Adolscent Development: When things go wrong
Performing a psychosocial evaluation
While many of the common psychosocial issues of adolescence can be dealt with adequately within the framework of a routine visit, others require a more formal psychosocial evaluation. Such evaluations are certainly within the competence of many health professionals, although some practitioners choose to refer them to a consultant. In the authors’ practice, when families request a psychosocial evaluation or a colleague refers an adolescent, parents are sent an information sheet before the visit and—when family circumstances make this appropriate—both parents are asked to be present for the appointment. The following rules are carefully observed.
The author’s policy on confidentiality is posted prominently and reviewed verbally:
Our discussions with you are private.
We hope you will feel free to talk openly
with us about yourself and your health.
Information is not shared with
other people without your permission
unless we are concerned that
someone is in danger.
When to refer
Although many health professionals are qualified to treat the common behavior problems of adolescents, referral to mental health professionals is indicated in some cases. Referrals should be made if the diagnostic interviews reveal dysfunction in more than one of three critical areas: 1) home, 2) school, and 3) peer relationships. Also, if parents request referral after the diagnostic interviews, their preference should be honored—even if the provider feels qualified to manage the problem.
Referral is also indicated when the adolescents’ particular problems make the professional uncomfortable. Situations involving homosexuality, seductive behavior, or serious acting out may provoke emotional reactions that make objectivity difficult to maintain. It is as unrealistic to assume that primary caregivers can treat all psychosocial problems as it is to assume they can treat all medical ones. Knowing one’s limitations is an important professional attribute.
Final pearls in the article included:
• Rapport should be built during the preteen years.
• Consider the family’s view of what constitutes a problem.
• Nondirective listening is best.
• Explore all facets of the problem.
• Avoid premature reassurance.
(Prazar, G. An office-based approach to adolescent psychosocial issues. Contemporary Pediatrics 1997; 14(5):59-75)
Comment: Although written for pediatricians in private practice, this article contains much information useful to school nurses. It is particularly heartening to see private doctors urged to get an accurate picture of school performance and relationships by talking to school officials—rather than accepting the parent’s and/or student’s perceptions at face value. The physician’s office is often most comfortable in communicating with the school nurse. — R.A.