A 14-year-old girl comes to the office accompanied by her mother for an annual examination. The patient's medical problems include acne, for which she takes clindamycin. When seen alone for examination, she is shy and quiet. The patient says everything is "going okay." She does not have a boyfriend and is not sexually active. When asked about drug and alcohol use, she says, "No, but I have tried alcohol and marijuana a few times at parties." Physical examination is normal other than mild acne, which has improved since her last visit. Following the examination, the physician informs the mother that everything is fine, renews the patient's clindamycin prescription, and asks if she has any questions. With the daughter present, the mother replies, "I remember what it's like to be a teenager, but she is really impossible to deal with now. I can't get her up on time in the morning because she stays up late on her computer. She no longer wants to spend time with the family. In the morning, she refuses to eat breakfast and then sleeps during the entire drive to school. I worry because her school friends use drugs. I think they are a bad influence and now her grades are falling. I don't know how she will get into a decent college. We warned her that she wouldn't be allowed to go on the family vacation if she doesn't improve her grades, but she doesn't seem to care."
Which of the following is the most appropriate next step in response to the mother's concerns?

Question

A 14-year-old girl comes to the office accompanied by her mother for an annual examination.  The patient's medical problems include acne, for which she takes clindamycin.  When seen alone for examination, she is shy and quiet.  The patient says everything is "going okay."  She does not have a boyfriend and is not sexually active.  When asked about drug and alcohol use, she says, "No, but I have tried alcohol and marijuana a few times at parties."  Physical examination is normal other than mild acne, which has improved since her last visit.  Following the examination, the physician informs the mother that everything is fine, renews the patient's clindamycin prescription, and asks if she has any questions.  With the daughter present, the mother replies, "I remember what it's like to be a teenager, but she is really impossible to deal with now.  I can't get her up on time in the morning because she stays up late on her computer.  She no longer wants to spend time with the family.  In the morning, she refuses to eat breakfast and then sleeps during the entire drive to school.  I worry because her school friends use drugs.  I think they are a bad influence and now her grades are falling.  I don't know how she will get into a decent college.  We warned her that she wouldn't be allowed to go on the family vacation if she doesn't improve her grades, but she doesn't seem to care." 
Which of the following is the most appropriate next step in response to the mother's concerns?

Quizplus · Accepted Answer

Explanation: In this scenario, the mother has raised concerns about the patient's behavior at the close of the visit. It is unclear whether these are legitimate concerns regarding declining academic performance and possible substance misuse or whether the mother is overreacting to normal adolescent changes in sleep patterns and/or the patient's need for increasing privacy and independence. Although the patient reported that she was "okay" when first seen alone, she was quiet and not forthcoming. The mother's report of changes in her behavior is concerning and requires further assessment. The most appropriate step is to ask to speak with the patient alone again to obtain a better understanding of these issues from the patient's perspective. Adolescents often feel uncomfortable speaking with a parent present, and sensitive topics, such as substance use and mental health issues, are better addressed privately. This will build trust and allow the patient to be more open than she might be if questioned in the presence of her mother. (Choice A) Asking the patient to respond directly to the mother may place her in an awkward and defensive position and inhibit her from speaking truthfully. (Choice B) Although a urine drug test might identify unreported substance use, the patient has been forthcoming about her occasional drug use; as a result, requesting a screening would likely damage the physician-patient relationship. (Choice C) There is not enough information to reassure the mother that these are normal adolescent behaviors. (Choice E) Although this mother might benefit from feedback regarding her critical communication style with her daughter, it is not appropriate at this time. The mother is genuinely concerned, and the most important step is to perform further assessment. Educational objective: Developing rapport and trust is particularly important in treatment of the adolescent patient. When a parent raises concerns, assessment should include interviewing the patient alone. References: Effective interviewing and counseling of the adolescent patient. (http://www.ncbi.nlm.nih.gov/pubmed/16570482) Skills for interviewing adolescent patients: sustainability of structured feedback in undergraduate education on performance in residency. (http://www.ncbi.nlm.nih.gov/pubmed/27413448)

A 14-Year-Old Girl Comes to the Office Accompanied by Her