ENGAGING

THE ADOLESCENTS
MODULE
Using HEADSS Framework

MINISTRY OF HEALTH 
MALAYSIA 

DIVISION OF FAMILY HEALTH DEVELOPMENT

MINISTRY OF HEALTH MALAYSIA
ii 

 
 Foreword
I would like to congratulate the Family Health Development
Division and all consultants, contributors and editors who
have been instrumental in developing this “Engaging
Adolescent Module HEADSS Frameworks”. I appreciate the
concerted efforts, persistences and endurance of all the
relevant agencies in assisting the Ministry of Health develop
this Module.

It is my hope that this module will be useful guide and

reference for the training of healthcare providers involved in adolescent-friendly health
services. The training includes sections on establishing rapport, empathy and trust. It also
emphasizes on the importance of confidentiality and the need for being non-judgemental
when dealing with adolescent who may have variety of health problems.

I am confident that this module will be useful not only to healthcare providers but all service
providers dealing with adolescents. We hope that, with this module, our service providers
who have been trained will be equipped with necessary skills to better manage adolescents
especially high risk adolescent and work towards effective, quality, comprehensive and
holistic care.

It is my hope that this module will lead to adolescent friendly services and better outcome of
the adolescent population in Malaysia

Thank you

TAN SRI DATO’ SERI DR. HJ. MOHD ISMAIL BIN MERICAN
Director General of Health
Malaysia

iii 

 
 Preface
Adolescent Health Services in Malaysia are provided by
various agencies such as government agencies, non-
government organizations and private sectors. The main
service provider is the Ministry of Health through its network
of health facilities throughout the country.

Ministry of Health established the Adolescent Health Programme in 1996 as an expanded

scope of the Maternal and Child Health Services at the primary health care level. Since its
implementation, many efforts have been made to strengthen the programme through pilot
projects, trainings of healthcare providers and development of health education and training
materials.

During the early phase of the Adolescent Health Programme, several pilot projects have
been conducted to identify gaps to further improve services delivery. These projects pilot
projects provided valuable insights into the real needs of the adolescents.

In 2005, Ministry of Health develop a guideline on the implementation of adolescent health

programme at the primary health care level which consist of adolescent health screening
tools and standard operating procedures on managing common adolescent health problems.

Feedbacks from service providers also revealed that they require more skills in dealing and
exploring further the problems highlighted by the adolescents through the health screening
tools. In response to this, the Family Health Development Division has taken the initiative to
develop this module Engaging The Adolescents using HEADSS Framework. The HEADSS
psychosocial framework was developed by Cohen and Goldenring in 1988 and has been
widely used in other established adolescent health centres such as in Australia and New
Zealand. It is hoped that this module will further facilitate and enhance the service providers’
skills in exploring and engaging the adolescents.

Finally, I wish to thank all the consultants, specialists, counselors, psychologists and
paramedics involved in the development of this module. Special thanks also goes to Prof.
Dr. Susan Sawyer, Director Centre of Adolescent Health, Melbourne, Australia for her
support and assistance in developing this module.

Dr. Hjh Safurah Bt. Hj. Jaafar

Director
Family Health Development Division
Ministry of Health Malaysia
iv 

 
Introduction
Engaging The Adolescent Using HEADSS Framework module is produced to supplement
the existing teaching materials which are available at the primary health care facilities. It is
hoped that this module will improve the knowledge and skills of service providers in
managing the adolescents and providing adolescent friendly services. This module has been
developed based on inputs from experts locally and abroad. It is primarily intended to be
used for in-service training of all health care providers involved in managing the adolescents.
However, this module is also useful to anyone involved in dealing with adolescents in
general.

The module incorporates relevant and important aspects in managing the adolescents which
includes overview of adolescent health issues and challenges, understanding the
adolescents, improving communication skills, engaging the adolescent using HEADSS
framework and how service providers can further enhance their confidence in dealing with
the adolescents.

The module consists of five units i.e. Overview of Adolescent Health; Understanding the
Adolescent; Communication, Confidentiality, Rapport, Empathy & Trust; Using HEADSS
Psychosocial Framework and Face Your Fears.

Unit 1, ‘Overview of Adolescent Health’ consists of concepts of adolescent health, risk and
protective factors, adolescent health problems and characteristics of adolescent friendly
services.

Unit 2, ‘Understanding the Adolescent Development, Environment and Culture’.

Unit 3, ‘Communication, Confidentiality, Rapport, Empathy & Trust (CRET)’ consists of

definitions of the above, factors that enhance and erode CRET, including tips on essential
skills.

Unit 4, ‘Using HEADSS Psychosocial Framework’ for assessment and interview.

Unit 5, ‘Face Your Fear’ consists of understanding and managing our fear, as well as some
knowledge on medico-legal issues when handling adolescents.

This module utilizes various approaches in providing knowledge and skills in handling
adolescents through lectures, role plays, brainstorming sessions, video clips etc. It also
incorporates subjective and objective methods for evaluating the effectiveness of the training
programme through pre tests, post tests and check lists.

It is hoped that with the help of this module, service providers will be well equipped,
comfortable and confident in engaging and handling the adolescents.

v 

 
TABLE OF CONTENTS PAGE

Foreword iii

Preface iv

UNIT 1: OVERVIEW OF ADOLESCENT HEALTH 1

UNIT 2: UNDERSTANDING THE ADOLESCENTS 29

UNIT 3: CONFIDENTIALITY, RAPPORT, EMPATHY & TRUST 101

(C’RET©)

UNIT 4: USING HEADSS 137

UNIT 5: FACE YOUR FEARS 179

Acknowledgements and Contributors 218

Editors 221

vi 

 
 

UNIT 1

OVERVIEW OF
ADOLESCENT
HEALTH
1 
 
 

2 
 
 UNIT 1:

OVERVIEW OF ADOLESCENT HEALTH

TABLE OF CONTENTS
PAGE

1.1 Teaching Outline (Framework) 4-5

1.2 Introduction 6

1.3 Time frame 6

1.4 Objective 6

1.5 Contents 6

1.5.1 Concept of Adolescent Health 6-7

1.5.2 Risk and Protective Factors 8-10

1.5.3 Adolescent Health Problems 10-12

1.5.4 Characteristics of Adolescent Friendly Health Services 13

1.6 Appendices

Appendix 1 Pre and Post-Tests 14

Appendix 2 Format A 15

Appendix 3 Format B 16

Appendix 4 PowerPoint Presentation on Overview of

Adolescent Health 17-26

ƒ Concept of Adolescent Health

ƒ Adolescent Health Problems

ƒ Risk and Protective Factors

ƒ Characteristics of Adolescent Friendly

Health Services

1.7 References 27

3
 1.1: TEACHING OUTLINE (FRAMEWORK)

Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time

Objectives (participant) materials Evaluation (min)

1. Understand the 1. The Concept of Health Lecture/discussion Interactive • Laptop Pre test on 20
concept of discussion • LCD Unit 1
adolescent Adolescent Health (MOH Definition) “A state Explain the concept of • PowerPoint
health of complete physical, social, mental and adolescent health and presentation
spiritual well-being of adolescents that will bio-psychosocial-
enable them to live a healthy and harmonious environmental
life within a supportive environment in concept
preparation for optimal health in adulthood.”

Bio psychosocial-environmental concept

looks into health of adolescent in the context
of:
• Individual
• Family
• Community
• Environment

2. Understand 1. Risk and Protective Factors Facilitate Brainstorming • Laptop Format A: 30

adolescent risk • Individual brainstorming session. • LCD “Case scenario
and protective • Family session. • PowerPoint on risk and
factors based • Peers List down presentation protective
on Bio • School Discuss the risk and risk and factors”
psychosocial protective factors protective
Model
• Community and suggest factors base
• Environment intervention. on the case
scenario
given.

4
Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time
Objectives (participant) materials Evaluation (min)
3. Describe and 1. Adolescent Health Problems Facilitate Brainstorming • Laptop Example of 30
understand the • Physical problems brainstorming session • LCD common
five main areas • Sexual reproductive problems session on common • PowerPoint problems
of concern in • Nutrition and eating disorder health problems in Interactive presentation within the five
dealing with • Mental health adolescent in the discussion main areas of
adolescent • Risk taking behaviour problems clinic. concern

Discuss the 5 main

areas of concern in
dealing with
adolescent.

4. Describe and 1. Characteristics of Adolescent Facilitate Brainstorming • Laptop Format B: 30

understand the Friendly Health Services brainstorming session • LCD “List down the
characteristics • Friendly policies session. • PowerPoint characteristics
of Adolescent • Adolescent friendly procedures Interactive presentation of Adolescent
Friendly Health • Adolescent friendly health care Discuss the discussion Friendly
Services providers characteristics of Health
• Adolescent friendly support staff Adolescent Friendly Services at
• Adolescent friendly health facilities Health Services at your clinic and
• Adolescent involvement your clinic and suggest
• Community involvement and dialogue suggest improvements”
improvements.
• Appropriate and comprehensive
Post test on 10
services
Unit 1
• Community based, outreach and
peer-to- peer services
• Effective health services for
adolescents

TOTAL TIME 2 Hrs

5
1.2 INTRODUCTION

This Unit provides information to help participants understand the adolescents and factors
contributing to their health. These include the concept of adolescent health, risk and
protective factors, common problems affecting adolescent and characteristics of adolescent
friendly services.

1.3 TIME FRAME

120 minutes

1.4 OBJECTIVE

At the end of Unit 1 participants will be able to:

• Understand the concept of adolescent health
• Understand adolescent risk and protective factors based on bio psychosocial
environmental concept
• Describe the five main areas of adolescent health problems
• Describe the characteristics of Adolescent Friendly Health Services

1.5 CONTENTS

• Concept of Adolescent Health

• Risk and Protective Factors
• Adolescent Health Problems - five priority areas
• Characteristics of Adolescent Friendly Services

1.5.1 CONCEPT OF ADOLESCENT HEALTH

Adolescent Health is defined as “A state of complete physical, social, mental and spiritual
well-being of adolescents that will enable them to live a healthy and harmonious life within a
supportive environment in preparation for optimal health in adulthood.” (Ministry of Health
definition). The physical, mental, social and spiritual health of adolescent are interrelated.
The majority of adolescent health problems are psychosocial.

CONCEPT OF HEALTH &

HEALTHY LIFESTYLE
„ Biopsychosocial spiritual concept of
health

Physical

Spiritual Mental

Social

The physical, mental, social and spiritual health of adolescent are interrelated
6

The life course perspective view life as a cycle from whom to tomb. Problems in early
childhood influence the growth and development of adolescent and their future. Many health
risk behaviours and lifestyle are established in adolescence and continue into adulthood
leading to chronic health problems e.g. smoking, alcohol and nutritional problems.

6
 CONCEPT OF HEALTH &
HEALTHY LIFE STYLE
Womb to tomb – Life course perspective

Newborn Elderly

Child Adult

Adolescent
9

Studies revealed that children who experience early-life stresses such as abuse, neglect or
loss of a parent have an increased risk of developing attachment disorders. Later in
childhood, these same children show an increased incidence of manifesting some types of
behavioural and emotional disorders, including attention deficit/hyperactivity disorder,
conduct disorders, anxiety, depression, suicide, drug abuse and post-traumatic stress
disorder.

CONCEPT OF HEALTH &

HEALTHY LIFE STYLE
Social & Environmental Model

Environment

Community

Family

Individual

The social environmental model looks into the various factors influencing adolescent health
and development in the context of:
• Individual
• Family
• Community
• Environment

In adolescents, family, peers, community and environment play a very important role in
shaping and determining their health and behaviour. There are protective as well as risk
factors within the individual, family, peer, community and environment. Service providers
need to be aware of and identify these risk and protective factors in order to help and
manage the adolescent effectively.

7
1.5.2 RISK AND PROTECTIVE FACTORS

Risk factors are factors that predict earlier engagement in a range of health risk behaviours
and social outcome. These include factors within the biological, individual, family, peer and
community.

Protective factors are factors that can ameliorate risk factors or increase the likelihood of
positive health and social outcomes. The more protective factors in an adolescent’s life the
more likely they are to make healthier choices.

There are various factors that influence health and behaviour. Among well researched
factors are having one responsible adult, safe and supportive environment as well as
parental approval. The following list of protective and risk factors can be used as the
guideline for exploring further adolescent health issues to manage the adolescent effectively.
The following highlights some of the potential risk and protective factors within the individual,
family, peer, school, community and environment.

A. Individual

Intrinsic factors and characteristics within the adolescent may affect their health and
wellbeing. Within an individual, the more the protective factors and the less the risk factors
will contribute towards better health outcomes.

Protective factors

• Resiliency – ability to cope with problems and stress

• Good self image
• Good self esteem – can be a risk factor
• Positive thinking
• Spirituality/Religiosity
• Overall satisfaction with life
• Connectedness with home
• Good relationship with parents
• Sense of security

Risk factors

• History of abuse
• Chronic illness
• Substance abuse e.g. smoking, alcohol

However, studies showed that individual protective factors such as high self-esteem, good
school achievement and problem-solving skills were not sufficient on their own to overcome
the negative social and environmental risk factors, thus intervention need to be holistic.

B. Family

Adolescent who grow up within a happy and warm family are most likely to experience
positive outcomes in their emotional wellbeing, school success, self esteem and avoid high
risk behaviour. While friendship becomes more important with age, family support continues
to be of importance into adulthood.

8
Protective factors

• Stable family – either two parents or one parent

• Authoritative parenting style
• Parental regulation
• Having meals with parents
• Adequate, reliable and stable family income
• Recognition of contribution and achievements

Risk factors

• Dysfunctional family
• Parenting style – authoritarian, permissive and neglectful
• Family history of substance abuse
• Family history of suicide
• Family history of mental disorder e.g. depression

C. Peers

Peer has very important influence on health and wellbeing of the adolescent. Mixing with the
right crowd helps to protect the adolescent from engaging in risky behaviour.

