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Evaluating the adolescent with asthma: Are we doing enough?
Clinical Communications Evaluating the adolescent with asthma: Are we doing enough? Iman Naimi, BSa, Andrea J. Apter, MD, MA, MSc, FAAAAIb, Kenneth Ginsburg, MD, MS Edc, and David R. Naimi, DO, FAAAAId Clinical Implication
According to our survey of the American Academy of Allergy, Asthma, and Immunology members, interviewing adolescents with asthma in the absence of a parent or caretaker is infrequent as are verbal inquiries about alcohol or substance abuse.
TO THE EDITOR: Asthma is the most common chronic disease in children and adolescents, and is one of the leading causes of school absenteeism.1 Adherence to medications with adolescents is poorer than with younger children and adults, whereas risky behavior such as tobacco, drug, and alcohol use is common. There is some evidence that risky behavior is associated with nonadherence to medications, poor treatment outcomes, and death.2 To address the subject of substance and/or alcohol abuse and medication adherence, effective patient-provider communication and trust are necessary and may require interviews both with and without the parent or caretaker present.3 In 2012, we sent by e-mail a 10-question multiple choice survey to American Academy of Allergy, Asthma, and Immunology members via Survey Monkey (Palo Alto, Calif). Our goal was to assess whether asthma care providers interview their adolescent patients in this manner and whether they inquire about tobacco and/or drug use. There were 641 responses from 5069 providers (12.7%); 94.7% were physicians; 95.3% treated adolescents with asthma (age range, 13-17 years); 83% reported infrequently (<25% of the time) dedicating at least part of the visit to interviewing their adolescent patients with asthma without a parent present (Figure 1); 44% reported that they never do this. The 2 most common reasons given: “not enough time” (24.7%) and “no reason/do not know the reason” (23.7%). Ninety-one providers (16%) gave a written explanation as to why they do not interview teens without a parent present: 23 of 91 participants cited general medical-legal reasons or concern about being in the room with an unsupervised adolescent, and 5 of 91 viewed this as the primary care provider’s responsibility. A total of 290 participants (50%) reported that they or their staff often (>75% of the time) verbally ask about cigarette smoking. Approximately 390 respondents (67%) infrequently (<25% of the time) verbally inquired about alcohol and/or substance abuse. The number of survey respondents was relatively low (12.7% [641/5069]). This could raise the question about how representative these data are of practicing allergists. Nevertheless, among those who did respond, interviewing adolescents in the absence of a parent or caretaker is infrequent as are verbal 230
inquiries about alcohol and/or substance abuse. Such interviews and inquiries present opportunities to improve communication, obtain a more accurate history, and ask about adherence and risktaking behavior. Adolescence is a time of rapid growth and development, which provides an important window of opportunity to encourage selfefficacy and a smooth transition from pediatric- to adult-centered care. In fact, better adherence to asthma medications in teens is linked to a good, long-term relationship with a provider;4 nevertheless, there often is reluctance on the part of physicians to speak with their teen patients alone and to ask potentially sensitive questions. Results of surveys in the United States suggest that only 30% to 50% of adolescent smokers are identified and counseled during visits to a physician.5 Notably, adolescents who smoke are 3 times more likely to abuse alcohol and 8 times more likely to use marijuana versus peers who do not smoke.6 A summary of findings regarding substance use from the 2011 National Youth Risk Behavior Survey of 9th to 12th graders is provided in Figure 2.7 Some of the concerns cited by respondents of the survey included medical-legal issues about speaking with a minor alone as well as noting that this should be the responsibility of their primary care physician. Who could have more legitimacy to discuss smoking than a health care professional treating asthma? In regard to medical-legal issues, the law states that a clinician can maintain confidentiality if a teen or minor wishes to keep the information private. Limitations of privacy would include the following: situations of abuse, suicidal ideation, or homicidal ideation. Clinicians who treat teens must be aware of the state and/or federal laws related to consent and confidentiality. Some variability between states can exist in regard to definitions of sexual abuse and/or statutory rape, parental notification of pregnancy or abortions, and so forth.8 The reluctance on the part of some clinicians to speak with a teen alone also could be partly attributed to it being a sometimes awkward process. However, accurate and complete information is more likely to be obtained by speaking with the adolescent patient alone and by clarifying with whom the information will be shared. Adolescents who are assured confidentiality report greater willingness to disclose sensitive information (substance abuse, sexuality, etc) and to seek future health care.3 It is important to talk with teens and parents early in the relationship to discuss confidentiality and to explicitly define the circumstances under which privacy and confidentiality must be broken. They should understand that your goal is to help them transition into being their own spokesperson and advocate. It should be clarified that this transition takes place gradually and with the support of their parents. Some physicians begin this transition by separating adolescents from their parents throughout the visit in an effort to promote independence; however, Kenneth Ginsburg (unpublished data) suggests that parents be present at the beginning of the visit. This is done to ensure that the parents understand both the “social contract” that you will be creating with their adolescent and the important role they have in their child’s care. Adolescents are more likely to trust the process, the social contract, and your relationship with them if their parents hear your commitment to privacy and agree to it in their
CLINICAL COMMUNICATIONS
J ALLERGY CLIN IMMUNOL PRACT VOLUME 2, NUMBER 2
231
FIGURE 1. The proportion of asthma care providers who interview their adolescent patients with asthma without a parent present in the room.
