Njm6/9/04

Adolescent Health Discussion Transcript

**May -- June 2004**

**Neil Murphy**

[nmurphy@ANMC.ORG]{.underline} 05/03/04 07:45AM

Did you know that in some AI/AN groups using methamphetamines is
reported at 20% at BIA school vs. public school 15%?

An introduction to this discussion is below. Here are some issues to
consider:

-   Are there culturally acceptable and more useable screening tools
    both for risk and resiliency factors?

-   What have providers found to be successful office strategies for
    addressing risk behaviors?

-   What are some of the issues unique to your AI/AN population?

-   Do you have some of these same problems at your facility?

Please let us know your thoughts on these, or any other issues,
concerning AI/AN Adolescent risk behaviors

**ADOLESCENT PRIMARY CARE: RISK BEHAVIORS, ASSESSMENTS, AREAS OF FOCUS**

**Donna R. Perry, MD, FAAP, FSAM**

Primary care providers and adolescent health care specialists all agree
that the major health issues for the adolescent are the products of
health risk behaviors. However, surveys of primary care providers have
shown responses of anxiety to acknowledged fear that if a teen is asked
about their behaviors one or more of the following will happen:

-   The teen will lie-which is true more often if the parent is in the
    room than if you send the parent out for part of the visit.

-   The teen will tell the truth and then the provider has to assess the
    behavior, prioritize it, and come up with a management plan

-   Screening is time-consuming and asking the question will
    significantly set back the schedule

-   The problem will be identified, the patient wants help and the
    provider has no resources to whom the referral can be sent-our more
    rural clinics and service units are particularly at risk for this

> Screening for high risk behaviors can be done by:

-   Direct history-taking (time consuming and dependent on the skill and
    comfort of the questioner)

-   Written trigger questionnaires (language, length and cultural
    appropriateness limit use in some AI/AN communities)

-   Computer based screening (need equipment, computer savvy, and
    culturally appropriate programs)

After reviewing the Navajo Nation, Arizona Public School, BIA Schools
and National Youth Risk Behavior data, the following were the problems
seen in the Navajo area:

-   Alcohol (or other mind altering substance) use

-   Driving or riding with an impaired driver (34%)

-   Depression and suicide, (20% seriously considered suicide in the
    last one year)

-   Increasing tobacco use in younger populations (38% in last month)

-   High rates of marijuana use, (38% used marijuana in the last month)

-   Rising methamphetamine use

-   Risky sexual behaviors

Below are some examples of risk behavior trigger questionnaires that
have been developed and validated in other settings. None have been
normed for the AI/AN population, but may be adaptable.

-   GAPS (Guidelines for Adolescent Preventive Services) developed by
    the AMA for general screening ( a little long and complicated)

-   Health Survey for Adolescents developed by the Adolescent Quality
    Improvement Work Group in the state of New York (GAPS-like but
    shorter and seemingly more understandable)

-   CRAFFT or CAGE for substance abuse screening (both are standardized
    screening tools)

-   Rosenberg Self-Esteem Inventory (has been used in multi-ethnic and
    multi-educational situations)

-   ACOG Adolescent Visit Questionnaire available in the ACOG Tool Kit
    for Teen Care

The full text of this primer with References is available here:

[www.ihs.gov/MedicalPrograms/MCH/M/PCForum_docs/AdolescentPrimaryCare2lis]{.underline}

Please note that the AAP SIG-IH and Indian Health Primary Care Forums
are combined for this discussion. Again, please let us know your
thoughts on these, or any other issues concerning AI/AN Adolescent risk
behaviors

-   Are there culturally acceptable and more useable screening tools
    both for risk and resiliency factors?

-   What have providers found to be successful office strategies for
    addressing risk behaviors?

-   What are some of the issues unique to your AI/AN population?

-   Do you have some of these same problems at your facility?