Protective factors

• Friendship with young people who like school, motivated and are doing well
• Friendship with peers who have authoritative parents
• Friendships with peers who have self worth and competence
• High quality of friendship and having close friends (more likely to prevent loneliness
and feelings of social unacceptability than non mutual friends)
• Recognition of contribution and achievements

Risk factors

• Friends who reject and relate negatively to one another (e.g. fights or teasing)
• Friends involved in risky behaviours such as smoking, alcohol and substance abuse.

D. School

Safe, secure and supportive school environment help adolescents achieve good outcomes.
Caring and support by teachers is associated with better mental health, higher motivation to
learn and better marks

Protective factors

• Positive regard by teachers where students contribution are valued, recognized and
acknowledged
• Close confiding relationship with at least one adult
• Positive relationship with peers and teachers
• Having communication skills and opportunity to talk with others who are supportive
• Involvement and participation in school activities

9
 • Involvement and participation in school decision making groups
• Sense of security from physical harm as well as to be able to express themselves.
They need to feel able to express their opinion, take part in school activities without
fear of being ridiculed, left out or isolated.
• Connectedness (sense of belonging) with school – interested in schooling and
learning activities.

Risk factors

• Absenteeism
• Alienation
• Bullying and harassment
• Disengagement
• Low academic achievement
• Violence
• Isolation

E. Community/Neighbourhood

Community/neighbourhood can have positive or negative impact on adolescent. Overall the

impact of neighbourhood is fairly low compared with family and other influences.
Adolescents in the healthiest most nurturing neighbourhoods where there is the greatest
number of strengths tend to have the best outcomes.

Protective factors

• Facilities – adequate and appropriate recreational and housing facilities

• Opportunity and skills for communication
• Opportunities and skills for achievement
• Involvement and participation in community activities
• Positive media influences

Risk factors

• Negative influence by the media and industries.

• Unhealthy social and physical environment

1.5.3 ADOLESCENT HEALTH PROBLEMS

Adolescent health problems can be classified into five main areas of concern that is physical
health, nutritional health, mental health, sexual & reproductive health and risk taking
behaviours. However, service providers need to be aware that adolescent health problems
are multifaceted covering biological, physical, emotional, social and economical issues.
Common health problems among adolescents are as listed below. Details of each condition
pertaining to its clinical manifestations and management can be obtain from the Adolescent
Health Care Manual (IKU) and Garispanduan Pelaksanaan Perkhidmatan Kesihatan Remaja
di Peringkat Kesihatan Primer (BPKK).

10
 A. Physical Health

Majority of adolescents who come to the primary care facilities present with physical
symptoms. However the service providers need to be aware of and explore the underlying
psychosocial problems. Based on evaluation of the pilot project done in eight districts in
2000, the commonest presenting symptom was upper respiratory tract infection (35.6%).
Other common presentations include the following:
• Headache
• Abdominal pain
• Non specific symptoms such as lethargy, insomnia.
• Skin problems (acne, dermatitis, fungal infection, scabies etc)
• AGE
• UTI
• Chronic disease such as asthma

There is growing evidence suggesting that young people with chronic conditions are doubly
disadvantaged i.e. engaging in high risk behaviour to at least similar if not higher rates as
healthy peers, while having potential greater adverse health outcomes from these
behaviours.

B. Nutritional Health

During puberty, adolescent require proper nutrition for the rapid growth and development
that occur during this stage and also to sustain good health. Balance nutrition is important in
adolescence but due to the environmental and social factors such as globalization, fast food
industry and media influence adolescent adopts unhealthy eating habits. During
adolescence, self awareness of physical appearance also play a very important role in
influencing their eating behaviour resulting in nutritional and eating disorders such as the
following:
• Nutritional deficiencies such as anaemia
• Underweight
• Overweight
• Obesity
• Anorexia nervosa
• Bulimia nervosa

C. Sexual and Reproductive Health

Puberty marks the onset of reproductive capabilities in adolescents. During this stage,
adolescents develop attraction to the opposite sex and may involve in sexual activities. Due
to limited knowledge and experience, they may engage in unprotected sex which may lead
to STI, pregnancy and suffer from psychosocial, economical and legal consequences. The
following are some of the sexual and reproductive health related problems:
• Problems associated with menstruation (irregular menstrual cycles, dysmenorrhoea)
• Sexual orientation (homosexuality, lesbianism)
• Sexually Transmitted Infections (Chlamydia, gonorrhoea, herpes genitalis, HIV etc)
• Sexual abuse and violence (rape, incest, sexual harassment)
• Sexual behaviours (masturbation, premarital sexual relationship, unprotected sex)
• Pregnancy and childbirth (teenage pregnancy, abortion, child abandonment).

11
 D. Mental Health

Adolescence is the period of gradual transition from childhood to adulthood. This transition is
accompanied by significant and challenging changes in the life of adolescent biologically,
physically, emotionally, socially and economically. Various factors may contribute towards
mental health problems in adolescents such as individual self, family, peer, school,
community and environment. Among the common mental health problems encountered at
primary care level are:
• Stress
• Emotional problems
• Depression
• Anxiety disorder
• Para suicide
• Conduct disorder
• Schizophrenia
• Suicide

E. Risk Taking Behaviour

Adolescent with limited or no experience engage in potentially disruptive behaviour with or

without understanding the immediate or long term consequences of their action. Although
some risk taking is necessary in the normal developmental process, too often the result of
risk taking are disastrous and may extend into adulthood. Common risk taking problems
among adolescents are as follows:
• Substance abuse (smoking, glue sniffing, alcohol, ATS)
• Violence (gangsterism, bullying)
• Illegal racing (Mat Rempit)
• Juvenile delinquency

12
1.5.4 CHARACTERISTICS OF ADOLESCENT FRIENDLY HEALTH SERVICES

To address the adolescent health problems, it is important to have adolescent friendly

services. Adolescent friendly health services need to be accessible, equitable, acceptable,
appropriate, comprehensive, effective and efficient. Health care providers must be well
trained and skilful in managing adolescent and their health problems. The following are
characteristics of adolescent friendly services based on the WHO Global Consultation in
2001 and discussions at a WHO expert advisory group in Geneva in 2002.

a. Adolescent friendly policies that

ƒ fulfil the rights of adolescents as outlined in
the UN Convention on the Rights of the Child
and other instruments and declarations
ƒ take into account the special needs of
different sectors of the population, including
vulnerable and under-served groups
ƒ do not restrict the provision of health
services on grounds of gender, disability,
ethnic origin, religion or (unless strictly
appropriate) age
ƒ pay special attention to gender factors
ƒ guarantee privacy and confidentially and
promote autonomy so that adolescents can
consent to their own treatment and care
ƒ ensure that services are either free or
affordable by adolescents
b. Adolescent friendly procedures to
facilitate
ƒ easy and confidential registration of patients,
and retrieval and storage of records
ƒ short waiting times and (where necessary)
swift referral
ƒ consultation with or without an appointment
c. Adolescent friendly health care providers
who
ƒ are technically competent in adolescent
specific
ƒ areas, and offer health promotion,
prevention, treatment and care relevant to
each client’s maturation and social
circumstances
ƒ have interpersonal and communication skills
ƒ are motivated and supported
ƒ are non-judgmental and considerate, easy to
relate to and trustworthy
ƒ devote adequate time to clients or patients
ƒ act in the best interests of their clients
ƒ treat all clients with equal care and respect
ƒ provide information and support to enable
each adolescent to make the right free
choices for his or her unique need
d. Adolescent friendly support staff who are
ƒ understanding and considerate, treating
each adolescent client with equal care and
respect
ƒ competent, motivated and well supported
e. Adolescent friendly health facilities that
ƒ provide a safe environment at a convenient
location with an appealing ambience
ƒ have convenient working hours
ƒ offer privacy and avoid stigma
ƒ provide information and education material
f. Adolescent involvement, so that they are
ƒ well informed about services and their rights
ƒ encouraged to respect the rights of others
ƒ involved in service assessment and
provision.
g. Community involvement and dialogue to
ƒ promote the value of health services and
ƒ encourage parental and community support.
h. Community based, outreach and peer-
to-peer
ƒ services to increase coverage and
accessibility
i. Appropriate and comprehensive services
that
ƒ address each adolescent’s physical, social
and psychological health and development
needs
ƒ provide a comprehensive package of health
care and referral to other relevant services
ƒ do not carry out unnecessary procedures
j. Effective health services for adolescents
ƒ that are guided by evidence-based protocols
and guidelines
ƒ having equipment, supplies and basic
services necessary to deliver the essential
care package
ƒ having a process of quality improvement to
create and maintain a culture of staff support
k. Efficient services which have
ƒ a management information system including
information on the cost of resources
ƒ a system to make use of this information

Source : WHO Global Consultation in 2001. An agenda for change

13
 APPENDIX 1

OVERVIEW OF ADOLESCENT HEALTH

PRE AND POST TEST

ANSWER ALL QUESTIONS: (Indicate “T” for True or “F” for False)

1. The following are correct regarding adolescent:

A. Age group 10-19 year old

B. The majority of adolescent problems are psychosocial problems
C. Early childhood experience does not influence adolescent development
D. Many health problems in adulthood are established during adolescence
E. Adolescent health are influence by factors within the individual, family, community
and the environment

2. Risks and protective factors

A. Risk factors are factors that predict earlier engagement in health risk behaviour
B. The more protective factors in an adolescent’s life, the more likely they are to make
healthier choices
C. It is important to identify individual risk factor in an adolescent such as chronic
illness, low self esteem and substance abuse.
D. Resiliency and religiosity are not protective factors in adolescent
E. Peers strongly influence adolescent’s risk and protective behaviour

3. The following is/are true on protective and risk factors in the family, school and
community

A. Connectedness to family and school are important protective factors in adolescent

B. Low academic achievement, and school absenteeism are risk factors
C. Having opportunity to communicate and participate in school activities are
protective factors
D. Teachers and family members play an important role in helping adolescents
E. Media, industries and neighbourhoods may influence adolescent’s behaviour and
lifestyle

4. Adolescent health problem

A. Majority of adolescents who come to the health clinic presented with physical
symptoms
B. Overweight and obesity are common nutritional problem among adolescent
C. Adolescent mental health and psychosocial problems are often overlooked.
D. Many adolescents experiment with at least tobacco or alcohol or sexual relationship
E. STI/HIV and sexual abuse should be excluded in adolescent presenting with
abnormal vaginal/urethral discharge

5. The following are true about adolescent friendly health services

A. Physically and psychologically accessible

B. Have adolescent friendly policies
C. Service providers and supporting staffs who are trained, competent with good
communication skill and non judgmental.
D. Active adolescent involvement and participation
E. Comprehensive adolescent health services.

14
 APPENDIX 2

FORMAT A

CASE SCENARIO

Nolin, a 15 year-old teenager come to the clinic with abdominal pain. In her screening form
(SKR2) it was noted that her last LMP was about 3 months ago.

She is staying with her parents in a low cost flat in Sentul KL. Both parents are working hard
to support the family and have no time for their children. Her parents frequently argue due to
financial problems. Nolin is more close to her mother but doesn’t want to further burden her
mother with her problems.

She is the eldest of 6 siblings. She goes to a nearby school about 2 km from her home. She
frequently did not complete her homework and always get scolded from her teacher and
teased by her classmates. She frequently missed school to take care of her younger
siblings.

She is unhappy with her life, feels lonely, inferior and has no one to turn to for help until she
met her boyfriend. Her boyfriend is a 17 year old drop-out, and involved in illegal racing and
invites Nolin to join in.

1) Identify the risk and protective factors in the above scenario

2) Identify the modifiable and non modifiable risk factors
3) Suggest ways to reduce the risk and increase protective factors for Nolin and her
family

Categories Risk Factors Protective Factors

Individual

Family

Peers

School

Community/
Environment

15
 APPENDIX 3

FORMAT B

CHARACTERISTICS OF ADOLESCENT FRIENDLY HEALTH SERVICES

i) List down the characteristics of Adolescent Friendly Health Services at your clinic
ii) Suggest how to improve it.

Characteristics of Adolescent Friendly How to make it better

Health Services at your clinic

16
17
18
19
20
21
22
23
24
25
26
1.7 REFERENCES

Bahagian Pembangunan Kesihatan Keluarga, Cawangan Kesihatan Keluarga, Kementerian

Kesihatan Malaysia. 2005. Garis Panduan Pelaksanaan Perkhidmatan Kesihatan
Remaja Di Peringkat Kesihatan Primer.

Institut Kesihatan Umum dengan kerjasama Bahagian Pembangunan Kesihatan Keluarga,

Kementerian Kesihatan Malaysia. 1997. Adolescence Health Care. Adolescent Health
Needs.

Institut Kesihatan Umum, Kementeriaan Kesihatan Malaysia. 1997. Adolescence Health

Care. Counseling the Adolescent.

McLaren, K. 2002. Youth Development. Literature Review. Building Strength: A review of

research on how to achieve good outcomes for young people in their families, peer
group, schools, careers and communities. Ministry of Youth Affairs June.

Ministry of Health Malaysia. 2005. National Adolescent Health Plan of Action.

Peter Chown, Dr Melissa Kang. Caah The Children Hospital at Westmead NSW Centre for
the Advancement of Adolescent Health Transcultural Mental Health Centre. In
partnership with Northern Rivers Division of General Practice. Department of General
Practice, The University of Sydney at Westmead Hospital. Adolescent Health.
Enhancing the skills of General Practitioners in caring for young people from culturally
diverse backgrounds. A RESOURCE KIT FOR GP s.

Phoon, W.O, Chen P.CY. 1987. Textbook of Community Medicine in South – East Asia.

The Gatehouse Project. 2002. Promoting Emotional Wellbeing: Team Guidelines for Whole
School Change. Centre for Adolescent Health.

