Using Your Head, Your Heart

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Using Your Head, Your Heart Your Feet to
Better Serve Teens

• Chuck Marquardt
• Lead Program Trainer
• California Family Health Council

3600 Wilshire Blvd., Suite 600 Los Angeles, CA
90010 [phone] ext. 4583 marquardtc_at_cfhc.org
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Overview

• Introduction
• CME Conflict of Interest Disclosure
• Objectives
• Review concerns specific to providing
  reproductive health services to adolescents.
• Demonstrate counseling techniques for encouraging
  family involvement with teen clients and for
  helping them to resist sexual coercion.
• Describe how to create a marketing plan for your
  family planning clinic or program.

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Concerns in Providing Services to Teens
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Head and Heart
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What is your comfort level when talking with
teens?
Pull out your response card

• Very comfortable
• Pretty good, once I figure out what theyre
  saying
• It comes and goes
• I dont run out the door
• Cant we just talk more about menopause?

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Small Group Activity

• Introduce yourselves
• Answer the following questions. Have one person
  keep a list of your responses
• What makes you uncomfortable or ill-at-ease when
  working with or serving teen clients, or
  something that you just dont like?
• What do you like about working with or serving
  teen clients?

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Thought Cycle
First, Always remember
Thoughts
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Teens and Adults
Teens are NOT mini-adults
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A Word about Brain Development
Brain Develops Back to Front

• This area, the prefrontal cortex, right above the
  forehead, is the brain area that regulates
• planning
• setting priorities
• organizing thoughts
• suppressing impulses
• weighing consequences of ones actions

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Resiliency

• is about bouncing back from problems and stuff
  with power and more smarts
• Sean, age 15

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Youth Development

• 40 Developmental Assets for Adolescents
• Source www.search-institute.org
• The more assets, the better
• Youth Development strengthening and developing
  more assets

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Five Core Needs of Teens

• ? Affirmation
• ? Information giving
• ? Values clarification
• ? Limit setting
• ? Anticipatory guidance

Remember why we're here
Roffman D. Sex and Sensibility The Thinking
Parents Guide to Talking about Sex. Perseus
Publishing, USA. 2001.
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General Principles in Working with Teens

• Rapport and alliance are key.
• Review the scope and nature of your relationship.
  
• Include a developmental assessment
• Seize every opportunity, recognize social and
  cultural norms that we work in.
• Invest more in the process than the outcome.
• You can express concern without judgment.

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Confidentiality and Consent Whats the Big Deal?

• Adolescents are going through tremendous
  physical, cognitive, emotional, sexual changes.
• Teens strive for autonomy and independence.
• Privacy is a key issue.
• Confidentiality is the cornerstone of alliance.

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Psychosocial Assessment - HEADSSS

• Review Confidentiality Limitations
• Home
• Education/Employment
• Activities
• Drugs/Alcohol/Tobacco
• Sexuality
• Suicide/Depression
• Safety

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HEADSSS Assessment

• An effective way to organize a psycho-social
  assessment
• A flexible tool which can be adapted to different
  stages of adolescent development and different
  risk profiles
• Can be used for brief screening or in-depth
  evaluation
• Should be updated regularly

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Confidentiality
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Concerns when Serving Teens
Communicate

• Confidentiality
• Confidentiality
• Confidentiality
• Confidentiality
• Confidentiality
• Confidentiality
• Confidentiality

• Written policy signed at intake
• Poster on wall (more later)
• Spoken at beginning of any verbal session

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Confidentiality

• Fear of disclosure prevents some minors from
  seeking services
• When providers assure young people that they will
  receive confidential care, they are more likely
  to seek care, especially when they need
  reproductive health services
• According to the American Academy of Pediatrics
  and the American College of Gynecologists and
  Obstetricians, lack or absence of confidentiality
  has been identified as a significant access
  barrier to health care

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When is Care Confidential?

