Abstract
Purpose:
The AAP recommends that adolescents have time to speak alone with their healthcare provider, though adolescent time alone is increasingly less supported. In addition to allowing adolescents space to be more forthcoming, this time alone may have additional developmental benefits.
Methods:
Adolescent-mother dyads were invited from an adolescent medicine clinic in Dallas, TX to complete a semi-structured joint interview. As part of the interview, dyads discussed the portion of the visit where adolescents have time alone with the provider. Interviews were recorded, transcribed, and coded through an iterative approach.
Results:
Within the eleven dyads, the adolescents ranged in age from 13-20 years, and adolescents and mothers primarily self-identified as white or Hispanic. Dyads noted adolescent time alone allowed for increased autonomy in medical decision-making and an independent relationship with their provider. Dyads were concerned that adolescent discomfort and inexperience and could lead to decreased self-advocacy in the medical visit.
Discussion:
From the perspective of dyads, adolescent time alone with a medical provider fosters autonomy and supports the transition from pediatrics to adult medicine. Concerns about adolescent discomfort and limited self-advocacy can be addressed by openly communicating with the dyad that this time alone will have a developmental approach and will support emerging autonomy.
Keywords: Mother-child dyad, adolescent autonomy, adolescent confidentiality, adolescent self-advocacy, emerging autonomy
The benefits of adolescent time alone with a provider have long been understood [1], yet there is evidence that most adolescents do not have access to this time [2], and the current political climate is increasingly less supportive of adolescent confidentiality [3]. In 2023, it was estimated that only half of adolescents had time alone with a healthcare provider at their last visit. Younger adolescents and those in less socially advantaged households have significantly lower likelihood for time alone [4,5]. Various factors, such as time constraints, concerns about facilitating adolescent-parent communication, acute medical needs, and health system factors have been noted to play a role in the likelihood of time alone [6]. Despite this, prior studies have highlighted many benefits to adolescent time alone including greater comfort discussing sensitive topics, higher likelihood of receiving sexual health services, and more positive attitudes toward providers [5,7].
It is imperative that adolescents assume increasing responsibility for healthcare decisions as they transition to adult medicine [8], and the benefits of time alone may play a crucial role in this transition. Thus, we sought to describe the perspectives of adolescentmother dyads about the role of this alone time in managing emerging adolescent autonomy.
Methods
We conducted semi-structured interviews with mother-daughter dyads on attitudes about contraception. Cis-female adolescents ages 13-21 years old with an Adolescent Medicine clinic appointment in Dallax, TX were eligible. Patients were recruited either with a mailed flyer or phone call prior to their appointment. Adolescents were interviewed with their caregivers, who were all mothers age 38-53 years old.
As part of the interview about contraception, dyads were asked specifically about the portion of the visit where adolescents have time alone with the provider. Two independent coders used an iterative approach to code data about emerging autonomy during time alone with differences reconciled by consensus. The Institutional Review Board (IRB) of the University of Texas Southwestern approved this study, and all participants received a gift card for participation.
Results
Demographics of the 11 dyads (22 participants) are presented in Table 1. One 18-year-old noted that time alone with a provider made her feel “respected” and “like I’m being treated like a person.” Others noted that time alone ensured that the provider spoke to the adolescent directly rather than through the parent. One 18-year-old noted, “I’ve had times…where we’ve had conversations where I didn’t really feel heard because you’re talking more to my mom than me when I was the patient.” The mother of a 16-year-old agreed that this time allowed for increased autonomy in the healthcare setting, stating, “she needs to be able to be given the choice to make decisions, so it’s a really good time in kind of a controlled setting to let her have some freedom to make choices and communicate with her doctors openly.” Dyads also indicated that privacy is an important part of autonomy, regardless of whether the information is known to the parent. The mother of an 18-year-old noted, “I mean I wouldn’t want an audience if I was discussing personal healthcare stuff. I wouldn’t want my mom in there.”
Table 1.
Demographics of Participants.
| Adolescents n = 11 |
Mothers n = 11 |
|
|---|---|---|
| Age (mean, range), y | 16.5 (13-20) | 43.9 (36-55) |
| Self-Described Gender | ||
| Female | 11 | 11 |
| Race/Ethnicity | ||
| White | 5 | 6 |
| Hispanic | 4 | 4 |
| Black/African-American | 1 | 1 |
| Native American | 1 | 0 |
| Education | ||
| Middle School | 2 | 0 |
| High School | 9 | 1 |
| Some College | 0 | 5 |
| College/Graduate school | 0 | 5 |
Several adolescents described feeling uncomfortable during these interactions, including a 19-year-old who stated that the conversation alone with a provider felt “kind of awkward at first.” An 18-year-old noted, “a younger child [could be] a little bit intimidated…having to answer all these questions with a random person they don't know.” There was concern that this could lead to a negative experience or hinder self-advocacy. An 18-year-old reported,
Sometimes I get nervous [and I don’t] know what to say when they ask me questions because I’m so used to my mom answering the questions for me… sometimes my mind just goes blank…sometimes like I forget because I’m so used to having my mom
The mother of another 18-year-old noted that her daughter is “such a non-confrontational type of person or she’s very polite and stuff and so I feel like in the instances when she’s had bad experiences, I was out of the room.”