National Youth Risk Behavior Survey, 2011 44.7%
Ever smoked cigarettes Reported *current cigarette use
18.1%
Ever smoked cigarettes daily
10.2%
Smoked a whole cigarette for the first time before age 13 years
10.3% 38.7%
Reported *current alcohol use Reported *current marijuana use
23.1%
*On at least 1 day during the 30 days before the survey
FIGURE 2. A summary of key statistics from the National Youth Risk Behavior Survey, 2011: the percentage of students (9th-12th graders) who reported cigarette, alcohol, and marijuana use.
presence. In parallel, parents are put at ease because their role as teachers and experts is clarified. For example, you might begin by stating: “I would like to talk about the way our visits will work. I will always start by asking you questions, including any concerns you might have today. I am also going to ask you the questions directly, because I want you to learn how to tell your story to a professional. However, I am glad your parents are in the room at the beginning of our visit because they are your teachers. For those questions that you are unsure of, we can turn to your mother or father and ask them to teach us both. Your job is to listen to what your parents say so you can learn and answer these questions next time. Once I know everyone’s concerns, we’ll spend a few minutes talking privately. Sound like a good plan?” Finally, the limitations of privacy should be stated (unpublished data).
The above approach may ensure that asthma care providers set the stage for a trusting relationship with teen patients and their parents so that the ultimate goal of optimal asthma care is achieved. More work needs to be done to further evaluate if and why asthma care providers infrequently interview their adolescent patients without a parent or caretaker present. As asthma care providers, we must strive to alleviate barriers that could compromise accurate history taking and result in lost opportunities to facilitate positive behavioral changes in our teenage patients. a
St George’s University School of Medicine, Grenada, West Indies Pulmonary, Allergy & Critical Care Division, University of Pennsylvania, Philadelphia, Pa c Craig-Dalsimer Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pa b
232
CLINICAL COMMUNICATIONS
d Northwest Asthma & Allergy Center and University of Washington, Seattle, Wash No funding was received for this work. Conflicts of interest: D. R. Naimi has received lecture fees from Teva’s Speaker’s Bureau and has received payment for performing oral food challenge for the VIPES peanut transdermal patch study from DBV Technologies. The rest of the authors declare that they have no relevant conflicts of interest. Received for publication September 17, 2013; revised November 6, 2013; accepted for publication November 19, 2013. Corresponding author: David R. Naimi, DO, FAAAAI, Northwest Asthma and Allergy Center 9725 3rd Ave NE, Suite 500, Seattle, WA 98115. E-mail: dnaimi@ nwasthma.com. 2213-2198/$36.00 Ó 2014 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2013.11.015
REFERENCES 1. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, 2005-2009. Nat Health Stat Rep 2011;32:1-14.
J ALLERGY CLIN IMMUNOL PRACT MARCH/APRIL 2014
2. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. Am J Respir Crit Care Med 2006;173: 953-7. 3. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997;278:1029. 4. Wamboldt FS, Bender BG, Rankin AE. Adolescent decision-making about use of inhaled asthma controller medication: results from focus groups with participants from a prior longitudinal study. J Asthma 2011;48:741-50. 5. Alfano CM, Zbikowski SM, Robinson LA, Klesges RC, Scarinci IC. Adolescent reports of physician counseling for smoking. Pediatrics 2002;109:E47. 6. Sims TH. Committee on Substance Abuse. From the American Academy of Pediatrics: Technical reports: tobacco as a substance of abuse. Pediatrics 2009; 124:e1045. 7. Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance—United States, 2011. MMWR Surveill Summ 2012;61: 1-162. 8. Greydanus DE, Patel DR. Consent and confidentiality in adolescent health care. Pediatr Ann 1991;20:80-4.