**Oski, Jane (TCRHCC)**

Sent: Thursday, May 06, 2004 10:52 AM

Dear Donna et al,

As Donna and others on Navajo Area are aware, we at Tuba City have been
using a Confidential Screening Questionnaire in our Adolescent
School-based clinics for nearly a decade. Our screening tool is a
compilation of questions from the GAPS questionnaire with retooling to
reflect local concerns and an attempt to make existing questions more
clear-cut for the adolescent reader. At our fall 2003 Area wide Peds
mtg, the subset of Adolescent providers resolved to use the current
questionnaire (with local changes as providers saw fit) for the duration
of a year and to then revisit the utility of the screening
questionnaire. I have personally found the questionnaire to be quite
helpful in identifying students with risk behaviors. While it is by no
means comprehensive, it does do a good job of covering specific areas of
concern and can, therefore, be used as a springboard to further
evaluation. The greatest downside in my mind is that it is currently
being used for those students seeking a PE for sports, ROTC, summer
programs or jobs. This is a self-selected group of students that is not
necessarily representative of their peers. I have toyed with the idea of
administering the questionnaire to all students seeking care in the
SBHC, but this seems untenable with our current staffing at the schools.

If folks are interested in sharing our version of the questionnaire, I
would be happy to send it around.

**Burt Attico**

nbattico@POL.NET 05/09/04 11:37AM

I find the discussion about adolescent health to be very interesting,
and would like to enter something, but I am afraid that it might
potentially be taken the wrong way. One of my former partners & I had
many discussions about adolescents, and the fact that many did not
relate to providers because they regarded the health care provider as
being their mother\'s (the parent\'s) doctor. Many providers almost
always speak directly to the parent, and deal with the child in the 3rd
person, such that they (the child) feel uncomfortable when they enter
adolescence, and then seek health care. The history will often say,
\"the mother says that \...,\" as stark confirmation. The procedure of
\"parentectomy\" is often not performed (or else not done \"well\"), and
the mother will often even answer a question for the child. I have seen
this when I see a young pregnant teen, and if you ask about drugs or
contraceptives, \... no luck! And if you ask the kid if they want their
mother in the room, it had better be done outside of the parent\'s
earshot (or you get accused of attempting to dominate or alienate the
child). This situation is made yet worse because we often require the
parent\'s signature for most exams & treatments, and don\'t get a type
of blanket consent, except for boarding school care. If they (the child)
once find out that their trust (a confidence) has been violated, you are
totally & absolutely \"dead in the water\" for the future (whether that
be as child or adult).

We in the Phoenix Area had gone over the entire issue of teen
confidentiality, especially at Sherman, and have had major conflicts
with BIA folks, who wanted to give the info in the child\'s chart to
parents, and even wanted asking the parent for consent for the use of
contraceptives. Needless to say, there was conflict over kids going for
VIPs. Conflict, conflict! (VIP = voluntary interruption of pregnancy, an
elective abortion)

Sorry, and I hope that I have entered this comment in a way that can be
seen (and appreciated) as constructive. I also think that something
needs to be said about teaching the child how to become a health
consumer, as many of them (the pregnant teen, as an example) are soon to
become a primary consumer in their own right, even though technically
still a minor.

Burt Attico

\"Above all, care and be fair\"

**Peter Stuart**

Peter.Stuart@IHS.GOV 05/10/04 12:24PM

Some comments:

First, I am a practicing psychiatrist working in the center of the
Navajo Nation with 11 years experience in my community. Adolescents and
their families are the heaviest users of our clinic.