World Health Organization Western Pacific Region. 2005. Sexual and Reproductive Health
of Adolescent and Youths in Malaysia. A Review of Literature and Projects.

27
28
  

UNIT 2

UNDERSTANDING
THE ADOLESCENTS

1 
 
 UNIT 2:

UNDERSTANDING THE ADOLESCENTS

PAGE
TABLE OF CONTENTS

2.1 Teaching Outline (Framework) 30

2.2 Introduction 31

2.3 Time frame 31

2.4 Objective 31

2.5 Contents 31
31
2.5.1 Introduction
31-46
2.5.2 Adolescent Development
46
2.5.3 Summary
47
2.5.4 Identity Crisis

2.5.5 Mental Health Needs of an Adolescent 47-49

2.5.6 Adolescent Environment 49-57

2.5.7 Understanding Adolescent Culture 58-68

2.6 Appendices 69

Appendix 1 Pre and Post-Test 70-98

Appendix 2 PowerPoint Presentation on Understanding

The Adolescents

• Understanding Adolescent Environment

• Understanding Adolescent and

Environment

• Adolescent Culture

2.7 References 99-100

29 

 
 2.1: TEACHING OUTLINE (FRAMEWORK)

Learning Objectives Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time

(participant) Materials Evaluation (min)
1. Understand the whole concept of 1. Definition Lecture/discussion Interactive • Laptop Pre and post- 60
‘adolescent’ 2. Classification discussion • LCD test
3. Normal development : Explain about the • Flipchart
• Physical and sexual difference between • PowerPoint
• Cognitive adolescence, youth presentation
• Emotional and young people 1
• Psychosocial
4. Stages of adolescence
5. Identity crisis
6. Adolescents mental health
needs

2. Understanding the adolescent 1. Understanding Adolescent Lectures/ Interactive • Laptop Pre and post- 60
environment and cultures Environment Brainstorming discussion • LCD test
• The role of environment and • Family • Flipchart
culture in shaping the - Bonding and Explain and discuss • PowerPoint
adolescent’s identity, values, Attachment positive and presentation
beliefs and behaviours - Parenting styles negative aspects of • Case
• School culture scenarios
• Adopt a non judgmental • Peers • Interactive
approach in dealing with illustrations
adolescents of differing cultural 2. Understanding Adolescent
norms and practices Culture
• Definition of culture and
subcultures in relation to
adolescent development

TOTAL TIME 2 Hrs

30 

 
2.2 INTRODUCTION

This Unit provides information to help participants understand the adolescent with regards to
their growth and development, mental health needs as well as cultural and environmental
factors affecting adolescents.

2.3 TIME FRAME

120 minutes

2.4 OBJECTIVE

At the end of Unit 2, participants will be able to:

• Define adolescence and describe the developmental changes that occur in adolescent
• Understand environmental factors that may influence adolescent
• Understand adolescent culture and how it affects adolescent

2.5 CONTENTS

• Introduction
• Adolescent Development
- Stages of Adolescent Development
- Identity Crisis
- Adolescent Health Needs
• Environmental Factors Influencing Adolescent
• Understanding Youth Cultures

2.5.1 INTRODUCTION

Adolescence is a period of gradual transition from childhood to adulthood. Most cultures relate
the beginning of adolescence to the onset of puberty and the ending of it, with the ability to live
independently. It is accompanied by significant and challenging changes; biologically,
physically, emotionally, socially and economically. The family, school, peers, community and
environment they live in are important factors that contribute to the health and wellbeing of the
adolescent.

WHO defined adolescence between the ages of 10 and 19 years. This can be further
subdivided into 3 categories, that is:
• Early adolescence : 10 – 14 years
• Middle adolescence : 15 – 17 years
• Late adolescence : 18 – 19 years

2.5.2 ADOLESCENT DEVELOPMENT

A. Physical and Sexual Development

Due to the endocrine logical changes during puberty, there are marked physical and sexual
changes in the adolescents. Among the major developmental changes are:
• Growth spurt resulting in increased height and weight
• Further development of the sexual organs
• The development of secondary sexual characteristics, typically divided into 5 stages,
known as Tanner Staging.

31 

 
Refer F
Figure 1 and d 2 - Physic
cal Change
es for boys and girls, Figure 3 andd 4 - Tanne
er Staging
for boyss and girls.

Figure 1
1: Physical Changes For
F Boys

32 

 
Figure 2
2: Physical Changes fo
or Girls

33 

 
Figure 3
3: Tanner Staging for Boys

34 

 
Figure 4a: Tanner Staging for Girls

BREAST

35 

 
Figure 4b: Tanner Staging for Girls

36 

 
 B. Cognitive and Emotional Development

Cognitive and emotional development constitutes an important component of adolescent

mental health and well being. Adolescents with good mental health have high self esteem,
good communication skills, are assertive, responsible, happy and are able to manage their
emotions well. They are generally healthier, resilient and have better coping skills.

i. Cognitive Development

Cognitive development is the process by which a child understanding of the world changes.
Cognitive development refers to the development of the ability to think and reason. Children (6
to 12 years old) develop the ability to think in concrete ways (concrete operations) such as how
to combine (addition), separate (subtract or divide), order (alphabetize and sort), and transform
(change things such as 10 cents = 2 five cents) objects and actions. They are called concrete
because they are performed in the presence of the objects and events being thought about.

Adolescence marks the beginning of more complex thinking processes (also called formal
logical operations) which includes abstract thinking (thinking about possibilities), the ability to
reason from known principles (form own new ideas or questions), the ability to consider many
points of view according to varying criteria, to compare or debate ideas or opinions, and the
ability to think about the process of thinking (Refer Table 1).

Table 1: Types of Thinking Processes

DEFINITION EXAMPLES

Egocentric thinking:
Viewing the world entirely from one’s own The adolescent begins to form and verbalize
perspective. his/her own thoughts and views on a variety of
topics, usually more related to his/her own life,
Seeing the world entirely from one own such as:
perspectives. • which sports are better to play.
• which groups are better to be included in.
• what personal appearances are desirable
or attractive.
• what parental rules should be changed.

They begin to question authority and society

standards and views. They feel like: I am the
most important person in the whole world.

E.g. what is an orange and an apple? Both are

Concrete thinking:
Ability to think in a more logical manner,
however still has difficulty understanding
abstract and hypothetical thinking
Abstract thinking:
The thought process becomes more formal,
logical, creative and critical.
fruits
• Pendulum test: Concrete thinking
involves pushing the pendulum harder
to increase its rate while with abstract
thinking: either change the length of the
string or the weight of the pendulum.
• It is dark, is it already night, are the
curtains pulled or is it going to rain.
• Can describe more differences and
similarities between an orange and
apple e.g. the colour, shape etc.

37 

 
The changes in thinking that occur during adolescence:
• Developing advanced reasoning skills: This involves the ability to think about
multiple options and possibilities. It includes a more logical thought process and the
ability to think about things hypothetically. It involves asking and answering the
question, "what if...?".
• Developing abstract thinking skills. This involves thinking about things that cannot be
seen, heard, or touched; examples include things like faith, trust, beliefs and spirituality.
• Developing the ability to think about thinking in a process known as "meta-
cognition." It is the active monitoring and regulation of cognitive processes. It re-
presents the “executive control” system and is central to planning, problem solving,
evaluation and many aspects of language learning. Meta-cognition allows individuals to
think about how they feel and what they are thinking. It involves being able to think
about how one is perceived by others. It can also be used to develop strategies, also
known as mnemonic devices, for improving learning or thinking.

The transition from concrete thinking to formal logical operations occurs over time and each
adolescent progress at varying rates in developing his/her ability to think in more complex
ways. Each adolescent will develop his/her own view of the world. Cognitive development is
enhanced by cognitive readiness and appropriate environmental stimulation. When emotional
issues arise, they often interfere with an adolescent's ability to think in more complex ways.
Thus it is important for parents, teachers and caregivers to know what can interfere with
healthy and appropriate cognitive development and how to be supportive through early
stimulation and providing positive childhood experiences and opportunities to allow the
adolescent to apply logical operations in their daily activities or interactions. Adolescent with
good cognitive development will be able to reason well, think maturely as well as acquire
positive mental health and wellbeing.

How Do These Changes Affect Teens?

During the adolescence years, the cognitive development is seen as, the complex thinking
goes from focusing on making personal decision in school and home environment in early
adolescence, to more philosophical and futuristic concerns in middle adolescence to focusing
on less self-centred concepts as well as personal decision making in late adolescence.

Examples of thinking in:

• Early Adolescence:
- They demonstrate a heightened level of self-consciousness. They tend to believe
that everyone is as concerned with their thoughts and behaviours as they are. This
leads them to believe that they have an "imaginary audience" of people who are
always watching them.
- They tend to believe that no one else has ever experienced similar feelings and
emotions. They become overly dramatic in describing things that are upsetting to
them. They may say things like "You'll never understand," or "My life is ruined!.
- They tend to exhibit the "it will never happen to me" syndrome also known as a
"personal fable." This belief causes them to take unnecessary risks like drinking and
driving ("I won't crash this car"), having unprotected sex (I can't possibly get
pregnant), or smoking (I can't possibly get sick").
- The early adolescent begins to demonstrate use of formal logical operations in
schoolwork.
- The early adolescent begins to question authority and society standards.

• Middle Adolescence :
- They tend to exhibit a "justice" orientation and often questions more extensively.
- They are quick to point out inconsistencies between adults' words and their actions.
They have difficulty seeing shades of gray and see little room for error.

38 

 
 - The adolescent thinks about and begins to form his/her own code of ethics (what I
think is right!).
- The adolescent thinks about different possibilities and begins to develop their own
identity (Who am I?).
- The adolescent begins to think about and systematically consider possible future
goals (What do I want?). They may be able to thing about long term goals.
- They think about and begin to make their own plans.
- Some are able to use their systematic thinking to influence others.

• Late adolescence, complex thinking processes includes:

- The adolescent often questions more extensively, analyzes things and situation.
They tend to become very cause-oriented and have increased thoughts about more
global concepts such as justice, history, politics, and patriotism.
- They often develop idealistic views on specific topics or concerns. They have
difficulties accepting opposing views from others and are not afraid to express their
views.
- They begin to focus on making career and future decisions.

What encourages healthy cognitive development during adolescence?

The following suggestions will help to encourage positive and healthy cognitive development in
the adolescent:
• Include children in discussions about a variety of topics or issues from an early stage. It
can start with things at home, e.g. how one or other’s feel, what goes on for them on a
daily basis, what happens to someone when events occur, what can be done and allow
some decisions which are age-appropriate.
• Encourage children/ adolescents to share ideas and thoughts with you. Adults should
avoid telling children to shut up or to stop talking.
• Encourage adolescents to think independently, think about and develop their own ideas.
Adults show avoid from being critical, putting them down or shaming them. Compliment
and praise them for well thought out decisions.
• Assist them in re-evaluating poorly made decisions or mistakes. Allow them
opportunities to redeem themselves and to try to make things right.
• Assist adolescents in setting their own goals. Encourage adolescents to think about the
possibilities what they want to see happen in the future and what can be done to reach
their goals.
• Allow them the opportunities to see adults make mistakes too, and we can and should
get our act together to overcome our difficulties.

Table 2: Example of Major Concerns in Adolescent Thinking

EARLY (10-14 YEARS) MIDDLE (15-17YEARS) LATE (18-19 YEARS)

CENTRAL QUESTION
“Who am I?” “Who am I?” “Where am I going?”
“Where do I belong?” “Where do I belong?” Who am I?
“Am I normal?” “Where am I going?”
* Where do I belong?”
“Am I normal?”
Note :
* Need to be further explore

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MAJOR DEVELOPMENTAL ISSUES
• Curiosity about opposite
sex
• Coming to terms with
puberty
• Struggle for autonomy
• Same sex peer
relationship
• Mood swings
• Mood swings
Note:
Some of this issues may be seen throughout the three stages and is normal
MAIN CONCERNS
• Anxieties about body
shape and changes
• Comparison with and
influence of peers
Note:
These concerns can occur at an early stage and may be seen throughout all the stages.
PRACTICE TIPS for adults
• Ensure confidentiality unless risk of self harm and harm toward others
• Reassure about
normality
• Ask more direct than
open ended question
• Offer short and simple
explanations
• Base interventions on
immediate or short term
outcomes
e.g. what the adolescent
want to see happen
within the next coming
weeks
• Help identify possible
adverse outcomes if they
continue the undesirable
behaviour
• New intellectual powers • Independence from
• New sexual drives e.g. parents
Specific love interest, • Body image
masturbation. • Acceptance of sexual
• Emergence of sexual identity
identity • Clear educational and
• Experimentation and risk- vocational goals, own
taking behaviour value system
including • Developing mutually
• Relationships have self- caring and responsible
centered quality e.g. I relationships
have the right to do what
I want.
• Need for peer group
acceptance
• Comparison with and • Self responsibility
influence of peers • Achieving economic
• Tensions between family independence
and the individual • Developing intimate
relationships
• Always assess for health • Ask more open ended
risk behaviour questions
• Focus interventions on • Focus interventions on
short to medium term short and long term goals
outcomes • Address prevention more
• Relate behaviours to broadly
immediate physical and
social concerns e.g.
effects on relationships,
schooling.
40 
ii. Emotional Development

Emotions are feelings that have both physiological and cognitive elements and it influences
behaviour. Due to the various changes, challenges and life events occurring during
adolescence, they experience various emotions. These emotions may be positive or
negative.

Example of negative emotions are feeling anxious, angry, ashamed, guilty, frustrated,
used, rejected, useless, depressed etc. Examples of positive emotions are feeling happy,
strong, useful, satisfied, enthusiastic etc.

It is important for adolescents to learn to express their feelings and emotions in an

appropriate manner e.g. it is ok to be angry but not to hit or throw things. Thus they need to
be taught techniques to control their emotion e.g. learning to recognize their anger, using
positive self- help talk.