• The authority to consent does not always mean
  care is confidential
• Providers are required to alert parents and
  arrange for a psychiatric evaluation if minor is
  an imminent danger to self or others
• Providers are required to alert authorities if
  there is reason to believe the patient is being
  abused

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When Is Care Confidential? Title X Exceptions

• Title X and other protections need to be
  considered
• Dictates that family planning services must be
  confidentialpre-empts state statutes
• Federal Medical Privacy Regulations apply

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Tips For Protecting Teen Confidentiality

• Refrain from discussing patient/client
  information in ANY public spaces
• Ensure privacy when teen is answering questions
  or filling out forms
• Collect up-to-date and service appropriate
  contact information
• Be attentive to paperwork flow. If EOB
  (explanation of benefits) or client satisfaction
  form is sent out, confidentiality may be
  breached. Consider alternative billing methods or
  referring out!

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Tips For Protecting Teen Confidentiality

• Make sure all doors are closed when discussing
  sensitive information
• Distribute small handouts on sensitive matters!
  Use discretion.
• Clarify confidentiality policies at the beginning
  of each visit
• Separate youth and parents starting at 11 years
  give teen parent a chance to have private time

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Keeping Care Confidential

• Inadvertent disclosures of information include
• Billing
• Telephone messages
• Responses to parental inquiries (More in a
  minute)

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Family Involvement
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A parent comes to the clinic.You feel
Pull out your response card

• Great! This is another opportunity to share
  information about our services.
• Generally okay, but I wonder what they want?
• Oh, dear, am I gonna be in the news?
• Im a little sick to my stomach.
• Completely violated. How dare they invade the
  sanctity of the private, teen visit!

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Family Involvement is a Perspective, Not a Policy

• It is a way of thinking about adolescents in
  their context
• It is an attempt to utilize the adolescent's
  adult support system
• It supports what we know makes a difference in
  adolescent sexual health parent/youth
  communication, connectedness and involvement

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Parents are NOT the Enemy
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Addressing Confidentiality with Parents Phone
Script

• Here at (your clinic or office), we offer
  confidential care to all of our patients.
  Therefore, we cannot give out information about
  any patients we may see here. We encourage you to
  talk with your son/daughter about any concerns
  you may have about him/her.

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Activity

• ROLE PLAY 1
• Separate into dyads (thats twos)
• Select who is Number One and who is Letter A
• Chuck will tell you who is the Administrator and
  who is the Parent calling for information about
  their teen at your clinic.

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Confidential AgreementParent

• I,____ (parent/guardian), allow___ (patient), to
  enter a confidential patient-physician
  relationship. I understand that she can make
  independent health care decisions, but that my
  input and involvement will be encouraged. ___
  (patient) has permission to schedule
  appointments and receive confidential reports
  from this office. I understand that various lab
  tests may be necessary in medical protocols and
  accept responsibility for physician and lab fees.
• ___________ ______________
• Parent/Guardian Physician

Developed by the American College of
Obstetricians and Gynecologists
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Confidential Agreement Patient

• I,________, (patient), am entering a confidential
  physician-patient relationship with________
  (physician). I will make an effort to communicate
  with my parent(s) or guardian(s) about issues
  concerning my health. I accept the personal
  responsibility of being honest and will follow
  the health care recommendations my physician and
  I establish.
• _____________ _______________
• Patient Physician

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OUR POLICY ON CONFIDENTIALITY Our discussions
with you are private. We hope that you feel free
to talk openly with us about yourself and your
health. Information is not shared with other
people unless we are concerned that someone is in
danger.
Sample statement developed by URMC Department of
Pediatrics
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Be Aware of the Impact

• Many programs have moved towards decreased adult
  presence in teen family planning programs through
  peer counseling, teen run clinics, etc.
• How does the presence of parents in the waiting
  room impact on youths perception of the clinics
  teen friendliness, confidentiality policies,
  etc?

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Steps to Fostering Family Involvement

• TRAIN ALL STAFF!
• Everyone who interacts with youth and their
  families must understand the perspective and
  integrate it into their interactions with clients
• Practice using client scenarios appropriate to
  each staff members positionfrom answering
  phones and making appointments to performing exams

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Communicating with Teens, Parents Partners
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You can get this poster at http//www.ahwg.net/re
sources/Poster_v2.pdf
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Performing An Atraumatic Parentectomy

• ROADMAP
• LAY OUT the course of the visit. Explain what
  will happen.
• EXPLAIN your program policy regarding adolescent
  visits.
• REVIEW your policy verbally early in the
  interaction with the youth and parent/partner.
• ACKNOWLEDGE that the youth is a minor and
  therefore has specific legal rights related to
  consent and confidentiality.
• INTRODUCE the concept of fostering adolescent
  self-responsibility and self-reliance.