Second: Screening tools - the Teen Screen from Columbia U while not yet
normed in NA/AI populations looks promising and is computer-based and
free if you participate with Columbia U - and is something most teens
these days are very comfortable interacting with. It is intended to
identify students with mental health concerns and direct them to early
rather than later opportunities for intervention. It will, however,
potentially overwhelm a system that is not prepared for what it finds -
a risk with any of the screening tools. Indian communities are often
under resourced - both at the system level and the family level. It is
not uncommon for me to see adolescents who have lost several family
members within a relatively short period of time due to traumatic
causes - and whose families themselves are so traumatized by the losses
that they are unable to provide effective support. Any initiatives to
implement screening unless you can provide the needed services yourself
need to consider the system in which they\'re being applied -
particularly in communities like mine whose capacity to deal with
increased human services loads are limited to start. In way of
illustration, Flagstaff, a community of 55,000 people in our region
serving possibly another 150,000 or so has nearly a 100 private
therapists as well as school based counselors, church counselors etc,
and well over 25 psychiatrists within driving distance - while the
entire Navajo Nation (\~200K) does not list any private counselors in
the yellow pages, has very limited school based services, maybe 30 some
counselors with IHS and 14 psychiatrists.

Third, in response to the issue of \"parentectomies\" - the use of the
term itself implies a culturally loaded perspective on the
involvement/non-involvement of parents and families. I recognize I may
be going against hallowed adolescent medicine precepts - but I believe
many of those precepts reflect the western, individualistic culture in
which they arose. Caution is in order in the application of these
principles in many NA/AI communities as such application can be
interpreted as unintentional yet insidiously colonializing efforts that
reinforce western concepts of the individual and their role in the
larger community over traditional mores. In our clinic we have very much
tried to operate within the context of family as the primary social
supports and resources for the adolescent in our communities will come
from families or kin relationships. There is an obvious tension between
the individual perspective of the adolescent and his or her larger
family that needs to be negotiated as part of treatment. In western
terms, many of the families I deal with would be called \"enmeshed\"
families. Individual rights to happiness and self-fulfillment are often
secondary to the security and integrity of the larger family. My own
personal experience suggests that this is not pathological but a
reflection of the resources needed to maintain effective functioning in
communities such as the ones our clinics serve. Suggesting to the
adolescent that he or she can go it alone, or that more individuation is
necessary often amplifies the presenting crisis and is practically
speaking untenable for the adolescent in the long run. Treatment and
long-term resolution of the adolescent\'s crisis often means identifying
someone in the extended clan who can function as a support and family.
That is not to say we don\'t see adolescents individually - we do - but
we work very hard to acknowledge the nature of their interdependent
relationship with their larger family network.

I will stop there for now.

Peter Stuart, MD

Chinle, AZ

**Lori Byron**

Lori.Byron@MAIL.IHS.GOV 05/10/04 01:51PM

Dear all,

At Crow, for the past 15 years, we have tried to schedule the majority
of our sports physicals on a few days. On those days, we have
dieticians, public health nurses, and substance and mental health
workers present. The kids have a sports nutrition questionnaire to fill
out, and the dietician sees those with \"red flags\". The kids also fill
out a risk assessment; if they are suicidal (there were 5 \"seriously
contemplating suicide\" last year, or substance abuse seems to be a real
concern, they will see the mental health and/or substance abuse
counselors that day. The counselors usually have time to actually
\"touch base\" with a lot of the other kids too. Then, the docs and
mid-levels can focus more on health issues and family
planning/sexuality!

It works pretty well!

Lori Byron

**Donna Perry**

Donna.Perry@IHS.GOV 05/14/04 11:21AM

Weekly update:

First, the issue of parentecomies.

1\. In the ideal world we would have been the primary care provider for
our youth in middle school years (when healthy kids RARELY show up) and
we could have transitioned from talking mostly with the parent, and
getting more input from the child. Children at 6-7 can give a pretty
good history of a specific event, and with a little prompting of any
pain. Asking the parent to please let the child describe the complaint
first, and then getting the parental perception can start that
perception. While seeing a special ed teen this week, when I talked
directly to her, we got a MUCH different description of how the trauma
occurred, than what dad had thought happened. If that relationship
between provider and family is established before the teen years,
parent\'s rarely have problems giving the provider and teen some time
alone.

My observation here is that most parents, due to the cultural privacy
ethic, would rather not be with a teen during the examination. It is an
ideal time to ask specific questions that may not have been covered with
the parent. Also, from work in the high school clinics, many teens want
some privacy from family and friends.