Tips for Adolescents

ƒ List one’s difficulties
ƒ List possible ways or options of overcoming the difficulties taking into one’s own
strengths and weaknesses
ƒ Set targets to overcome the difficulties and steps needed to reach the target.
ƒ Create opportunities to try out the above e.g. participation and involvement in the
difficult areas
ƒ Review one’s actions, feelings and thinking about the difficulties
ƒ Give oneself positive reward or positive regard for successful endeavours
ƒ Review one’s actions for less successful endeavours and repeat the above steps

Another important aspect of emotional development is the development of more intense

relationship with peers and adults. The way adolescents establish relationships is
dependent on their past and present experiences, and the degree to which they have been
loved, valued and respected as individuals. The individual’s emotional development will
have consequences on their relationships.

Factors contributing to adolescent‘s emotional changes:

• Adolescents are at crossroads, as they transit from childhood to adulthood.
- Failure to meet their needs can lead to frustrations, giving rise to self destructive
behaviours (e.g. illicit drug usage, self harm and/or aggressive behaviours).
- Feeling loved and valued provides the platform for positive self development.

• Adolescents undergo adjustments, from various changes and challenges.

- Adjustments can be hampered by their lack of understanding of what is happening
to their body and the accompanying intense emotions.
- Their difficulties are aggravated by the being adults’ insensitivities towards their
problems and feelings. Thus adults should play a more positive role by being
supportive

• Adolescents are experiencing hormonal changes during puberty

- There is an increase in the production of androgen in boys and estrogen in girls.
- This closely correlates with many behavioural and psychological manifestations
characteristic of early adolescence such as first ejaculation, beginning of
masturbation, onset of nocturnal emissions, and interest in girls etc.
- For girls, menarche correlates with changes in attitude and behaviour such as
childlike play and recreational activities to fashion consciousness, body image
41 

 
 awareness, and preoccupation with the body, interest in romantic stories, dancing,
parties and social events.

• Adolescents’ coping skill

- Adolescence is a period of rapid growth and development, characterized by change
and challenges that requires appropriate coping skills.
- The majority of adolescents move through their adolescent years without
experiencing major difficulties. However, some encounter serious psychological and
behavioural problems that affect not only their lives, but those around them.
- Coping in adolescent requires positive self image, trust in one’s abilities and
strengths, managing one’s stress and emotions, knowing when and where to seek
help.

Tips for Adults

ƒ Understand the changes that are occurring in adolescents.
ƒ Be supportive
- acknowledge what they are feeling and the difficulties that they are
going through e.g.
“I know you are sad when your friend reject you….”
- Do not nag, lecture or criticize them
ƒ Maintain effective communication and close relationship
ƒ Allow them to verbalize their thoughts, feelings and possible ways of
overcoming their difficulties
ƒ Listen, and treat them with respect. Be sensitive to their feelings

C. Psychosocial Developments

This encompasses five sets of development concerns i.e.:

• Identity
• Autonomy
• Intimacy
• Sexuality
• Achievement

i. Identity

The critical task of an adolescent is the development of a unique identity and a sense of
self. The development of one’s identity is complex and multifaceted. It is usually the result
of how the individual sees or feels about oneself in relation to what others in the society
thinks about one’s own worth and importance.

The dramatic changes that occur in adolescents will impact on their self concept and their
relationship with others – friends, siblings, parents and the community at large.
- At this stage they tend to wonder ‘who am I really?, Who will I become?’, The
challenges and experiences which they go through will have an impact on their
believe system (their thoughts, attitude), their emotions and feelings, which will have
further consequences on their behaviour, motivation and expectation.
- The adolescent begin to integrate the opinions of significant others (e.g. parents,
other caring adults, friends etc.) into their own likes and dislikes. The eventual
outcome is someone who has a sense of their values and beliefs, goals and

42 

 
 expectations. Adolescents with secure identities know where they fit (or where they
don't want to fit) in their world.
- In social roles, guide the adolescent and allow them opportunities to participate and
decide to determine what do they want out of life, and what things are important to
them

ii. Autonomy

People assume that autonomy refers to becoming completely independent from others.
They equate this with the adolescent becoming rebellious. Establishing autonomy during
the adolescent years means becoming an independent and self-governing person within
their environment and relationships. Autonomous adolescents have the ability to make and
follow through with their own decisions, live by their own set of principles of right and
wrong, and are less emotionally dependent on their parents. Autonomy is a necessary
achievement for any adolescent to become self-sufficient in society.

The ability to shift from being dependent on parents to being independent person and able
to make one’s decisions is facilitated by cognitive and intellectual maturity, as well as the
adequate emotional and social development.

iii. Intimacy/Close Relationship

The development of close relationships is an important development for adolescent. Many

people equate intimacy with sex. Intimacy and sex are not the same. Intimacy refers to
close and enduring relationships in which people are open, honest, caring and trusting. It is
when friends learn how to begin, maintain, or terminate relationships; learning how to value,
accept or contain different or similar behaviour, thoughts and ideas amongst friends. It also
involves acquiring and practicing social skills. Intimacy is usually first learned within the
context of same-sex friendships, then later in the development of romantic or opposite sex
relationships. Adolescent needs the support from friends and confidants especially when
they feel emotionally vulnerable. Having a solid past foundation in preadolescent years
helps in the development of close relationships with others.

Adolescents will form relationship with many different people to search for self identity and
intimacy with others. Adolescents with insecure identity will have difficulties forming intimate
relationships. The main challenge for the adolescent is to integrate his/her established
needs for intimacy with the emerging need for sexual contact. Adolescents are biologically
developed in that they are able to experience the normal sexual desires and response. This
is enhanced when the adolescent is involved in an intimate relationship.

However, sexual maturity does not necessarily correlate with their cognitive maturity and
they are not likely to comprehend the consequences of pre-marital sexual relationships.
Therefore, it is essential that adult maintain a close relationship with the adolescent and to
be supportive of their actions. Encourage involvement in multiple groups or activities both
within school and away from school. Adolescents need and are trying to gain a sense of
achievement, a sense of being good at something or everything. Praising them for their
efforts as well as their abilities will help them to stick with their activities or ideas instead of
giving up when they do not immediately see success.

43 

 
 iv. Sexuality

Sexuality is an important aspect of development during adolescence. It is a fundamental

quality of human life, important for health, happiness, individual development, and indeed
for the preservation of the human race. The essential aspects of sexuality are as follow:

Early adolescence Middle adolescence Late adolescence

• Girls ahead of boys • Concerns about sexual • Concerned with

• Same-sex friends and
group activities
• Shyness, blushing and
modesty
• Show-off qualities
• Greater interest in privacy
• Experimentation with body
(masturbation)
• Worries about being normal
attractiveness serious relationships
• Frequently changing • Clear sexual identity
relationships • Capacities for tender
• Movement towards and sensual love
heterosexuality with
fears of homosexuality
• Tenderness and fears
shown towards opposite
sex
• Feelings of love and
passion

Tips for Adult

ƒ It is important for parents and teachers to impart appropriate knowledge on
sexuality education at an early age to serve as a guide for adolescents in dealing
with their growing sense for intimacy in a safe and healthy manner.

Adolescent is also the time for them to be comfortable with one’s sexuality. During the
adolescent years mark the first time for many of them where they are both physically
mature enough to reproduce and cognitively advanced enough to think about their
sexuality. The adolescent years are the prime time for the development of sexuality.
Whether or not they develop a healthy sexual identity will depend on whatever knowledge
that they are exposed to and their experiences. There have been increasing reports of high
school students report being sexually active or intimate. This worrying phenomenon has
been contributed to mixed messages about sexuality, a desire to experiment, the seeking of
peer approval and the availability of opportunities.

v. Developmental Task

The major task facing adolescents is to establish a stable identity and become productive
adults. Over time, adolescents develop a sense of themselves that endures and
encompasses the many changes in their experiences and roles. They find their role in
society through active searching that leads to discoveries about themselves. The changes
that adolescents experience during puberty bring them new awareness of self and influence
others’ reactions to them. For example, sometimes adults perceive adolescents to be adults
because they physically appear to be adults. However, adolescents are not adults especially
in their thinking process. They need room to explore themselves and their world. As adults,
we need to be aware of their needs and provide them with opportunities to grow into adult
roles.

44 

 
There are eight main achievements or developmental tasks that adolescents must complete
in order to establish an identity.

• Achieving new and appropriate relationship with others including with both
gender and in one’s age group

• Achieving an appropriate gender role in the society

Each adolescent should develop his or her own definition of what it means to be
male or female based on one their upbringing, culture and society. Most
adolescents conform to their respective sex roles.

• Accepting one’s physique

The timing of the onset of puberty and the rate of body changes for adolescents
varies greatly. How easily adolescents deal with these changes will partly depend
on how closely their bodies match the well-defined stereotypes of the “ideal” body
for young women and men. Adolescents whose bodies do not match the
stereotypes will need support from adults and peers to improve their feelings of
comfort and self-worth.

• Achieving emotional independence from parents and other adults

Children derive strength by internalizing their parents’ values and ideas.
Adolescents, however, must redefine their sources of personal strength and move
toward self reliance. This change is smoother if adolescents and parents can
agree on some level of independence and trust that increases over time. For
example, parents can give opportunities for adolescents to established their own
behaviour guidelines and consequences e.g. they can be allowed to have input
into curfew and other family rules.

• Acquiring a set of values

Adolescents gain the ability to think abstractly and to visualize possible situations.
With these changes in thinking, the adolescent is able to develop his or her own
set of values and beliefs.

• Preparing for marriage and family life

Sexual maturation is the basis for this developmental task. This developmental
task is usually not achieved until late adolescence or young adulthood.

• Preparing for a career

This developmental task is generally not achieved until late adolescence or young
adulthood, after the individual completes his/her education and gains some entry-
level work experience.

• Desiring and achieving socially responsible behaviour

The family is where children learn to define themselves and their world.
Adolescents must learn to define themselves and their world in the context of their
new social roles. Status within the community beyond that of family is an
important achievement for older adolescents and young adults. Adolescents and
young adults become members of the larger community through financial and
emotional independence from parents, which in turn teaches them the value of
socially responsible behaviour.

45 

 
 The many developmental tasks facing adolescents are challenging, but they can be achieved.
Many take small steps and at times may falter as they adapt to changes and experience. Adults
need to provide a supportive environment. Adults can help turn mistakes made by adolescents
into opportunities that enhances and allows them to master their life skills.

2.5.3 SUMMARY

EARLY (10-14 YEARS) MIDDLE (15-17 YEARS) LATE (18-19 YEARS)

Physical • Significant physical/ • Continuing physical/ sexual • Physical/sexual changes
and sexual sexual maturation changes complete
• Intense concern with • Less concern with body • Greater acceptance of
body image image physical appearance

• Same-sex friends and • Movement towards • Concerned with serious

group activities
• Experimentation with
body (masturbation)
Cognitive • Still fairly concrete
thinkers
• Less able to understand
subtlety
• Daydreaming common
• Difficulty identifying how
their immediate
behaviour impacts on the •
future
Emotional • Growing independence in •
decision-making
heterosexuality with fears
of homosexuality
• Tenderness and fears
shown towards
opposite sex
• Able to think more
rationally and logically
• Concerned about individual
• Longer attention span
freedom and rights
• Able to accept more
responsibility for
consequences of own
behaviour
Begins to take on greater
responsibility within family
as part of cultural identity
Development of sense of
identity
relationships
• Clear sexual identity
• Ability to understand
abstract thoughts
• More able to synthesize
information and apply it to
themselves
• Able to think into the
future and anticipate
consequences of their
actions
• Sense of identity
established

Social • Increasing influence of
peers
• Feeling attracted to
others begins
Behavioural • Experimenting with new
ways of behaving begins
• Exploration of ability to
attract partners begins
• Enormous influence of
peers/school environment
• Increase in sexual interest
• Risk-taking
behaviour
• Peer influence balances
out in relation to family
influences
• Serious intimate
relationships begin to
develop
• Transition to work,
college, independent living
• Capacity for realistic risk
assessment
- able to understand the
consequences

46 

 
2.5.4 IDENTITY CRISIS

Identity crisis is a common event and failure to negotiate this stage leaves the adolescent
without a solid identity and feeling despondent.
• It is characterized by not having a sense of self and being confused about one’s
place in the world.
• It manifest itself as behavioural and / or emotional problems such as running
away, defiant behaviour or being involved in risky-behaviours.

Identity is made up of two components (American Psychological Association, 2002):

• Self-concept
The set of beliefs about oneself, including attributes, roles, goals, interests, values
and religious or political beliefs
• Self-esteem
How one feels about one's self-concept

The process of developing a sense of identity involves going through the stages,
experimenting and experiencing. Each adolescent will approach each task in their own
unique way, to get a sense of individuality. Hopefully they will move towards acquiring
skills to manage demands, expectations, learning to interact and connect with people.
Though they seemed to be “separating” from the adults, it should be seen as the adults
and adolescents working together to negotiate a change in the relationship,
accommodating the individual needs (individuality), autonomy and expectations. The
adolescent will feel comfortable with adults who see them as an individual and
acknowledge them.

y Feeling positive about one's identity is important to the self-esteem of an

adolescent. When they feel good about themselves, they are likely to
incorporate this into their identity and will have a smoother transition
compared to those with low self-esteem, feeling inferior and incompetent.

By the end of adolescence years, most will have a fairly clear idea about what is important to
them and what they believe in.

2.5.5 MENTAL HEALTH NEEDS OF AN ADOLESCENT

The mental health needs of adolescents include the need for unconditional love, a balance of
affection and control, appropriate guidance, involvement and supervision from adults to
establish appropriate self discipline and time for play/ recreational activities.