Discussion
Time alone with a provider, from the perceptive of dyads, signals the start of adulthood, fostering emerging autonomy and privacy in healthcare [7]. Overall, dyads viewed time alone as key to autonomy while recognizing it is still emerging. Specifically, dyads noted increasing independence in decision-making, the importance of building rapport one-on-one with their provider, and the significance of privacy as the adolescent enters adulthood. Dyads noted several concerns about this time alone, specifically that adolescents may struggle to self-advocate due to inexperience and/or discomfort, and that negative experiences could impact their future experiences in healthcare.
In order to normalize this transition, it is helpful to present in an opt-out approach (“I will be meeting with your adolescent alone”) rather than an opt-in (“would it be alright if I met with your adolescent alone?”) [9]. While adolescents may perceive this time alone as awkward, providers could easily address this by reassuring adolescents that their voices matter. Some mothers’ concerns about daughters’ ability to self-advocate [10], can be addressed by reaffirming the developmental nature of this approach and that each adolescent is given the support that they need [9]. Omitting alone time from the adolescent visit would contribute to a cycle of decreased autonomy and added challenges in the transition to adult medicine.
A limitation of this study is that participants were recruited using convenience sampling from one Adolescent Medicine clinic and the participants were all cis-females and caregivers all mothers. This may limit the generalizability of these findings – especially for adolescents who have limited/conflictual parental involvement or are less connected to medical care.
Conclusion
Adolescent time alone with their provider builds autonomy and preparedness for the transition out of pediatrics, and this time remains a crucial part of the adolescent visit. Concerns about self-advocacy and discomfort can be overcome by utilizing a developmental approach and openly communicating with dyads about the purpose of this time. Future research should include diverse dyads to explore cultural and developmental influences on time alone.
Implications and Contributions.
Time alone for adolescents and their medical provider encourages emerging adolescent autonomy and supports the transition from pediatrics to adult medicine. In a political climate where adolescent confidentiality is increasingly less supported, it is crucial to maintain this time alone to foster and support adolescent development.
Acknowledgments:
We thank the participants and coordinators of this study.
Sources of Funding:
This work was funded by the National Institutes of Health (NIH K22HD097291) and UT FOCUS.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Disclosure of potential conflicts, real and perceived, for all named authors: The authors have no conflicts of interest.
References
- 1.Chung RJ, Lee JB, Hackell JM, et al. Confidentiality in the Care of Adolescents: Policy Statement. Pediatrics. 2024;153(5):e2024066326. doi: 10.1542/peds.2024-066326 [DOI] [PubMed] [Google Scholar]
- 2.Edman JC, Adams SH, Park MJ, Irwin CE. Who Gets Confidential Care? Disparities in a National Sample of Adolescents. Journal of Adolescent Health. 2010;46(4):393–395. doi: 10.1016/j.jadohealth.2009.09.003 [DOI] [PubMed] [Google Scholar]
- 3.Kannappan A, Chaphekar A, Butler P, Middleman AB. Confidentiality and Contraception: Protecting Adolescent Care in Response to One State’s “Parents’ Bill of Rights”. Journal of Adolescent Health. 2023;73(4):650–654. doi: 10.1016/j.jadohealth.2023.03.016 [DOI] [PubMed] [Google Scholar]
- 4.So M. Differences in Receipt of Time Alone with Healthcare Providers Among US Youth Ages 12–17. J Am Board Fam Med. 2024;37(2):309–315. doi: 10.3122/jabfm.2023.230222R1 [DOI] [PubMed] [Google Scholar]
- 5.O’Sullivan LF, McKee MD, Rubin SE, Campos G. Primary Care Providers’ Reports of Time Alone and the Provision of Sexual Health Services to Urban Adolescent Patients: Results of a Prospective Card Study. Journal of Adolescent Health. 2010;47(1):110–112. doi: 10.1016/j.jadohealth.2009.12.029 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.McKee MD, Rubin SE, Campos G, O’Sullivan LF. Challenges of Providing Confidential Care to Adolescents in Urban Primary Care: Clinician Perspectives. Ann Fam Med. 2011;9(1):37. doi: 10.1370/afm.1186 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Grilo SA, Catallozzi M, Santelli JS, et al. Confidentiality Discussions and Private Time With a Health-Care Provider for Youth, United States, 2016. Journal of Adolescent Health. 2019;64(3):311–318. doi: 10.1016/j.jadohealth.2018.10.301 [DOI] [PubMed] [Google Scholar]
- 8.Cooley WC, Sagerman PJ, American Academy of Pediatrics AA of FP and American College of Physicians, Transitions Clinical Report Authoring Group. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2011;128(1):182–200. doi: 10.1542/peds.2011-0969 [DOI] [PubMed] [Google Scholar]
- 9.Mehus CJ, Voller V, Gewirtz O’Brien JR, Gower AL, McRee AL, Sieving RE. How is Time Alone Introduced? Experiences and Preferences of Adolescents and Parents. Journal of Adolescent Health. 2023;73(1):190–194. doi: 10.1016/j.jadohealth.2023.02.026 [DOI] [PubMed] [Google Scholar]
- 10.Pampati S, Liddon N, Dittus PJ, Adkins SH, Steiner RJ. Confidentiality Matters but How Do We Improve Implementation in Adolescent Sexual and Reproductive Health Care? Journal of Adolescent Health. 2019;65(3):315–322. doi: 10.1016/j.jadohealth.2019.03.021 [DOI] [PMC free article] [PubMed] [Google Scholar]