The GAPS protocols included a parent questionnaire, and time with the
parent at least every 3 years. This includes the parent while allowing
the teen some space and time alone.

2\. Many practices that seen teens have written policies that are given
to parents and teens when the teen arrives, or in the 11-12 y.o. range,
so parents and teens know what to expect during the transition from
being the parent\'s advocate, to becoming the teen\'s advocate. This is
not an issue of excluding or trying to alienate the parent, but of
allowing enough separation to attend to the personal concerns of both
parent and teen.

Second, the plan of doing \"mass PE\'s.

While doing mass PE\'s can be done in ways that allow for risk behavior
screening and \"triage\" by bringing back teens with identified risk
behaviors, these are tough venues for doing confidential assessments.
They can bring together the specialists that are great for screening
athletes, but the athletes are a small segment of the population. The
other school attendees aren\'t put through that sort of screening on a
regular basis, and certainly not screened yearly. How can we entice more
of the teens to receive complete health evaluations at least every 2-3
years to include risk assessments and health education.

Doing more complete examinations is also more time consuming. Seeing
both a teen and their parent and doing assessments, and doing patient
education or triaging to return for more is time-consuming. There is
good evidence that provider intervention can decrease high risk
behaviors.

There is also new evidence from California that comprehensive sexuality
education including primarily abstinence, but including risk reduction
for those who become sexually active, can decrease teen pregnancy and
STD\'s. Partnering with schools and health educators can reduce the time
burden of doing it all in the clinical setting of our health care
facilities.

3\. Parental access to records vs. right of teen to confidential health
care.

This sounds a little like the dilemma I had with Navy regulations for
the 22 years I was there. Law provides teens with access to confidential
testing and treatment for STD\'s in ALL 50 states and DC. The Guttmacher
Institute website has the most up to date information of the variations
in state laws. We have discussed this with our records people and if we
include in the Purpose of Visit: Teen presents for confidential care\"
that part of the record is held back if parent\'s ask to view the
record. In the Navy, our clinic kept a confidential record separate from
the main record, and when the patient turned 18, we either put the
confidential information in their main chart, or shredded it.

Have a good weekend, hope to hear more ideas over the next week.

Donna R. Perry, MD, FAAP, FSAM

**Peter Stuart**

Peter.Stuart@IHS.GOV 05/14/04 05:54PM

Donna,

As usual you speak words of wisdom and experience!

A couple of comments - as a psychiatrist there are definitely
differences in how things end up in our clinics as compared to
pediatricians. In our case, the parent is often here dragging the
adolescent in because of behavior or performance issues either perceived
at home by the parent or by the school. In such cases there seems to be
little reluctance on the part of the parent in regards to participating.
This is obviously different from a teen that comes in with a physical
complaint where modesty and privacy at least here locally are more
issues. I always start with both parties in the room and tell the teen I
want to hear both their stories and also want to give the teen the
opportunity to hear what the parental concerns are. I encourage them to
speak up if they have disagreements with what is being discussed (and
they often do) but do tell them they will have a chance to go over
things in private. This approach respects the teen as part of the family
unit but also offers the teen to later expand or talk about concerns
that they may feel uncomfortable with the parent knowing.

As to mass PE\'s/screenings etc. there is fairly recent literature that
suggests that one-shot screens that occur without connection to
follow-up and other resources may actually increase unhealthy behaviors.
I would also caution providers about universal \"suicide prevention\"
programs as these may actually increase suicide and other self-harm
behaviors. I recently came across a program that was quite proud of
handing out nifty \"Suicide Prevention\" cards that had Suicide
prominently emblazoned on them. This is probably not a good idea! See
your local behavioral health expert for assistance and be cautious in
the implementation of such programs. Current best practice appears to be
a focus on amplifying resiliency and supports with more focused
interventions for specific high risk populations.

**Angela Erdrich**

angela.erdrich@MAIL.IHS.GOV 05/17/04 04:58PM

Dear IHS Adolescent Providers -

How do you handle a situation in which, when taking a confidential
history, you find out that the child is at risk for serious harm?