Unmet mental health needs occur in families with chronic discord (conflict), abuse, lack of
affection, ineffective and inconsistent monitoring and disciplines (e.g. lax or lack discipline,
punitive disciplining, excessive and vague commands or demands).

47 

 
 A. Understanding Adolescents Mental Health Needs
Specific mental health needs of adolescent include as follows:
• Safe enough environment
- Environment that is free from violence, abuse and aggression
• Basic needs met enough
- The adolescent is provided with the basic need such as food, shelter, clothing and
schooling
• Adults in the child’s life is united enough
- Adults in the adolescent’s life is united enough and with minimum conflict.
• Child feels loved and cared for enough
- The child is able to feel unconditional love from the adults without the use of
threats or guilt
- There should be enough opportunities for the expression and reception of feelings
and messages from all members of the family, and if there are conflicts, it is sorted
out appropriately, timely and without the use of violence or aggression.
• Parents reflect enough rather than react
- Parents must think through their actions before reacting and being aware of the
consequences of their actions on their children.
• Child knows their place within boundaries enough
- If the above needs are met, the child would be able to express him/her self, and
behave appropriately. They will be able to negotiate through life and their
difficulties using appropriate ways. They feel comfortable with and trust their
parents, and consciously aware of their place and responsibility in the family.
B. Understanding Adolescent Stress

The adolescent period can be very stressful. The sources of stress in the environment can be
from peers and adults in the form of:
• Rejection or neglect
• Threats or guilt’s
• Criticism, constant teasing or attacking
• High expectations
• Role-reversal e.g. taking on an adult role at a young age
• Inability to manage failures and mistakes
• Inappropriate and continuous punishment for mistakes and failures
• Violence/ aggression
• Poor self-esteem, self-confidence
• Poor or nil role model
• Involvement in criminality and substance abuse
Consequences or indicators of unmet needs include:
• Disturbance of appetite and sleep.
• Isolation from others.
• Excessive worries/ anxieties/ fears.
• Lost of interest and enjoyment in usual pleasurable activities.
• Problems at school.
• Persistent disobedience/ aggressive and antisocial behaviour.
• Rebellion against parents and authority figures.
• Inappropriate sexual behaviour.
• Use of substance.
48 

 
 • Lack of self-control and self confidence.
• Sadness and irritability
• Self harm

Tip for Adults

ƒ Adolescent need space to explore themselves and their world. Adults need to
be aware of their needs and provide them the opportunities and space to
develop into healthy adults.

ƒ Adults need to provide adolescents opportunities to be responsible for their

own decisions and be accountable for the consequences of those decisions.

2.5.6 ADOLESCENT ENVIRONMENT

Adolescents may be influence by their environment and they may in turn influence it. The
environment consists of the family, school, peers and the bigger community which may be
protective or harmful.

A. Family Environment

The fundamental unit of all societies is the family. A safe and healthy family environment will
promote one’s health and wellbeing. Some factors within the family that influence the
adolescent are types of family, parenting styles, family dynamics, family belief systems and
practices, opportunities provided, and early childhood experiences. The relationship between
the members of the family (parent-parent, child-parent), their roles and influence are also
important.

Children and parents exist in relationship with each other i.e. the feeling and behaviour of one
affects the other in a circular manner and the feedback between them modifies each person’s
participation in the relationship. The relationship can evoke feelings of comfort or distress. The
modelling of appropriate behaviours by adults is also important. For example, parents who
constantly feel and react angrily toward their child, will result in the child learning and reacting
angrily back towards the parents. Parents, who think appropriately and react calmly towards
their child, will result in the child learning and responding accordingly.

Families in which there are on-going dialogues, good conflict-resolution practices, mutual
respect and flexibility seem to have more positive outcomes..

Issues to be aware in the family are:

• Presence and practice of love and respect
• A balance of control and affection
• Discipline and appropriate guidance,
• Involvement and supervision
• Communication skills
• Presence or lack of problems solving skills
• Trust and responsibility

It has been traditionally believed that children who have been orphaned or abused are the
primary victims of poor bonding and attachment in the early years. However, in our society,
a new phenomenon has emerged:

49 

 
• Children are being overindulged by parents who have more money than time to spend
with them.
- The result is that children are being raised in financially secure, but emotionally
empty environments, with little discipline and structure.
• Children are in homes where the socio-emotional is not practised.

In homes, where it is a socially and emotionally stimulating environment:

- Children will learn to deal effectively with their feelings, difficulties, maintain self-
control communicate assertively.
- See success at home, in schools.
- Able to sustain healthy relationships.

i. Bonding and Attachment

The early years of a child's life are crucial for cognitive, social and emotional
development thus it is important to take every step necessary to ensure that children
grow up in environments where their needs are met:
• Cost to society: when less than optimal development occurs, are enormous and far-
reaching.
• The children are at an increased risk for compromised health and safety, and learning
and developmental delays with long term effects on the health care, and education
systems.

The early childhood experiences in a family that affect bonding and attachment have
strong influence on the later life of an adolescent.

Bonding is the basic link of trust and the development of love between a child and their
parents. It develops from the interactive process that occurs through repeated daily
interactions and exchanges between the child and their parents.

Attachment is the unique and exclusive relationship that a child feels towards his parents
or caregivers which will shape the child’s relationships with others for the rest of his or her
life. There are now increasing scientific evidence on the importance of secure bonding and
attachment which can influence every component of a human being (Bowlby and
Ainsworth).

In infancy, effective bonding has vital biological function for survival. Warm responsive
care that a child receives from their carer(s) will help the child to feel protected, understood
and consequently learns to trust others and to see the world as a safe place.

A child will seek closeness with a specific person to get support and protection, in order to
have their needs met and to reduce internal tension. If the relationship is warm and
secure, then the child learns to love and trust. Children who are securely bonded grow up
to have self-confident, good self-esteem and function at high levels socially, emotionally,
mentally and physically. They are able to engage in appropriate reciprocal relationships
and are concerned about the feelings and needs of others.

When the bonding is emotionally distant and inconsistent, the child becomes incapable of
genuine trust and will develop a negative and pessimistic view of self and others. Their
relationships tend to be emotionally distant with lack of trust or care. Children, who are
insecurely bonded function at less optimal levels, have low self esteem and lack
confidence. They tend to be anxious, withdrawn, unable to engage and cooperate with
others. They tend to be controlling and aggressive. This results in emotional, behavioural,
social and academic problems.

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 This cycle will be repeated with their own children when they become adults unless
intervention occurs and they are receptive to mending their ways.

Adolescent attachment research has continually shown that relationship quality has an impact
on an individuals’ psycho-social adjustment. A high quality of interpersonal relationships in
adolescence and adulthood is strongly associated with higher levels of self-esteem, less
depression and better social adjustment. During adolescence, changes in attachment bonds
occur as individuals learn to develop and value non-familial relationships. Independence and
associations with others becomes increasingly important and young adolescents begin to
identify with and seek support from peers more frequently. However, parental attachments
continue to remain salient and constant throughout adolescence.

Attachment is all about building relationships.

y Humans need attachments with others for their psychological and emotional
development as well as for their survival.
y Children need to feel that they are safe, that they will not be abandoned, and
that they are loved and valued.

ii. Parenting Styles

The way the parent approaches a child is influenced by:

• model of care they experienced as a child
• conflicts around parent’s own self-esteem, identity, self-control and relationships.
Unresolved attachment issues may lead to unresolved dependency conflicts carried
into adult life and relationships, and this can be aggravated by social or on-going
stresses.

Adolescents are affected by their parents’ parenting styles. There are three main types of
parenting styles as described by Baumrind (1989):
• Permissive
• Authoritarian
• Authoritative

a. Permissive Parenting Style

Outcome of permissive parenting style,

Parents:
- Do not control through the exercise of
power
- Non-punitive, non-directive and non-
demanding to their children
- Place few demands, allow children to
make their own decisions and to
govern their own activities
- Do not set consistent limits and do not
get their children to cooperate
children:
- More positive in their mood
- Show more vitality
- Immature in their behaviour i.e. lack
impulse control, social responsibility
and self-reliance

b. Authoritarian Parenting Style

Outcome of authoritarian parenting style,

Parents: children:
- Have firm and clearly identified - Moderately competent and
51 

 
 standards of conduct based on responsible
cultural and religious beliefs - Socially withdrawn and lack of
- Demand and value obedience, spontaneity
- Exercise power to make children - Low self-esteem
conform. Children are NOT given - Girl will be dependent and lack of
responsibility for personal decisions ambition
nor involved in rational discussion - Boy will be more aggressive
- Assert power without warmth,
nurturance or two way communication
- Punish inappropriate behaviour instead
of instructing or role-modelling right
from wrong

c. Authoritative Parenting Style

This parenting style falls between permissive Outcome of authoritative parenting style,
and authoritarian control Parents: children:

- Apply democratic concept - they place - Higher levels of autonomy,

a high value on the development of confidence, maturity, social skills and
autonomy and self-direction but academic achievement
assume the ultimate responsibility for - More able to adapt successfully to
their child's behaviour. life’s challenges
- Authoritative parents deal with their - Independent, self-assertive, friendly
child in a rational, issue-oriented with peers, and cooperative with
manner, frequently engaging in parents
discussion and explanation with their - Likely to be successful both
children over matters of discipline. intellectually and socially, they seem
- They are firm yet warm to enjoy life and have strong
- They encourage equality and trust motivation to achieve
- Equal need for dignity and worth
- Teach independence and self
responsibility
- Use firm control but allows rational
discussion of standards and
expectations
- Set realistic standards and values and
have a right balance of love with
appropriate boundaries
- Solicit children’s opinion and feelings
when family decisions are made
- Offer explanations and reasons for
punitive or restrictive measures
whenever they feel these must be
imposed
- Get child’s cooperation and respect
- Have standards derived from
reasoning rather than adult’s personal
beliefs or experience
- Value obedience but allow and try to
promote independence and
cooperation

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A fourth category: Indifferent parents. This group of parents tries to do whatever is necessary
to minimize the time and energy that they must devote to interacting with their child. In extreme
cases, indifferent parents may be neglectful. They know little about their child's activities and
whereabouts, show little interest in their child's experiences at school or with friends, rarely
converse with their child, and rarely consider their child's opinion when making decisions.
Rather than raising their child according to a set of beliefs about what is good for the child's
development (as do the other three parent types), indifferent parents are "parent centered"–
they structure their home life primarily around their own needs and interests.

The important dimensions of parenting are:

- Warmth (acceptance or responsiveness),
- Firmness (demandingness or behavioural control), and
- Restrictiveness (intrusiveness or psychological control).

Within this parenting-style framework, parents are classified as authoritative (high in warmth,
high in firmness, and low in restrictiveness), authoritarian (low in warmth, high in firmness, and
high in restrictiveness), or indulgent (high in warmth, low in firmness, and low in
restrictiveness). Research shows that children and adolescents fare better when their parents
are warm, firm, and non-restrictive.
Child adjustment indicators in relation to each of these dimensions of parenting:
- psychosocial development (including social competence, self-conceptions, and self-
reliance);
- school achievement (including school performance, school engagement, and academic
motivation);
- internalized distress (including depression, anxiety, and psychosomatic problems); and
problem behavior (including delinquency, aggression, and drug and alcohol use).

Tips for parents

• Establish a positive relationship with the child. This will result in parent-teen
interactions that are warm, kind, consistent, respectful and loving. The relationship
will flourish and so will the child's self-esteem, mental health, spirituality and social
skills.

• Be genuinely interested in the adolescent’s activities. Make an effort to get to know

the adolescent’s friends. Monitor their behaviour to keep them out of trouble. Set
family rules with input from the adolescent, have firm and consistent boundaries and
appropriate expectations.

• Encourage independent thought and expression. These will help the adolescents to
develop a healthy sense of self and enhance their ability to resist peer pressure.

• Be mindful of expression of emotions. This is an area which is commonly not looked

into or taught thus the adolescents are left on their own to develop their own way of
expressing themselves. In many adolescents, they are told to control their emotions
but not allowed to express themselves.

“Children are natural mimics; they act like their parents in spite of every effort to
teach them good manners”, be a good role model to your children.

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 B. School Environment

The school environment plays a very important role in the adolescent’s life. Adolescent can
have a strong bond to their school. To an adolescent, school can mean achievement and
motivation, support or disappointments.

Four factors associated with social bonds to school (Wehlage et al., 1989):
• Attachment
• Commitment
• Involvement
• Belief

i. Attachment
Students will have social and emotional ties to adults and peers in the school. This
attachment is usually reciprocal, that is, "the school / teacher care about me thus I will care
about my actions." This helps the students to have a vested interest in meeting the
expectations of others and abiding by the norms expected in the school.

ii. Commitment
Commitment is a conscious decision by students about what they have to do to achieve
their goals (e.g. the adolescent will be committed in the classes where they feel the
teacher has interest in their well being). If students do not have hope for the school, they
are less likely to show commitment.

iii. Involvement
Student involvement in school activities, both academic and non-academic, increases the
likelihood of bonding. If students are disillusion, frustrated they will not actively participate
and are often disengaged as evidenced by their apathy.

iv. Belief
Students believe that education is important and have faith in the school to provide them
with an education. Teachers in turn should also believe that students are competent to
learn and achieve the goals of the school.

School can also be a cause for separation and frustration, resulting in grouping among
students. Teacher and adults can positively or negatively influence the separation among
groups (Brown, 1993) i.e.
• Passive acceptance of the peer-group structure
• Peer group separation
• Blame or excuse the victim

i. Passive Acceptance of the Peer-Group Structure

Teachers, who do not agree to peer group base on academic achievement etc and make
no attempt to intervene, can promote separation amongst students.

ii. Peer Group Separation

Grouping base on achievements forces isolation among students at different achievement
levels with each group forming its own peer culture. When students are grouped by ability
tracks, low achievers are isolated from models of achievement, which in turn affect their
motivation and strategies.

iii. Blame or Excuse the Victim

Teachers who stereotype their students based on social, cultural, economic background
may further undermine the students’ achievement.