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Atraumatic Parentectomy

• REINFORCE that this policy applies to all
  adolescents in your program (in other words, this
  is not specific to YOUR child or YOUR
  relationship).
• VALIDATE the parental role in their teens health
  and well-being.
• ELICIT any specific questions or concerns from
  the parent.
• DIRECT questions and discussion to the client
  while attending to and validating parental input.
• REMOVE
• INVITE parents to have a seat in the waiting
  area, assuring them that you will call them prior
  to closing the visit.

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Atraumatic Parentectomy

• REVISIT
• REVISIT issues of consent confidentiality with
  the youth, including conditions when
  confidentiality has to be breached (suicidality,
  abuse), once you are alone with the client.
• REVISIT areas of parental concern with the youth
  and obtain the youths perspective.
• CONDUCT the psycho-social interview (HEADSSS).
• CLARIFY what information from the psycho-social
  interview the youth is comfortable sharing with
  parent.

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Atraumatic Parentectomy

• REUNITE
• INVITE the parent back to close the visit with
  both the parent and the youth

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Parent/Teen Communication

• Talk with Your Kids
• http//www.talkwithyourteen.org/

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Is Your Program Teen Friendly?

• Were more popular than MySpace!
• Teen Posters, Teen Magazines, friendly staff
  Yup!
• Well, I like teens.
• Those kids should feel lucky were here for them.
• Teen friendly?

Pull out your response card
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Concerns when Serving Teens

• Teen Friendly
• Posters
• Magazines
• Special hours
• Time to talk to them
• Special entrances
• Images of teens
• Confidentiality
• Staff trained

• Non-judgmental
• Un-biased
• Youth development focused
• Peer Educators
• Peer Counselors
• Referrals to programs as well as services

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Prevention Starts Early Risk for Older Partners

• Be aware of timing of sexual development
• Early developing girls are at risk
• Teens with a history of childhood physical or
  sexual abuse are at risk
• Teens who date early are at risk
• Runaway and homeless youth are at risk

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Sexual Coercion
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Definitions

• Sexual Coercion
• Creating a feeling, situation or atmosphere where
  emotional and physical control lead to sexual
  abuse or rape, or a victim feeling that he or she
  has no choice but to submit to sexual activity
  with the perpetrator.

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Definitions

• Coercion typically involves threats of harm
• Losing job or decreased grades
• Damaging reputation
• Revealing other secrets
• Threatened physical harm
• Threats of harm to family or significant others
• Loss of relationship

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Definitions

• Sexual Abuse
• Sexual interaction with a minor that is initiated
  through coercion, including bribery and
  affection, fraud, intoxication, physical or
  emotional threats or force. In certain states,
  consensual sex may be reportable based on age
  differences.

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Definitions

• Rape
• A crime of violence carried out through sexual
  means. Refers to unwanted penetration (mouth,
  vagina, anus) using physical force, emotional
  threats, fraud or intoxication of the victim.

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Definitions

• Acquaintance/Date Rape
• A crime of violence carried out through sexual
  means by someone known to the victim where there
  is no mutual consent, including situations in
  which the victim is too intoxicated to consent.

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Definitions

• Relationship or Intimate Partner Violence (IPV)
• Emotional, physical and sexual control, coercion
  and abuse within an intimate relationship.