I am learning to start out my talk with the phrase, \"What you tell me
will be kept confidential unless I learn that you are at risk for harm
or that someone has been hurting you.\"

Situations that can up:

1\. Teenagers disclose ongoing or past sexual abuse or child abuse on
the GAPS questionnaire. We are obligated reporters.

2\. Teenagers might inadvertently disclose statutory rape while telling
about their sexual history (especially their STD contacts). A 14
year-old may have no desire to get her 23 year-old \"boyfriend\" in
trouble!

3\. Sometimes the health history picks up illegal activity of the
parents -On more than a few occasions, the \"have you ever been a
passenger of a car or truck when the driver has been drunk or high?\"
question has revealed that the parent has driven with the children while
drunk.

We should be prepared to deal with these answers. How can we/ should we
promise confidentiality on these questionnaires?

In the past, I have really found these questionnaires helpful but I came
to feel uneasy about having kids reveal so much in writing. At present
we are not using one at our clinic.

Angie Erdrich, MD

Pediatrician

Belcourt, ND

**Bernard Birnbaum**

[Bernard.Birnbaum@ihs.gov]{.underline} Monday, May 17, 2004 4:45 PM

In response to Dr. Erdrich\'s questions I have a few thoughts\... Teen
confidentiality is limited and we do have an obligation to inform them
of this. I use a similar phrase to disclose this - i.e. \"our
conversations today are private, but if there is something that poses a
life risk to you then I have to discuss this with your
parent/guardian/etc.\" I think each case has to be taken on a case by
case basis\... it is clear that issues related to clear risk of harm
such as parental child physical or sexual abuse, homicidality,
suicidality (with a plan), etc need to be disclosed. I think this issue
of statutory rape or parental \"illegal activity\" is more dicey. These
probably need to be taken more individually with active discussion with
the teen. My practice has been to avoid automatically reporting
statutory rape unless the patient consents to this\... for example, I
will inform a teen that the situation they are in is technically
statutory rape and ensure that their involvement was \"consensual.\" I
then offer to assist them in reporting it if they choose. I feel that to
report against their wishes in most circumstances is more detrimental to
their long term relationship with the medical community. These kids need
trust and secure relationships modeled for them. I have found, however,
that when offered referral and support many adolescents choose to go
forward with reporting (or allowing you to report) things like potential
abuse and \"illegal\" activity. It would be nice to have a lawyer's
opinion on this.

In regards to the GAPS questionnaire\... I agree with the teen upon
review of the gaps that I will destroy it. I then shred it and put only
in the chart what is relevant to their care. I\'m not sure that we\'re
obligated to put everything that we discuss with kids in the chart. In
our IHS service-unit, for example (I think Dr. Erdrich is very familiar
with Chinle), I\'m often not convinced that I can guarantee
confidentiality of some information because we live in such a small and
tightly knit community. The Gaps (or like screen) still can serve as a
very useful tool to uncover risk factors or concerns that I can then
focus on and document \"safely\". It would be nice to have a shorter and
more culturally appropriate tool.

Just a few thoughts,

Bernard Birnbaum, MD

Chinle, AZ

**Jane Oski**

jane.oski@TCIMC.IHS.GOV 05/20/04 12:34PM

Dear all,

Reading through the list of responses, I realize that I need to make a
few clarifications re: our use of the Confidential questionnaire here in
Tuba City.

As others have noted, I (we) begin our discussion with a definition of
confidentiality and the fact that if their responses reveal that the
teen is regarded as a risk to themselves or others, that we are
obligated to

intervene in some way. (Risk to themselves generates either an emergent
referral for Mental Health Services or a referral to our on-site
Telepsychiatry link with Peds/Adolescent psychiatrists and psychologists
at the U of AZ. Risk to others generates the appropriate Mental Health,
Social Services and/or PD referral as well as notification of school
personnel).