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In conclusion, teachers are responsible to ensure that all students experience the value of
group, being in a team and contributing. They can channel peer influence into positive ways
and experience as well as utilize the powerful effects on one another by encouraging activities
in school that promote leadership, team building and community spirit.

Bullying behaviour occurs in schools worldwide and is associated with poor health in
schoolchildren. Bullying behaviour harms both the victim and the perpetrators; however it is
often the victims that receive the focus while the perpetrators are set off free. Adults often
minimize, rationalize or even deny that this sort of behaviour occurs in the environment. Adults
need to be concern and pro-active when these issues are brought up.

C. Peer Environment

Peer environment is a major aspect of an adolescent’s life. The peer influence on adolescent
development is generally associated with negative connotations and makes many parents
anxious. However this is a normal part of development. Membership in peer group is a powerful
force and the group provides an important developmental point of reference through which
adolescents gain an understanding of the world outside of their family environment.

Failure to develop close relationships with peers, often results in a variety of problems from
delinquency and substance abuse to psychological disorders. Higher stress and less support
from peers have also been associated with a lower social self-concept and competency.

Everyone needs to feel belonged, connected and be with others who share similar attitudes,
interests and circumstances. Adolescents choose friends who accept, like and see them in a
favorable light. Peer acceptance and recognition help reinforce their personal identity, feeling of
security, importance and also facilitate independent decision making.

Peer pressure is define as social pressure by members of one’s peer group to take certain
action, adopt certain values or conforms in order to be accepted.

There are two types of peer pressure.

i. Positive Peer Pressure

Positive peer pressure is where peers can and act as positive role models i.e. they
demonstrate appropriate social behaviours. This kind of peer pressure will shape
adolescents to conform to healthy behaviour and motivates them for success.

ii. Negative Peer Pressure

Negative peer pressure means when one uses power and control over others to get what
they want. It can be physical, emotional or social. Examples of this type of peer pressure
are when the adolescents are being bullied, isolated or rejected by their peers. Some are
even forced to engage in risky behaviours in order to fit in with the group. Peer pressure
can impair good judgment, lure them into dangerous and risk-taking behaviour and draw
them away from the family and positive influences.

A powerful negative peer influence can motivate an adolescent to make choices and
engage in behaviour that might otherwise be rejected. Some adolescents will risk
being grounded, punished or losing their parents' trust, just to try to fit in or feel like they
have friends they can identify with and who accept them. They will change the way they

55 

 
 dress, give up their values or create new ones, depending on and to please the people they
hang around with.

Some teens harbour secret lives governed by the influence of their peers. They appear to
be well-behaved, high-achieving teens when they are with adults but engage in negative,
even dangerous behaviour when with their peers.

Impact of Peer Environment on Adolescent

Positive Negative
• Sense of connectedness • Bullying
• Acceptance • Violence and aggression
• Support • Smoking and substance abuse
• Trustworthy • Sexual behaviours
• Confidence • School problems
• Skilled • Defiance and gang problems
• Motivation • Problems with law
• Stable emotion

Tip for parents

• Parents can support positive (good) peer behaviours by giving the adolescent their
love, support, time, boundaries and encouragement to think for themselves. This
allows them to develop and practice social skills.

• Be genuinely interested in the adolescent’s activities, know their friends and monitor
their activities. This is crucial for parents in keeping the adolescents out of trouble.

• When misbehaviour occurs, parents who involved their adolescents in setting family
rules and consequences can expect less opposition from their adolescents as they
will know they need to comply with the rules.

• Parents, who set firm boundaries, have appropriate expectations and allow
negotiations with their adolescents will find that their adolescents’ abilities to live up to
those expectations grow. They will model and bring these behaviours into their peer
group, and thus influence their peers with more socially appropriate behaviour.

• Provide fun things to do at home to encourage them to “hang out” at home so that the
adults will know where they are and what they are doing.

• Continue to provide a supportive and structured environment while allowing them

independence. Despite their complaints, the adolescent rely on adults to provide
them with the sense of safety, support and structure they need to deal effectively with
all their psychosocial tasks.

“Peer pressure is not a monolithic force that presses adolescents into the same mould.
Adolescents generally choose friends whose values, attitudes, tastes and families are
similar to their own. In short, good kids rarely go bad because of their friends”
(Laurence Steinberg, You and Your Adolescent)

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 D. Global Environment

Adolescent is expose to the bigger environment which includes the global community, the
media and the virtual universe. Adolescents now are also exposed to massive influx of
information, ideologies and support system through the information communication technology
that have a major implication on their development. It brings negative as well as positive
influences to the adolescents. Examples of negative influences are internet addiction,
unhealthy pre-occupation such as eating habits, self harm, violent, aggression, and impairment
of decision making abilities.

Examples of positive influences are rapid and appropriate information, pro-social peer support;
enhance connectedness through virtual space, immediate reinforcement such as feeling of
shared acknowledgement, frustration, freedom of self expression.

Adolescents and adults need to be educated on the pros and cons of ICT and for the adult to
supervise appropriately. The new technology can be a source of power, empowerment,
enrichment or destruction and disappointment.

Figure 5: Social Environments That Influence Adolescent Development

Economic
Social
Cultural

Family  
   

  Young   
Person 
                        School/ 
                     Training/ 
Community                  Work 
                    
 
Value/
Belief
Systems
Peers

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2.5.7 UNDERSTANDING ADOLESCENT CULTURE

A. Culture

Culture encompasses the entire lifestyle of any particular group of people including their
inventions and thoughts which are in line with the group’s spiritual and physical values. But in
daily conversation, most of us define culture by associating it with phenomena like dancing,
music, food and style of costumes only.

In sociology, culture is defined as the entire result of ideas which were learned and shared by
certain communities. This includes their beliefs, political values, customs, laws, moral values,
social institutions, arts, languages and material products.

Culture can be grouped as follows:

• Thoughts/ideas - like knowledge, languages, philosophy, literature, myths, legend,
beliefs and folk stories.
• Materialism - like buildings, machineries, object of art, costumes, foods, medicines
and furniture.
• Arts - divided into two fields which are acting art (theater, dance, music, songs) and
visible art (carvings, engraving, drawings, plaiting and weaving).
• Values and norm - like rules, law, custom, folk-lore and tradition, style and behavior,
prohibitions, religious values and politeness.

B. Adolescent Culture

Contact between adolescents and their peers is a universal characteristic of all cultures.
However, there is a great deal of variability in the nature and degree of such contact. The
concept of peer culture was introduced by Corsaro (1998) and contains the following aspects of
social interaction:
• Adolescents appear to adhere and behave according to a set of social rules and
behavioural routines. If such rules and routines are breached, then comments and
negotiations between adolescent follow.

• Adolescents share a mutual understanding of actions and norms for procedures. This
shared framework of understanding enables children to systematically interpret novel
situations.

• Adolescents engage in activities that focus on themes that are repeated and that all
members of the peer group recognized.

Important characteristics of adolescents peer culture are:

• Seeking more autonomy - free from adult supervision
• Formation of bigger groups or cliques
• Increase contact with members of opposite sex

As the dynamics of society changes, adolescent cultures also change. The change in
adolescent culture is a reaction to the changes in politics, economic, education, technology and
globalization.

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 C. Adolescent Subcultures

Within every family, each adolescent develops individual characteristics such as likes and
dislikes, talents and disabilities, strengths and weaknesses. The adolescent group within the
community, on the other hand, may develop their unique adolescent subculture.

Adolescent subcultures can be defined as meaning systems, modes of expressions or lifestyles

developed by groups in subordinate structural positions in response to dominant systems i.e.
reflect their attempt to solve structural contradictions rising from the wider societal contact.
These are teenage-based with distinct styles, behaviours and interests.

Adolescent subcultures offer members an identity outside of that ascribed by social institutions
such as family, work, home and school. Adolescent can’t choose their ethnicity but they can
choose their culture. Specifically adolescent culture is a particular relationship on the part of
young people with the whole world of fashion (clothing style, hair style and footwear), image,
style, music and dance, dialects and slang. It is the collection of learned assumptions that
adolescents bring to their daily practice of interpreting the meaning of reality and ourselves.

Thus the culture of a group is the glue that binds its members together through a common
language, religion, beliefs, aspirations and challenges, while subculture (dress code, hairstyles)
gives distinctive characteristics to the group.

This subculture have certain positive or negative characteristics:

Positive Characteristics Negative Characteristics

• Healthy lifestyles • Unhealthy lifestyles
• Positive behaviours • Risky behaviours
• Pro-social attitudes • Anti-social attitudes
• Knowledge and skill driven • Non knowledge and skill driven
• Resilient • Vulnerable
• Competent • Incompetent
• Autonomy • Dependent
• Effective coping strategies • Non-productive coping strategies

Adolescents culture may be positive (pro-social behaviour) or negative (anti-social behaviour).

The following are examples of pro-social and anti-social behaviour.

Pro-social Behaviours
Pro-social behaviours are helping behaviours. Everybody helps somebody sometime. People
are motivated to help others based on:
• Human Values
• Understanding and Learning Experience
• For personal Development
• Community Expectation

Antisocial Behaviour
Adolescent antisocial behaviour is an issue of major concern to parents, teachers, police and
governments and is a significant cost to the community. Antisocial behaviour refers to a variety
of acts that violate social norms and the rights of others (Kazdin, 1985) and it includes a large
and varied set of behaviours, ranging from serious to relatively minor acts. The behaviours
range from non-compliance to adults, breaking rules, fighting, lying and cheating to more
serious acts such as bullying, truancy, physical assault or property offences for example theft
59 

 
or vandalism, Juvenile delinquency implies an antisocial misdeed in violation of the law by a
minor. If left unchecked, these behaviours in primary school settings escalate in high schools
and frequently, there is the use of violence and aggression. Violent behaviour typically includes
serious and extreme behaviour that is intended to cause physical harm to another person or
property while aggression is less extreme behaviour and can be physical or verbal in nature,
typically it is also intended to cause physical, psychological or emotional harm.

Onset of antisocial behaviours can be divided into:

1 Early Onset
• Individually based risk
- Neuro-cognitive deficits e.g. mental retardation, scholastic disorder, Attention
Deficit Hyperactive Disorder
- Personality e.g. temperamental and poor anger control
• In interaction with
- Adverse family environment or parenting e.g. domestic violence, authoritarian
parenting style and extreme poverty.

2 Adolescent Onset
• Individually based:
- Normal rebelliousness
- Excitement seeking
• Social factors:
- Influence of deviant peers
- In interaction with
- Adverse family environment or parenting e.g. domestic violence, authoritarian
parenting style and extreme poverty

Early onset anti social behaviours is usually chronic and severe unless intervened. The
development of escalating antisocial behaviour is difficult to reverse and the children who
engage in these behaviours are often:
• A danger to themselves and others
• Not identified early enough
• Are at risk for negative outcomes including school dropouts, vocational maladjustment,
alcohol or other illicit drug use and relationship problems

Programs designed to address antisocial behaviours range from general education (school or
community base) to intervention that target specific types of behaviour including educating
adolescents about the dangers of their behaviours and providing them with appropriate
alternatives to meet their social, emotional and economical needs.

D. Resilience

Adolescents overcome the many life stressors during their development using their resiliency,
assertiveness and inner strength. Rutter (1990) describes resilience as 'the ubiquitous
phenomenon of individual difference in people's responses to stress and adversity. It refers to
the ability to sustain competence under stress, and the ability to recover from trauma.
Resilience and resiliency are not static traits but are influenced by both internal and
environmental factors.

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i. Factors that influence resilience

Various literatures have shown how life events, personal, family and school factors
influence resilience and have identified protective factors in relation to the
adolescents’ world i.e. their family, school and community.

• Life events
Life events are incidences, events or experiences that are emotionally charged
for the adolescents which maybe positive or negative to the individual.

- Adolescents in discordant and disadvantaged homes are more likely to demonstrate

resilient characteristics if they attend schools that have good academic records and
attentive, caring teachers.
- Teachers play an important role in building resilient adolescents.
- Adolescents in disadvantaged areas are generally more 'at risk' than those in more
affluent areas.
- The strength of social support networks provided by kins and social service
agencies, operate as protective factors.
- Positive relationships and new opportunities will provide much needed resources or
new directions in life.
- Experiences that promote self esteem and self efficacy through achievements
and opportunities to join and belong to supportive groups, contributes to resilience.
- High mobility due to changes in parental employment contributes to adolescents’
disconnectedness and their vulnerability.
- Serious injury or the death of a close relative increased adolescents’ vulnerability
while the departure of an aggressive parent from the household proved to be
protective.

• Personal Factors
- Protective factors are activities, events which focus on personal attributes and skills
of the adolescents and a combination of positive coping strategies, feeling good
about oneself and one’s abilities
- Other characteristics include good communication and social skills, an internal locus
of control, impulse control and reflectiveness (Beardslee & Scwoeri, 1994).

• Family Factors
- Consistent parenting practices can promote attachment and emotional bonding
which promote resilience.
- Parents and members of the extended family who provide emotional and material
support as well as model positive and appropriate social behaviour can contribute to
building resilience.

• School Factors
Schools can contribute to the adolescents’ resilience by:
- promoting academic competence,
- Attending to their social and emotional needs
- Providing a sense of purpose, autonomy and connectedness through safe, positive
and achievement-oriented environment.
- Teaching valuable life skills such as problem-solving, social competence and
developing positive self esteem.

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 • Community Factors
Individuals and groups within the community can provide opportunities for adolescent
involvement and participation in social, sporting and cultural activities. These activities
promote feelings of belonging and connectedness that are central to the development of
resilience.