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Look for Behavioral Indicators of Abuse

• General behaviors
• lack of boundaries
• inability to make good decisions
• inability to trust
• behaviors which alienate/push others away

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Look for Behavioral Indicators of Abuse

• Risky Behaviors
• early onset of substance use with wider range of
  drugs used
• early sexual activity (volitional)
• higher risk of rape
• more likely to be involved with older men

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Look for Behavioral Indicators of Abuse

• Other Behaviors
• higher (more than 2 X) the rate of symptoms of
  poor mental health
• lower self-confidence and sense of self efficacy
• twice the rate of eating disorders, particularly
  bulimia

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Explore, but Do Not Assume Abuse

• These behaviors or characteristics can be
  indicators of ANY severe stress including
• Significant family dysfunction
• Mental health problems such as depression,
  anxiety or other diagnosis
• Substance involvement
• Academic stress

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Target girls who are at risk

• Be aware of timing of sexual development
• Early developing girls are at risk
• Teens who
• Have a history of physical or sexual abuse
• Live with a non-related adult male
• Date early or date older partners
• Have disabilities
• Are runaways or homeless
• Are at risk for sexual coercion and abuse

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Teach Resistance and Awareness Skills

• Reinforce positive behaviors and choices
• Emphasize the sexual activity is ALWAYS a choice
• Even if they have had sex in the past
• Even if they have been sexually active with other
  partners
• Even if they have had sex or sexual interactions
  in the past with this partner

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Teach Resistance and Awareness Skills

• Teach teens what constitutes sexual assault
• Males and females need this information
• Include information about under the influence
  sex
• Explore the characteristics of risky situations
• Elicit risky experiences from the teen
• Individualize intervention to this teens
  explicit risk

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Discuss the Continuum of Coercion and Abuse

• Discuss approaches to stop progression along the
  continuum
• Address the role of alcohol and drugs from the
  perspectives of both victim and perpetrator
• Discuss behaviors that may increase vulnerability
• Discuss behaviors that can be protective and
  reduce vulnerability

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IPV Resources

• National hotline
• 1-899-SAFE
• Tip/info sheets for youth and parents
• http//www.chooserespect.org/scripts/teens/rights.
  asp
• Fact Sheet
• http//www.cdc.gov/ncipc/dvp/DatingViolence.htm

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www.ahwg.net Behavioral Health Toolkit
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It is never too late to intervene

• Remember that you never know if the teen that you
  are talking with has been victimized in the past
• Challenge rape myths
• Provide information about resources and support
  help-seeking

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Teach Healthy Sexuality

• Sexually Healthy Adolescents
• Appreciate their own bodies
• Interact with all genders in respectful ways
• Express love and intimacy in appropriate ways
• Recognize and avoid exploitative relationships
• Can identify their own values
• Take responsibility for their own behavior

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Teach Healthy Sexuality

• Ask questions about sexual issues
• Enjoy sexual feelings without necessarily acting
  on them
• Are able to communicate and negotiate sexual
  limits
• Talk with a partner about sexual activity before
  it happens
• Understand the impact of media on sexual values
• Communicate desires not to have sex and accept
  refusals to have sex
• (Adapted from SIECUS, 1993)

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More information

• Adolescent Health Working Group
• www.ahwg.net
• National Center for Youth Law
• Oakland, CA
• www.teenhealthrights.org
• www.youthlaw.org

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Providers Toolkit Series www.ahwg.net
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What is RIGHT is more important than what is wrong
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Marketing Plan
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Marketing Tool

• Your Business
• Your Product
• Customer Needs
• Examine Your Business
• Your Customers

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Marketing Tool

• Promotion
• Competition
• Prospects
• A Marketing Plan
• Measuring Outcomes Evaluating

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Take Home Messages

• Youth Development Focused
• Strength based
• Confidentiality is Key
• Parents are Not the Enemy
• Help Teens to Learn Skills to Resist Unwanted
  Sexual Activity
• Teach about Healthy Sexuality
• Market, Market, Market

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Do you feel more comfortable working with teens
now than before?

• This has revolutionized the way that Im going to
  interact with teens!
• Im taking home some real gems, today.
• Im a little more comfortable doing what I do.
• It wasnt a total waste of time.
• I was pretty good already.

Pull out your response card
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References

• Monasterio, E. Educating and Counseling
  Adolescents. Workshop at California Family Health
  Council, Inc., Friday, October 12, 2007.
• Adolescent Reproductive Health Educaiton Project
  Curriculum, 2nd Edition. Physicians for
  Reproductive Choice and Health. October 2006.