According to our survey of the American Academy of Allergy, Asthma, and Immunology members, interviewing adolescents with asthma in the absence of a parent or caretaker is infrequent as are verbal inquiries about alcohol or substance abuse.
TO THE EDITOR: Asthma is the most common chronic disease in children and adolescents, and is one of the leading causes of school absenteeism.1 Adherence to medications with adolescents is poorer than with younger children and adults, whereas risky behavior such as tobacco, drug, and alcohol use is common. There is some evidence that risky behavior is associated with nonadherence to medications, poor treatment outcomes, and death.2 To address the subject of substance and/or alcohol abuse and medication adherence, effective patient-provider communication and trust are necessary and may require interviews both with and without the parent or caretaker present.3 In 2012, we sent by e-mail a 10-question multiple choice survey to American Academy of Allergy, Asthma, and Immunology members via Survey Monkey (Palo Alto, Calif). Our goal was to assess whether asthma care providers interview their adolescent patients in this manner and whether they inquire about tobacco and/or drug use. There were 641 responses from 5069 providers (12.7%); 94.7% were physicians; 95.3% treated adolescents with asthma (age range, 13-17 years); 83% reported infrequently (<25% of the time) dedicating at least part of the visit to interviewing their adolescent patients with asthma without a parent present (Figure 1); 44% reported that they never do this. The 2 most common reasons given: “not enough time” (24.7%) and “no reason/do not know the reason” (23.7%). Ninety-one providers (16%) gave a written explanation as to why they do not interview teens without a parent present: 23 of 91 participants cited general medical-legal reasons or concern about being in the room with an unsupervised adolescent, and 5 of 91 viewed this as the primary care provider’s responsibility. A total of 290 participants (50%) reported that they or their staff often (>75% of the time) verbally ask about cigarette smoking. Approximately 390 respondents (67%) infrequently (<25% of the time) verbally inquired about alcohol and/or substance abuse. The number of survey respondents was relatively low (12.7% [641/5069]). This could raise the question about how representative these data are of practicing allergists. Nevertheless, among those who did respond, interviewing adolescents in the absence of a parent or caretaker is infrequent as are verbal 230
inquiries about alcohol and/or substance abuse. Such interviews and inquiries present opportunities to improve communication, obtain a more accurate history, and ask about adherence and risktaking behavior. Adolescence is a time of rapid growth and development, which provides an important window of opportunity to encourage selfefficacy and a smooth transition from pediatric- to adult-centered care. In fact, better adherence to asthma medications in teens is linked to a good, long-term relationship with a provider;4 nevertheless, there often is reluctance on the part of physicians to speak with their teen patients alone and to ask potentially sensitive questions. Results of surveys in the United States suggest that only 30% to 50% of adolescent smokers are identified and counseled during visits to a physician.5 Notably, adolescents who smoke are 3 times more likely to abuse alcohol and 8 times more likely to use marijuana versus peers who do not smoke.6 A summary of findings regarding substance use from the 2011 National Youth Risk Behavior Survey of 9th to 12th graders is provided in Figure 2.7 Some of the concerns cited by respondents of the survey included medical-legal issues about speaking with a minor alone as well as noting that this should be the responsibility of their primary care physician. Who could have more legitimacy to discuss smoking than a health care professional treating asthma? In regard to medical-legal issues, the law states that a clinician can maintain confidentiality if a teen or minor wishes to keep the information private. Limitations of privacy would include the following: situations of abuse, suicidal ideation, or homicidal ideation. Clinicians who treat teens must be aware of the state and/or federal laws related to consent and confidentiality. Some variability between states can exist in regard to definitions of sexual abuse and/or statutory rape, parental notification of pregnancy or abortions, and so forth.8 The reluctance on the part of some clinicians to speak with a teen alone also could be partly attributed to it being a sometimes awkward process. However, accurate and complete information is more likely to be obtained by speaking with the adolescent patient alone and by clarifying with whom the information will be shared. Adolescents who are assured confidentiality report greater willingness to disclose sensitive information (substance abuse, sexuality, etc) and to seek future health care.3 It is important to talk with teens and parents early in the relationship to discuss confidentiality and to explicitly define the circumstances under which privacy and confidentiality must be broken. They should understand that your goal is to help them transition into being their own spokesperson and advocate. It should be clarified that this transition takes place gradually and with the support of their parents. Some physicians begin this transition by separating adolescents from their parents throughout the visit in an effort to promote independence; however, Kenneth Ginsburg (unpublished data) suggests that parents be present at the beginning of the visit. This is done to ensure that the parents understand both the “social contract” that you will be creating with their adolescent and the important role they have in their child’s care. Adolescents are more likely to trust the process, the social contract, and your relationship with them if their parents hear your commitment to privacy and agree to it in their
CLINICAL COMMUNICATIONS
J ALLERGY CLIN IMMUNOL PRACT VOLUME 2, NUMBER 2
231
FIGURE 1. The proportion of asthma care providers who interview their adolescent patients with asthma without a parent present in the room.