I let the student know that the questionnaire itself will be shredded at
the end of our visit but that information deemed critical to appropriate
follow-up is entered into the chart in a shorthand style (SA=sexual
activity, MJ =marijuana, DOAb-drugs of abuse, Grass, EtOH, Tob etc,
DV-domestic violence). I instruct the student that under AZ state
statute that their parents can petition for access to the chart but tell
the student that a) information protected by state and/or fed statute
related to SA, STDs, Family Planning, pregnancy, etc is protected and
that b)in my 10 years here, have not had a situation where a parent has
sought access to their

child\'s chart.

All of that being said, I recognize that the questionnaire remains a
useful but imperfect tool for identifying risk behaviors or situations
of potential harm that might otherwise not come to light. We are not
perfect in our

ability to intervene and we do not see every child, but those who are
identified do at least get referred to the appropriate services and do
get follow-up on a regular basis from our Adolescent Health Team. The
more

difficult aspect of the process is determining when and how to involve
the parent or guardian. I would be interested in others\' approaches to
parental involvement when dealing with students in a SBHC setting.

Jane Oski

Tuba City, AZ

**Donna Perry**

Donna.Perry@IHS.GOV 05/21/04 11:40AM

Resources for dealing with high risk behaviors identified in clinic
screening are a major challenge for almost every medical institution I
have seen or heard about. Rarely, through incredible amounts of work
with grant funding and local support, resources or programs have been
identified. Innovative solutions like the Tuba City Telepsychiatry links
are options rural places might consider exploring. Local tribal
behavioral health programs can be partners.

What sorts of successes have been demonstrated in communities? What have
been the most successful partnerships that have resulted in resources to
with the risk behaviors that have been identified.?

To introduce a slightly tangential issue, several respondents have
mentioned their school based clinics. Nationally these clinics have had
some success in dealing with risk behaviors by their proximity and
cooperation with school districts. The National Assembly on School Based
Health Centers (SBHC\'s)wants to partner more with AI/AN communities
that have SBHC\'s. The first challenge is to identify all the AI/AN
communities that have SBHC\'s, and schools that have a large proportion
of AI/AN students who also have SBHC\'s. IF your service unit has a
center, please contact Carrie Yamamura at headquarters, IHS. Many of the
school programs can be sites to identify risk behaviors, do primary
prevention programs support community and education resources

At the MCH Biannual meeting in Albuquerque in August, 3 of us are going
to be discussing SBHC\'s and approaches to reaching and serving teens
and some pre-teens, in our communities. We are still planning the
workshop, so we are open to suggestions from those who might be
considering attending the meeting and our workshop.

**Peter Stuart**

Peter.Stuart@IHS.GOV 05/25/04 09:26AM

I\'ll mention a couple of attempts our communities locally have
attempted to increase resources available to youth with identified
behavioral problems:

A very rural school system near us was selected for the Safe
Schools/Safe Students grant (3 year funding)several years ago. On the
whole this was successful insofar as it demonstrated the feasibility of
implementing a school-wide system of screens, referral sources and
supports for students. The more significant components included
establishing mental health resources at the school, creating coherent
behavior expectations across the schools, co-locating a judge and
probation officer on campus and providing support to teachers in working
with struggling kids. It unfortunately was too briefly funded to
determine real impact - behavioral health resources were literally
overwhelmed with presumably previously ignored kids and parents by the
middle of the second year and unfortunately the school was not able to
pull together its efforts to establish independent funding for the
mental health component (and this should clearly be distinguished from
guidance counselors who have generally little time or interest in MH
issues). Still, it and other similar schools have demonstrated how
integrated behavioral health supports are feasible and well accepted by
students, parents and teachers - and in some studies can improve school
performance. This is a \"big\" solution but one I would encourage
everyone advocating for in their systems.