Table I: Summary of Protective Factors for Building Resilience

LIFE EVENTS SELF FAMILY SCHOOL COMMUNITY

• Full term birth • Personal • Love & • Good teachers • Adults

- Satisfactory attributes Attachment - Positive - Supportive
birth weight - Easy - Parents relationships - Protective
- Injury free temperament - Siblings - Knowledge of - Culturally proud
birth - Academic ability - Extended children &
- No disability - Emotional strength Family adolescents • Pro-social Peers
- Sense of - Positive behaviour - Supportive
• Continued autonomy • Support - management skills - Common
good health - Sense of humour - Material - Positive sense of interests
- Social competence - Emotional efficacy - Common
• Opportunities - Physical - Appropriate experiences
at competence • Parenting expectations - Sharing
- major life practices - Helpful
stages • Coping behaviours - Consistency • Support - Talk with &
and during - Problem solving - Positive and - Time listen
transitions strategies appropriate - Other adults
- Active engagement expectations - Agencies • Sports & clubs
• Meeting - Optimism - Positive self-
significant and - Persistence • Models of • School climate identity
supportive - Reflectivity resiliency by - Child-focused - Belongingness
persons - Parents - Collaborative & connectedness
• Beliefs about self - Siblings - Caring - Opportunities
• Moving into a - High self - Extended - Safe/Secure for success
more supportive esteem family - Empowering
community - Positive self • Agencies
efficacy • Positive links • Curriculum - Supportive
- Sense of Purpose with - Relevant - Protective
- Positive attitude - School - Enriched
- Self confidence, - Community - Age appropriate
etc groups
• Special programs
- Social ('Life Skills')
- Co-curriculum

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ii. Characteristics of Resilient Adolescent

- Having an active approach to life’s problems, including a proactive problem-solving

perspective that enables them to negotiate emotionally hazardous experiences.
- Having an optimistic tendency to perceive pain, frustration and other distressing
experiences
- Able to gain positive attention from others, both in the family and elsewhere.
- Having a strong faith that maintains the vision of a positive and meaningful life.
- Being alert and autonomous (independent) with a tendency to seek new experiences.
- Competent in social, school and cognitive areas.

iii. Adolescents Resiliency Skills – The 5Cs

Resilient adolescents develop social competencies that help them negotiate life’s
challenges, emerge as healthy, strong and contributing individuals. Below are the five
competencies or skills that adolescents should acquire:
• Critical school competencies
• Concept of self and self-esteem
• Connectedness
• Coping ability
• Control and strategies for cognitive change

a. Critical School Competencies

Critical school competencies consist of both basic academic skills and academic survival
skills. Basic academic skills are reading, writing, arithmetic, etc while academic survival
skills are social competency skills which are critical for school survival and survival in life.

Social competence can be described as the ability to make use of personal resources to
influence the environment and to achieve a positive outcome. Social competence is made
up of a variety of skills that provide effective ways of being with others such as:
• Behaving appropriately in class
• Formation of relationships and friendships
• Using nonviolent resolution of conflicts
• Assertiveness and resistance to peer pressure
• Negotiation of relationships with adults

Thus the school curriculum should include information on life skills such as:
• Study skills and time management
• How to study for tests
• How to make friends
• How to manage emergencies
• Managing one self when home alone
• How to avoid, identify or report abuse
• How to prepare for intimate relationships
• How to prevent oneself from engaging in premarital sex
• How to avoid drug use
• How to resist negative peer and media pressure

63 

 
b. Concept of Self and Self-Esteem

Self-esteem refers to how adolescents value themselves and believes that they are
important and have something valuable to contribute. It also refers to an individual's sense
of his or her value or worth or the extent to which a person values, approves of,
appreciates, prizes, or likes him or herself. Self-esteem can be favourable or unfavourable
towards the self. While self-concept refers to their overall beliefs of who they are (their
values, traits, skills, characteristics). Self-esteem is generally considered the evaluative
component of the self-concept, a broader representation of the self that includes cognitive
and behavioural aspects as well as evaluative or affective ones

Generally, high-risk adolescents tend to struggle with negative self-concepts and low self-
esteem. They have biased attributions and often placing blame on other people.

The environment around adolescents influences the value they place on parts of that
environment e.g. academic success, popularity etc. and with whom they compare
themselves. The low average student from a family of scholars is likely to have lower self-
esteem than the low average student from a family in which no one has graduated from
high school.

The adolescent may face biased attributions from significant others e.g. when parents and
peers react in a critical manner (judgmental or punitive or exhibit limited caring and
interests) making adolescents believe that they are not good enough cannot and they are
not lovable.

The adolescent learns from negative processes of learning and this result in a spiral of
negative views about self and others. For example, when an adolescent is made fun of, he/
she feels insecure and develops negative perceptions toward others (e.g. Anger, hatred or
vengeance), and may lower his/her self-expectations.

As a consequent, the adolescent may exhibit behavioural or learning problems and

alternatively, becomes passive, withdrawn or react aggressively towards others. This will
result in high risk behaviour because of the alienation and miscommunication in
interpersonal relationships. Having good self-esteem does not mean being boastful or
conceited, it is about believing in oneself and one’s ability.

The following are basic steps that are used to enhance self concept based on Cognitive
Behavioural Therapy (CBT):

• They way we behave, feel and think are very much correlated to each other.
Example: If you think that you are not good enough, you will feel worried or anxious
when out with friends. This will result in the person being quiet or totally avoiding
others.

64 

 
• Core beliefs is the way we see ourselves, judge what we do and view our future,
and over time, our cores beliefs become very strong and fixed. These beliefs and
assumptions come to the front of our thinking and are often triggered by important
events and experienced.

• Some core beliefs are helpful while some are not. These unhelpful core beliefs or
assumptions will prevent us from doing things and lead us to having false
assumptions about our self, abilities and future. They prevent us from making real
and more appropriate decisions or choices.

• By learning to recognize these thoughts, they can be changed or challenged.

• Automatic Thoughts are beliefs or ideas, that come to our head when triggered by a
stimulus e.g. events or situation. They are usually negative and self defeating.

• Positive or nice thoughts often produce pleasant feelings, while negative thoughts
often produce unpleasant feelings.

• People often get trapped in a negative cycle and are not aware of how feelings and
thoughts are powerful and important to our functioning.

• Learning to monitoring and recognize our thoughts, then challenging or changing

them can make us develop a more balanced and healthier way of thinking,
Alternative Thoughts. These thoughts make us feel better, more capable to explore
the world and make real choices about important things in our life.

• If not the negative automatic thoughts will go around and around in our heads and
make us feel unpleasant and prevent us from doing things. These are call Thinking
Errors – many of our core beliefs are useful but there are others that are unhelpful.
They prevent us from making good choices and decisions, and can lead us to make
false assumption about our self and prevent us from doing things.

65 

 
Common Thinking Errors*

1. The downers: focusing on the negative things that happen. We only see the things
that go wrong or not right.

2. Blowing things up: where negative things are blown up and become bigger that
they really are.

3. Predicting failure: we predict the worst and for all our effort to fail.

4. Feeling thoughts: with this thinking, out emotions become very strong and cloud
the way we think and see things. These thoughts include using labels on oneself.

5. Setting yourself up to fail: we set our targets to be too high and way above our
capabilities. These thoughts are often used with such words: I should, must, can’t
or shouldn’t

6. Blame me: here is when we take or feel responsible for the negative things that
happen, even though we have no control over them.

7. All-or-nothing thinking: Classifying things into rigid, black-or-white categories. For

example, believe things: 'My mother either loves me, or she doesn't."

8. Over generalizing: You view a single event as proof that any similar event will turn
out the same way. For example, you reason that because one man or woman acted
hurtfully, all men or women must behave that way.

9. Demands: You make grandiose, demands of yourself, other people, or the world.
You do this with rigid and absolute shoulds or shouldn'ts, musts, oughts, cant's, or
have tos. You say things to yourself and others like, "They should have done this,"
or "They shouldn't have done that, I have to do this," or, "I ought to do that."

10. Mental Filter: You dwell on one positive or negative detail so your perception of the
entire situation gets distorted--like a drop of ink that discolors an entire pitcher of
water. You filter all new information through this distorted perceptual lens. You may
attend only to the things you consider good about a desirable lover, or dwell only on
the things you consider bad about the loss of job.

11. Discounting contrary information: Here, you discount or minimize the importance
of new information coming to you that seems to contradict your beliefs. You make
preserving your beliefs about what goes on around you a higher priority than
discovering the facts.

12. Jumping to conclusions, three kinds: (a) Mind reading. You assume you know
what others think and why they do what they do when you have no objective
evidence of this. (b) Fortune-telling. You make predictions that things can't change
or will turn out badly, or that they will change only for the better. (c) Invented
causation. If you don't know why something happened, you invent a cause, or
believe a previously invented cause. You may devoutly believe something exists in
spite of a lack of objective evidence. This reduces anxiety, but it also stops any
further investigation; it stops helpful learning and change.

66 

 
 * Adapted from Cognitive Therapy o/Depression by Aaron Beck. It seems important to
note that much of the work of Aaron Beck relates directly or indirectly to the earlier work
of Dr. Albert Ellis.

Identifying automatic thoughts, searching for evidence, generating alternatives

and decatastrophizing are extremely important in developing optimism and
lowering pessimism.

c. Connectedness

Connectedness with others is critical in people’s lives and is a major component of

effective and comprehensive life-skills training programs. Connectedness involves both
intrapersonal awareness and interpersonal skills in order to understand self and others.
One important component of connectedness is interpersonal communication skills as
lack of these skills often leads to social isolation and rejection.

Training in interpersonal communication should include:

• Training in verbal and nonverbal communication
• Creation of healthy friendships
• Minimizing and handling understanding
• Development of long-term love relationships
• Assertiveness Skills

Assertiveness Skills
Some adolescents get into trouble because they are timid, withdrawn or express
themselves in hostile, angry and aggressive ways. Assertiveness is founded on respect
for oneself and others, and for ones’ own values. It involves:

• Being able to verbally and non verbally communicate one’s positive and negative
feelings
• Expressing one’s thoughts and emotions without feeling guilty
• Not violating the rights of others
• Taking responsibility for what happens in one’s life
• Making decisions, being a friend and maintaining one’s dignity and self respect
• Recognizing that one have certain rights and a value system to be respected
• Protecting one’s self from being victimized by others
• Being able to monitor and discriminate when one’s behaviour may lead to negative
as well as positive behaviour

d. Coping ability

Many at-risk young people are affected by stress and anxiety. The ability to cope with
life’s stresses will assist the adolescent to adapt and survive whatever situations they
may face. Among the positive ways to cope is through stress management training
which should incorporate:
• Coping styles
• Spiritual beliefs and practices
• Relaxation techniques e.g. Physical exercise, mediation and breathing exercise

67 

 
 e. Control

Control refers to control of decisions, emotions and self. A variety of cognitive-

behavioural techniques have been devised to help adolescents develop control over
their internal reactions and overt behaviour.

Self-management and self-control are related. Self-management is the ability to

maintain or alter goal-directed behaviour without depending on external forces. Self-
control is an important component of self-management and refers to control over one’s
affective, cognitive, and behavioural reactions. These will help adolescents to avoid
problem situations, limit negative emotional reactions, resist problematic behaviours
and delay gratification.

Training in self-management and self-control includes the following skills:

• Self-assessment
Being able to evaluate and compare present functioning with internal standards
• Self-monitoring
Being aware and attuned to one’s present level of functioning
• Self-reinforcement
Providing positive consequences when performance meets standards and negative
consequences when adequate performance is not attained

Helpful Steps for Control of Decisions

• Define the problem
• Examine variables
• Consider alternatives
• Devise a plan and carry it out
• Evaluate effects or consequences and return to the problem if plan not work out
well

Conclusion

The adolescents’ experience is one of great change. It has been defined as a period of rapid
biopsychosocial growth and development. Many have difficulties coping effectively. Adults
play a crucial role; they should be aware, acknowledge, understand and support the
adolescents to maximize the adolescents’ potential.

68 

 
 APPENDIX 1

UNDERSTANDING THE ADOLESCENT

PRE TEST AND POST TEST

ANSWER ALL QUESTIONS: (Indicate “T” for True or “F” for False)

1. The following are true adolescebt

A. Adolescent ia a phase of change

B. Adolescent violence ia reaching alarming rate
C. Adolescent are rebellious
D. Adolescent should be given the opportunity to express their thoughts and feelings
E. Adolescent physical and cognitive development may develop at a different rate

2. The following are true about adolescent development

A. Tanner staging is used to assess the development of adolescent secondary sexual

characteristics
B. The adolescent thinking changes from abstracts to concrete
C. Adolescent are often searching for their own identity
D. Adolescent need to be taught to control their emotion
E. Emotional changes in adolescent are due to hormonal changes

3. The following are mental health needs of adolescents

1. To be constantly criticized and teased

2. To be rewarded for their positive behaviour
3. Do not need privacy
4. To feel loved and supported
5. Require consistent parenting by adults

6. The following are true of adolescent environment and culture

A. Adolescent culture include their thought, values and norms

B. Permissive parents lead to immature, impulsive and irresponsible adolescent
C. Adolescent mimic adult behaviour and manners
D. Peer does not influence adolescent behaviour
E. Familiy, school and community environment is not important in supporting
adolescent development

69 

 
 APPENDIX 2

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2.7 REFERENCES

Bates DG, Plog F. Cultural Anthropology. 3rd ed. New York: McGraw-Hill; 1990

Beardslee W, Schwoeri I. Preventive intervention with children of depressed parents. In:

GP Scholevar. Ed. The Transmission of Depression Families and Children:
Assessment and Intervention. Northvale, NK: Aronson; 1994.

Brown BB, Eicher SA, Rae CD. Perceptions of Peer Pressure, Peer Conformity
Dispositions and Self-Reported Behaviour among Adolescents. Developmental
Psychology 1986;22:521-530

Darling, Nancy, Steinberg. Laurence. Parenting Style as Context: An Interrative Model.