National Youth Risk Behavior Survey, 2011 44.7%
Ever smoked cigarettes Reported *current cigarette use
18.1%
Ever smoked cigarettes daily
10.2%
Smoked a whole cigarette for the first time before age 13 years
10.3% 38.7%
Reported *current alcohol use Reported *current marijuana use
23.1%
*On at least 1 day during the 30 days before the survey
FIGURE 2. A summary of key statistics from the National Youth Risk Behavior Survey, 2011: the percentage of students (9th-12th graders) who reported cigarette, alcohol, and marijuana use.
presence. In parallel, parents are put at ease because their role as teachers and experts is clarified. For example, you might begin by stating: “I would like to talk about the way our visits will work. I will always start by asking you questions, including any concerns you might have today. I am also going to ask you the questions directly, because I want you to learn how to tell your story to a professional. However, I am glad your parents are in the room at the beginning of our visit because they are your teachers. For those questions that you are unsure of, we can turn to your mother or father and ask them to teach us both. Your job is to listen to what your parents say so you can learn and answer these questions next time. Once I know everyone’s concerns, we’ll spend a few minutes talking privately. Sound like a good plan?” Finally, the limitations of privacy should be stated (unpublished data).
The above approach may ensure that asthma care providers set the stage for a trusting relationship with teen patients and their parents so that the ultimate goal of optimal asthma care is achieved. More work needs to be done to further evaluate if and why asthma care providers infrequently interview their adolescent patients without a parent or caretaker present. As asthma care providers, we must strive to alleviate barriers that could compromise accurate history taking and result in lost opportunities to facilitate positive behavioral changes in our teenage patients. a
St George’s University School of Medicine, Grenada, West Indies Pulmonary, Allergy & Critical Care Division, University of Pennsylvania, Philadelphia, Pa c Craig-Dalsimer Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pa b
232
CLINICAL COMMUNICATIONS
d Northwest Asthma & Allergy Center and University of Washington, Seattle, Wash No funding was received for this work. Conflicts of interest: D. R. Naimi has received lecture fees from Teva’s Speaker’s Bureau and has received payment for performing oral food challenge for the VIPES peanut transdermal patch study from DBV Technologies. The rest of the authors declare that they have no relevant conflicts of interest. Received for publication September 17, 2013; revised November 6, 2013; accepted for publication November 19, 2013. Corresponding author: David R. Naimi, DO, FAAAAI, Northwest Asthma and Allergy Center 9725 3rd Ave NE, Suite 500, Seattle, WA 98115. E-mail: dnaimi@ nwasthma.com. 2213-2198/$36.00 Ó 2014 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2013.11.015
REFERENCES 1. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, 2005-2009. Nat Health Stat Rep 2011;32:1-14.
J ALLERGY CLIN IMMUNOL PRACT MARCH/APRIL 2014
2. Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. Am J Respir Crit Care Med 2006;173: 953-7. 3. Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997;278:1029. 4. Wamboldt FS, Bender BG, Rankin AE. Adolescent decision-making about use of inhaled asthma controller medication: results from focus groups with participants from a prior longitudinal study. J Asthma 2011;48:741-50. 5. Alfano CM, Zbikowski SM, Robinson LA, Klesges RC, Scarinci IC. Adolescent reports of physician counseling for smoking. Pediatrics 2002;109:E47. 6. Sims TH. Committee on Substance Abuse. From the American Academy of Pediatrics: Technical reports: tobacco as a substance of abuse. Pediatrics 2009; 124:e1045. 7. Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance—United States, 2011. MMWR Surveill Summ 2012;61: 1-162. 8. Greydanus DE, Patel DR. Consent and confidentiality in adolescent health care. Pediatr Ann 1991;20:80-4.