On a smaller scale, we have been successful in establishing a day
treatment program for high risk students here at the Junior High School.
The program has been successful in managing students who otherwise might
have required residential care - and I believe it also acts as a support
to the remainder of the school in that it provides a source of expertise
on behavioral health issues to teachers and staff. It is paid for
through a combination of direct billing (under Medicaid guidelines) as
well as special ed funds from the school.

These are not simple solutions but have made a significant difference.
It emphasizes for me the need to see screening in the context of the
overall system it\'s being provided in.

**John Ratmeyer**

jrlili@CNETCO.COM\> 05/26/04 10:42PM

Thanks to all for much of the thoughtful discussion in regard to these
thorny issues. I have a couple of comments in response to what I\'ve
read thus far. I agree with the comments and suggestions tendered by
Donna Perry (Chinle) with one addition. It\'s great to call attention to
our need to establish long-term relationships with children, beginning
from an early age, so that we\'ve earned the trust of teens long before
they are teens. That\'s certainly what we advise parents to do. For
those of us who\'ve stayed in one place for a number of years (as I have
in Gallup for 13 years), it\'s still a challenge, but not too difficult.
We\'re well-known, with faces to match our names and a reputation that
says, \"I\'m not going anywhere any time soon.\" Fortunately, in Navajo
Area, we have many long-term folks (as Diana Hu \[Tuba City\] says of
us, \"lifers\"), but that doesn\'t appear to be the rule in many sites
throughout the Native health care system. Why should people trust us if
we don\'t invest a good chunk of time calling their community our own? I
didn\'t honestly feel I was \'breaking through\' until I had been here
for nearly five years, when I started to meet 2nd and 3rd children in
young families, and when the questions re: \"how long are you in for?\"
started to dry up! Like many of you, I came out here to Indian Country
with the idea that I\'d spend 3 or 4 years, then go get a \'real job\'
or do a fellowship. But, as I held on, I came to understand there is no
more real job than this one and that my vocation has become my calling.
I hope, in the future, that more pediatricians will choose to stay in
sites for longer periods than the usual 3 or 4 years. That stability and
continuity represents the greatest hope for lasting relationships with
our families and their children. With the families for whom I care,
I\'ve found that this relationship is almost the only thing that matters
in the end. It\'s the open door without which nothing else can happen.

In response to Bernard Birnbaum (Chinle), statutory rape warrants
mandated reporting, no matter what one\'s personal feelings may be. I\'m
not a lawyer, but I have considerable experience in this area of the law
through many discussions about such cases brought before our
multidisciplinary child protection team. Your approach \-- to engage the
child with your support and to assist her (him) in reporting \-- is a
great way to tackle the problem. It\'s always better if the victim is
invested in reporting. However, at the end of the day, your legal
obligation is to report. The prosecutors will do what you suggest we do
\-- look at situations case by case. When they feel the relationship is
\'consensual\', they decline to prosecute. For example, when the girl\'s
parents think the guy is the best thing that ever happened to their
daughter, they have a baby between them, they\'re living together, and
the father of the baby is lending financial support, prosecutors would
rarely go after the guy in our jurisdiction. But that is their decision
to make, not ours. It\'s perfectly appropriate to share that information
with the affected teen at the time of reporting. Although rarely, if
ever, enforced, physicians failing to report child maltreatment face
large fines or incarceration. Lastly, the law regarding statutory rape
exists for a reason: to say that there is an age below which consent is
developmentally difficult or impossible. We may think the ages or the
age differences between the affected parties are arbitrarily set too
rigidly or too old or too young, but the law is what it is. We can only
do our own jobs, then turn things over to law enforcement for the
decision of how to proceed, if to proceed at all.

Thanks for listening and I welcome any and all responses and other
perspectives!

John Ratmeyer, M.D., FAAP

Gallup Indian Medical Center

**Ursula Knoki-Wilson**

Ursula.Knoki-Wilson@IHS.GOV 05/27/04 02:55PM

I agree it would be nice if providers stayed beyond the average 2 years.
Don\'t forget about the value of first impressions and the compassionate
heart whose words and actions make meaningful connections with those in
our care in memorable ways. UKW