“I’m not leaving my teen alone with the provider in the exam room”
In my pediatric clinical practice, I also specialize in the care for adolescents and young adults (AYA). Adolescence is a dynamic period with multiple opportunities for decision-making as youth transition into adulthood. During patient visits, it is standard of care to allow for independent or alone time for the AYA patient to speak with the provider privately. This longstanding practice is supported by research over three decades which shows improved adolescent satisfaction and access to care at clinical settings that offer some level of confidential care. Adolescents are also more likely to feel empowered to take charge of their health and report more honest information about their history when they are given the opportunity to speak privately with their provider. However, youth and caregivers are informed that confidentiality does not apply if a youth shares information that could be potentially harmful to oneself or others, and must be disclosed for safety concerns.
When I first practiced this process during my medical training, I remember seeing a 15-year-old girl for her well-child visit and her mom declined to leave the room. She expressed confusion as to why she had to leave the room at any point during the visit because her teen was still a minor. This mom was not isolated in her perspective as I have engaged with many caregivers over the years with the same view. I usually proceed to discuss the topics with the teen and their caregiver(s) the same way I would during the independent time, including questions about safety, activities, relationships, moods, substance use, and sexual/reproductive health. I also ask every young person about their strengths and wishes for healthy living.
Whenever teens deny substance use, and early or unsafe sexual activity with caregivers present, it is not always clear how having their caregivers in the room affected the teens’ responses. Nevertheless, I applaud youth when they report healthy decision-making early in life. To further explore the teen’s ability to think critically, I also integrate some role-playing to simulate situations where peer pressure or external circumstances may challenge their decisions to lead positive, healthy lives.
What amazes me sometimes is the caregiver’s expression when they believe their teen’s responses means they’ve ‘failed’ those hypothetical scenarios. One parent berated his son for not knowing how to respond to a hypothetical peer who was offering marijuana for him to smoke. One mom looked disheartened when her daughter said she wouldn’t feel comfortable telling her parents if anyone touched her inappropriately. There is a gap when youth are expected to mature into thriving adults without intentional preparation.
Addressing caregiver hesitancy to independent time with providers
For youth without severe developmental disabilities, most parents and caregivers expect that their teen will one day become an adult who will be responsible for making independent decisions about their health and well-being. However, there are still some caregivers who insist on not leaving the room to allow for the teen to speak about their health independently. While some share their thoughts without prompting, I usually ask the caregivers to share their thoughts on why they do not believe their teen should be left alone. From my informal discussions, the majority of the caregivers are concerned about providers having unrestricted access to influence their teen on sensitive matters related to sexual/reproductive health. Other caregivers report that they just want to know what questions are being asked of their youth and want to be in the room to prevent any questions they deem inappropriate.
Personally, I commend the caregivers for taking a vested interest to safeguard the avenues that influence the patient’s mind, body, and soul. My heart aches for those youth who are victims of child neglect and abuse, sometimes at the hands of those who have been entrusted to keep them safe. In recent news related to the young women’s Olympic gymnastics team, cases of inappropriate provider behaviors against vulnerable girls reignite those fears among parents and caregivers of young children.
Gatekeepers vs Agents: Developmental milestones for caregivers
When it comes to sensitive topics such as sexual development and relationships, it is important to acknowledge the family’s core values and beliefs that guide the caregivers’ readiness to communicate those matters with their teenagers and young adults. The key lies in the practice of communication. It’s one thing to prevent your teen’s provider from discussing sensitive topics and it’s another thing to avoid discussing those same topics within your home. While we, as caregivers, want to protect our youth as they grow, our ability to continuously shield them will wane as they become more autonomous. Along the way, we too must evolve from our role as their gatekeepers to become agents of positive youth development.
“I am not a child anymore” has been expressed by every teen to their caregiver in some form, at some point in their development. This attests to the challenge parents and caregivers have in supporting their child’s development toward autonomy. One way to manage this challenge is to consider the caregiver role on a spectrum, from gatekeeper to agent. A Gatekeeper acts as a frontline person responsible for controlling the flow of information or people through an entry point. Some examples include the receptionist in companies, the security guard in buildings. There are certain rules which dictate what can pass through to the person(s) of interest. Sometimes those rules are set by higher authorities and other times, they can be self-imposed. We see caregivers as gatekeepers early in the teen’s development as the objective is to simply keep the child from harm without consulting for any feedback. As the child matures, elements of harm become more subtle when more teen influences extend beyond the home.
Agents can be contract experts negotiating on behalf of their clients, career counselors who help with big decisions and are proactively seeking resources on behalf of their client’s growth. Building autonomy is a necessary part of adolescent brain development and caregiver agents who provide safe spaces for teens to practice independent decision-making ensure that their teen develops skills to navigate life’s uncertainties.
How to transition from gatekeeper to agent as your teen grows up
It’s not always easy to know which situations call for you, as a caregiver, to act in the best interest of your teen as a gatekeeper versus an agent. Here are 3 key questions to ask yourself as you transition along with your teen into their adulthood.
1. Am I trying to protect my teen from harm or uncertainty?
- Not every decision a teen is faced with has clear right and wrong responses. If it is clear that the information or person seeking access to your teen may lead to negative outcomes, allow your gatekeeper alarm to sound loud and clear. For other matters, guide your teen with questions, as an agent, to help them plan ahead with possible pros and cons of any decision they face.
2. Do I believe my teen should NEVER experience the activity OR is the activity acceptable LATER in life under certain parameters?
- Youth have more access to global information through technology and if you are not educating your teen to navigate sensitive life matters before they leave for college or travel away from home, they may be ill-equipped to handle those situations independently. Setting expectations for certain experiences that may be acceptable later in life can be helpful such as stating what parameters are important for safeguarding against social media threats (agent) instead of avoiding all online communications (gatekeeper).
3. How will I address sensitive topics with my teen to empower them with skills for adulthood?
- Most caregivers express little comfort talking with their teens about sexual/reproductive health. Youth may get anxious if they are told to prepare for “The Talk”, but appreciate when sensitive topics are practically weaved into daily natural occurrences. Rather than creating a taboo around sexual or reproductive health matters (gatekeeper) consider exploring ways to create safe spaces for developmentally-appropriate dialogue with your youth (agent). Luckily, there are various community and online resources such as Amaze.org, Kidshealth.org and Your Teen Magazine for Parents to guide caregivers seeking to transition to become agents.
Over time, I learned the benefit of having other members of the clinical team share the standard of care for independent time with the provider so that caregivers are aware of that expectation before the provider enters the room. In addition, my caregiver resistance rates declined (anecdotally) as I addressed the rationale behind the caregivers’ hesitancy and shared a main benefit of the brief separation: to prepare their teen for adult models of healthcare. Hopefully, the 3 key questions offer a helpful guide for caregivers transitioning from gatekeepers to agents.