e v e r w o r r y a b o u t y o u r h e a l t h ? explain:
No Yes
- -
Do you have any o t h e r p r o b l e m s you would l l k e b u t w o u l d r a t h e r n o t w r i t e them down? Yes
No
If
yes,
please
to d i s c u s s w i t h the d o c t o r , No
Name : ~ a n k you, R o b e r t M Cavanaugh, J r . , Adolescent Medicine
M.D.