secrets, lies and testing dilemmas: parents’ requests for adolescent drug testing, sexual behavior...
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Secrets, Lies and Testing Secrets, Lies and Testing Dilemmas: Dilemmas:
Parents’ Requests for Adolescent Drug Parents’ Requests for Adolescent Drug Testing, Sexual behavior Information Testing, Sexual behavior Information Sharing and Ownership of Diagnostic Sharing and Ownership of Diagnostic
ResultsResults
Leslie R. Walker, MDLeslie R. Walker, MDAssociate Professor, Chief of Division of Associate Professor, Chief of Division of
Adolescent MedicineAdolescent MedicineDepartment of PediatricsDepartment of Pediatrics
Treuman Katz Center for Pediatric Bioethics - 2009 Conference
Territory to CoverTerritory to Cover
Parent –Provider-Teen TriadParent –Provider-Teen TriadProviders DilemmaProviders DilemmaStatutes/Laws influenceStatutes/Laws influenceContext mattersContext matters
Communication Communication RelationshipRelationship
Parent Parent TeenTeen
The TriadThe Triad
TeenTeen
ProviderProviderParentParent
Management of Management of InformationInformation
Assumption: Disclosure of information Assumption: Disclosure of information will allow the parent to monitor and will allow the parent to monitor and control an adolescent outcomecontrol an adolescent outcome
Adolescent non-disclosure is typically Adolescent non-disclosure is typically regarded as negative in studiesregarded as negative in studies
Increased parental monitoring is Increased parental monitoring is regarded as positiveregarded as positive
Management of Information: Management of Information: Dynamic ProcessDynamic Process
A parents desire for disclosure is dependent A parents desire for disclosure is dependent
on the adolescents’ willingness to discloseon the adolescents’ willingness to disclose Tilton-Weaver, Marshall 2008Tilton-Weaver, Marshall 2008
Increased disclosure parental Increased disclosure parental monitoringmonitoring
Decreased disclosure parental Decreased disclosure parental monitoringmonitoring
Management of Management of InformationInformation
Adolescents privacy and Adolescents privacy and disclosure:disclosure:
Important for boundary developmentImportant for boundary developmentHelp establish autonomous identityHelp establish autonomous identity
Management of Management of InformationInformation
Darling, et. al.2006Darling, et. al.2006703 11-19 year old Chilean students703 11-19 year old Chilean students97.5% reported non-disclosure to 97.5% reported non-disclosure to
parentsparents
Reasons to tell: Reasons to tell: 51% Felt obligated to disclose51% Felt obligated to disclose 34% To persuade parents34% To persuade parents 15% Would get caught15% Would get caught
Management of Management of informationinformation
Reasons to withhold: Reasons to withhold:
39% fear of punishment39% fear of punishment
37% emotional reasons37% emotional reasons
24% their private business24% their private business
Management of Management of InformationInformation
Adolescent medical disclosure of Adolescent medical disclosure of information:information: Adolescents reluctant to disclose without Adolescents reluctant to disclose without
confidentiality assurance.confidentiality assurance. Ford C et. al. Ford C et. al.
19971997
Management of Management of InformationInformation
Parents demand to knowParents demand to know
Adolescent need for autonomy Adolescent need for autonomy
Providers charge to provide care to Providers charge to provide care to
patientpatient
THE DILEMMATHE DILEMMA
Management of Management of InformationInformation
Provider contribution: Provider contribution: Culture plays a roleCulture plays a roleTrust plays a roleTrust plays a roleAgenda to improve/treat adolescentAgenda to improve/treat adolescentLegal considerations have a roleLegal considerations have a role Increased possibility of cooperative Increased possibility of cooperative
adherence to recommendationsadherence to recommendations
Provider requestsProvider requests
“ “Can’t you just test him secretly?” Can’t you just test him secretly?”
“ “I want to know, is he/she….”I want to know, is he/she….”
“ “Doctor, we do not want to tell Doctor, we do not want to tell her her
yet she has terminal cancer…..yet she has terminal cancer…..
ChallengeChallenge
To slow downTo slow downTo communicate effectivelyTo communicate effectivelyTo negotiate with parentTo negotiate with parentTo negotiate with teenTo negotiate with teenTo achieve workable rapport with To achieve workable rapport with
bothbothTo maintain trustTo maintain trust
Legal ConsiderationsLegal Considerations
State statutes must be known by State statutes must be known by providerprovider
Can be helpful for Provider to form Can be helpful for Provider to form clinic process/treatment guidelinesclinic process/treatment guidelines
Have little to do with successful Have little to do with successful negotiation of the conflictnegotiation of the conflict
““I need you to tell me if he is I need you to tell me if he is using drugs”using drugs”
You are in the middle of a busy You are in the middle of a busy clinic day and Sam B’s mother calls clinic day and Sam B’s mother calls and leaves a frantic message to the and leaves a frantic message to the office from her car to inform you she office from her car to inform you she is on her way with Sam to be drug is on her way with Sam to be drug tested. She has just found a baggie tested. She has just found a baggie of marijuana and a lighter in his of marijuana and a lighter in his backpack.backpack.
““I need you to tell me if he is I need you to tell me if he is using drugs”using drugs”
Already you know useful information Already you know useful information that may diffuse the urgent situation.that may diffuse the urgent situation.
Is it likely he is using?Is it likely he is using? Is it likely mom is not happy it and wants Is it likely mom is not happy it and wants
it to stop?it to stop? Is it likely that a drug test will solve the Is it likely that a drug test will solve the underlying issues?underlying issues?
What’s NeededWhat’s Needed
TimeTimeConfidential inquiry with SamConfidential inquiry with SamOutcome oriented discussion with Outcome oriented discussion with
MomMomAgreed upon information that can be Agreed upon information that can be
used in joint conversationused in joint conversationNext steps planNext steps plan
Information ExchangeInformation Exchange
Sexual BehaviorsSexual BehaviorsSecretive BehaviorsSecretive BehaviorsSeeing the boyfriend/crew againSeeing the boyfriend/crew againChronic or Terminal …..Chronic or Terminal …..STD’sSTD’sDrugsDrugsAdherence to medicationAdherence to medication
Context MattersContext Matters
Private Primary Care officePrivate Primary Care officePublic Health ClinicPublic Health ClinicSchool based Health ClinicSchool based Health ClinicClosed HMO systemClosed HMO systemPayment SourcePayment SourceEase of AccessEase of Access
Road Map to ConsensusRoad Map to Consensus
No clear answersNo clear answersMany considerationsMany considerationsAwareness of personal beliefs/biasAwareness of personal beliefs/biasAwareness of cultural concernsAwareness of cultural concernsNeed to provide effective care to Need to provide effective care to
teenteenContext mattersContext matters
Ultimate GoalUltimate Goal
AccessibleAccessibleAcceptableAcceptableAppropriateAppropriateEffectiveEffectiveEquitableEquitable