Psychological Bulletin. 1993;113:487-496.

Davis-Kean, Pamela, Sandler H. A Meta-analysis of measure of self-esteem for young

children. A framework for future measures in Child Development. 2001 May/June;
72(3):887-906

Garbarino J. Raising Children in a Socially Toxic Environment. San Francisco, CA:

Jossey- Bass. 1994.

Greenfield P. Children, Adolescent and th Internet: A New Field of Inquiry in

Development Psychology. 2006;42(3)

Hayward C, Killen J, Wilson D, Hammer L. Psychiatric risk associated with early puberty
in adolescent girls. Journal of the American Academy of Child & Adolescent
Pcychiatry.1997;36(2):255-262.

Halpern-Felsher BL, Millstein SG, Irwin CE. Work group II. Healthy adolescent
psychosocial development. J of Adolescent Health. 2002 Dec;31 (6) Suppl 1:201-207.

HuittW, Hummel J. Piaget’s theory of cognitive development. Educational Psycholoyg

Interactive. Valdosta, GA. Valdosta State University;2003.

Kaufman M. Change is the essence: adolescent development. In: Kaufman AM, ed.
Mothering Teens: Understanding the Adolescent Years. Toronto. Ontario. Gynergy
Books; 1997 p. 15-26.

Larson R, Ham M. “Stress” and “storm and stress” in early adolescent: The relationship
of negative events with dysphoric affect. Developmental Psycologiy. 2002;73:1151-
1165.

Presentation and Sexual Exploration in Online Teen Chat Rooms.

Rak CF, Patterson LE. Promoting resilience in at risk children. J of Counseling and
Development. 1996;74:368-373.

R Quigley. Positive Peer Groups: “Helping Others” Meets Primary Developmental Needs.
Reclaiming children and youth. 2004;13(3):395-406.

Stallard P. Think Good-Feel Good. John Wiley and Sons Ltd; 2002

Steinberg, Laurence. We Know Some Things: Adolescent-Parent Relationships in

Retrospect and Prospec. J of Research on Adolescent. 2001;11:1-20.
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Stenberg, Laurence et al. Over-Time Changes in adjustment and Competence among
Adolescents from Authoritative, Authoritarian, Indulgent and Neglected Families. Child
Development. 1994;65:754-770.

U.S Department of Education Office of Communication and Outreach. Helping Your

Child through Early Adolescent. Washington DC; 2005

Wilkinson RB Kraljevic M. Adolescent Psychological Health and School Attitudes: The

Impact of Attachmnet Relationships. Proceedings of the Australian Psychological
Society’s Psychological of Relationship Interest Group 4th Annual Conference.
Melbourne, Australia: the Australian Psychological Society; 150-155.

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UNIT 3

CONFIDENTIALITY,
RAPPORT, EMPATHY &
TRUST (C’RET@)

101 
 
 

102 
 
 UNIT 3:

UNIT 3: CONFIDENTIALITY, RAPPORT, EMPATHY & TRUST

(C’RET©)

TABLE OF CONTENTS
PAGE

3.1 Teaching Outline (Framework) 104-108

3.2 Introduction 109

3.3 Time frame 109

3.4 Objective 109

3.5 Contents 109

3.5.1 Building Rapport With Adolescents 109-111

3.5.2 Expressing Empathy 111-112

3.5.3 Confidentiality 113

3.5.4 Building Trust 114

3.6 Appendices

Appendix 1 Ice-breaking Activities 115

Appendix 2 Building Trust Activities 116-117

Appendix 3 Instructions for Role Play (Facilitator) 118-120

Appendix 4 Instructions for Role Play (Participant) 121-120

Appendix 5 Evaluation Activities 124

Appendix 6 Snippets of Video 125-129

Appendix 7 PowerPoint Presentation on C’RET© 130-134

3.7 References 135

103
 3.1: TEACHING OUTLINE (FRAMEWORK)

Learning Contents Activities Activities AVA/Teaching Assessment/ Time

Objective (Trainer) (Participants) Materials Evaluation (min)
1. Engaging 1. Getting to know Introduction Participative games • Large Space Participants’ 90
Adolescents each other in a fun • Post-It mood meter
and friendly way Ice Breaking Group Forming • Ball
• Line up • Present for the Ear-of-the-Day
2. Elicit participants’ • Poison Ball Group (e.g.
personal • Sound, Body & cake)
experience Movement

Select 3 Ear-of-the -
Day

2. Revision 1. Understand Show Video Clip on Identify Adolescent • PowerPoint Pre-Test 30

Adolescent Adolescent Culture & Culture and Issues Presentation
Culture Issues Related to Related to Working • Video Clip on
Working With with Adolescents -Adolescent
2. Identify challenges Adolescents Culture
faced by Relate to previous -Dealing with
adolescents Brainstorm on the lectures on the Adolescents
challenges faced by the Adolescents as well as • Flip Chart
adolescents as well as
3. Identify challenges
health care providers
personal experience • Marker
faced by health • Video Camera
care providers (HCP) Discuss typical session Clip-on
(HCP) Facilitate discussion of in the clinic Microphone
a typical session in the
clinic
Inform participants that
session will be
recorded for review
later

104
 Learning Contents Activities Activities AVA/Teaching Assessment/ Time
Objective (Trainer) (Participants) Materials Evaluation (min)
3. Understand 1. What is rapport? Interactive lecture Listening • PowerPoint Discussion 30
Concept of presentation points on flip
Rapport 2. Why is rapport Video clip discussion Identify concerns • Video Clip chart
important? before, during and after (Rapport)
meeting adolescent • Flip Chart
3. When & where to • Marker
use rapport? Identify different
approaches used in
4. How to use engaging adolescent
rapport?
Identify good practise
5. Factors enhancing
& eroding rapport

4. Understand 1. What is empathy? Interactive lecture Listening • PowerPoint Discussion 30

Concept of 2. Why is empathy presentation points on flip
Empathy important? Present case scenario Self reflection • Case scenario chart
3. When & where to Video Clip
use empathy? Video clip discussion Observe both verbal (Empathy)
4. How to use and non-verbal • Flip Chart
empathy? Guide descriptions on behaviour • Marker
5. What is listening factors enhancing and
behaviour? eroding empathy Describe skills shown
6. Factors enhancing that can enhance or
& eroding empathy Question and answer erode empathy
session

105
 Learning Contents Activities Activities AVA/Teaching Assessment/ Time
Objective (Trainer) (Participants) Materials Evaluation (min)
5. Understand 1. What is Interactive lecture Listening • PowerPoint Pre and post- 30
Concept of confidentiality? presentation test
Confidentiality Present case scenario Group discussion on • Video clip
2. Why is how to develop the (Confidentiality)
confidentiality Discussion and verbal confidentiality • Flip Chart
important? feedback contract • Marker
• Oral
3. When & where to Question and answer Short presentation presentation
use session (2 minutes/group)
confidentiality? followed by discussion

4. How to use
confidentiality?

5. Factors enhancing
& eroding
confidentiality

6. Understand 1. What is Trust? Interactive Game- The Participative games • Strings Participants’ 60
Concept of Lost Blind Man • Tables Mood Meter
Trust 2. Why is Trust Sharing on self- • Chairs
Important? Facilitate post-game reflection and general • Napkin/Cloth for
discussion on the observation from the Blindfold
3. When & Where to experience of the lost game • PowerPoint
use Trust? blind person, the helper presentation
and the crowd Understand the
4. How to use Trust? concept of trust
Interactive lecture
5. Factors Enhancing Identify important
& Eroding Trust Question and answer issues in scenario
session

106
 Learning Contents Activities Activities AVA/Teaching Assessment/ Time
Objective (Trainer) (Participants) Materials Evaluation (min)
7. Provide 1. Practice on Prepare venue Read the handouts for • Appendix 3- 15
participants engaging with role play Facilitator
with skills to adolescent using Ensure technical • Appendix 4:
carry out C’RET © support is available for Participant
C’RET © recording • Video camera
• Clip-on
Explain task to microphone
participants • Extension Wire

2. Participant able to Set timer for role play Form triads consisting • Handouts for Video clips 30 x 4
engage in Group of the Healthcare role play during practice
Dynamics and Facilitate discussion Provider, Adolescent, • Video camera
share their after role play to and Observer(s) for • Clip-on Observers
experience explore feelings in each role play and take microphone check list
participants’ own role turns playing different • Extension Wire
and others as well as roles • Time keeper
lessons learnt from the
role play

107
 Learning Contents Activities Activities AVA/Teaching Assessment/ Time
Objective (Trainer) (Participants) Materials Evaluation (min)
3. Participant able to Edit and select the • Recording of 30
give feedback recording for discussion Role Play
based on pictures/ in big group • Projector
video clips on • Screen
specific issues Facilitate discussion in Participate in big group • Speaker 45
big group using discussion based on
recording recording

8. Conclusion 1. Summary of Facilitate group Share experience and • Flip Chart Participants’ 30
experience discussion on CRET© lesson learnt from • Marker Mood Meter
module • Post-It
2. Identification of • Feedback Form Post-Test
challenges Identify future • Course
challenges Evaluation
Form

TOTAL TIME 8 Hrs

108
3.2 INTRODUCTION

In dealing with adolescent health and well being, health care providers possess limited
knowledge and skills in providing service that is friendly to them. Factors such as lack of
exposure and emphasis on adolescent health during their earlier training is not surprising as
this is a new scope altogether. This has made the personnel feel inadequate especially in
dealing with the practical skills to communicate and handle adolescent health effectively.
The challenges posed by adolescents themselves are also contributing to this inadequacy.
Areas on building trust, developing rapport, empathy and confidentiality has not been
addressed effectively. It is hoped that this module will be able to help the health care
professional to gain knowledge as well as skills while managing adolescents in their setting.

3.3 TIME FRAME

8 hours (For a group of 30 participants with a ratio of 1 facilitator: 5-8 participants)

3.4 OBJECTIVES

At the end of this module, participants should be able to:

• Recognize the importance of confidentiality and internalize the concept.
This consists of:
- understanding what is confidentiality
- how to maintain confidentiality
- identifying factors that erode confidentiality
- when and how to break the confidentiality

• Gain knowledge and develop skills required for effective communication.

This includes:
- developing rapport with adolescents
- expressing empathy towards adolescents
- building and gaining trust from adolescents

3.5 CONTENTS

• Building rapport with adolescents

• Expressing empathy
• Confidentiality
• Building trust

3.5.1 BUILDING RAPPORT WITH ADOLESCENTS

A. Aim: To initiate and sustain positive relationship with the adolescent

This can be achieved by certain preparation before, during and at the end of meeting the
adolescent. Healthcare providers need to equip themselves with these skills before engaging
with adolescents.

109
 B. Meeting the Adolescent
Before
• Create an environment that is
comfortable to the adolescent
• Appropriate attitude – make
mental and physical
preparation, emotional
connectedness, unconditional
acceptance
• Punctuality – keeping to the
appointment
• Standard practice – bring
family in together at the
beginning to introduce/greet,
explain the purpose of the
session and see the
adolescent alone first (*with
an exception if the adolescent
refuse)
Never leave an impression that
the healthcare provider and the
parents are collaborating
During At the End
• 2 ways of approaching. • Summarize the gist of
the discussion and
• Bringing yourself to their gather adolescent’s
level response (use
appropriate phrase
• Allowing them to test the
situation • Involve adolescent in
his/her management
• Make them feel in control plan and decide on the
of the situation – allow plan of action (discuss
freedom to choose and with the adolescent on
decide and then follow- what can/cannot be
through shared with their
parents)
• Address adolescent
appropriately (by name/ Invite parents and give
nickname) feedbacks
• Take note if adolescent
initiates handshake
• Maintain appropriate
body language – facial
expression (includes
smiling), posture, tone of
voice, gesture, distance,
hand movement, eye
contact
• Explain confidentiality
with regards to the
session – to include
exception and verbal
confidentiality contract
(VCC)
• Avoid factors that can
affect good rapport
building – i.e. appears to
be in a hurry, distracted,
uninterested, judgmental
(listen to them before
jumping to conclusions)
• Show respect for their
views and be flexible
• Avoid domination of the
session
110
 Factors that enhance Factors that erode
1. Two way communication 1. One way communication
2. Working in partnership with adolescent 2. Secrecy
3. Being flexible but consistent 3. Domination and threat
4. Appropriate body language 4. Lack of privacy
5. Be yourself 5. Distraction- noise, movement of staff,
phone calls
6. Lack of trust

3.5.2 EXPRESSING EMPATHY

A. Aim:
To acknowledge and accept the adolescent’s feelings
To express understanding and reflect upon the experience

B. Definition
Empathy- ‘put oneself in another person’s shoe’
It refers to the ability of the healthcare provider to understand and feel what the adolescent is
experiencing. This includes his/her feeling, thought and action.

Factors that enhance

• Genuine interest to help
• Appropriate body language
• Maintaining eye contact
• Active listening
• Bringing yourself to their level
• Consistency in behaviour, thought and feeling
• Be honest, warm and friendly

Example of positive listening behaviour

• Give the adolescent your full attention, stop doing other things.
• Nod or shake your head in response to adolescent comments.
• Change your facial expression top reflect appropriate emotion such as concern,
excitement, fear etc.
• Ask question to clarify what the adolescent is saying e.g. ‘Are you saying…?’ or ‘I
am not sure I understood. Could you explain?’
• Compliment the adolescents with statement like, “I really liked the way you handle
that”.

Factors that erode

• Being judgmental
• Insensitive
• Imposing your personal value
• Counter transference (negative reaction of the health care provider towards
adolescent)

111
 Example:
• Interrupt the adolescent while he or she is talking.
• Change the subject to something unrelated to what the adolescent us talking about.
• Whisper to someone while adolescent is talking.
• Listen carefully at first then begin to look bored, gazed around the room, sigh, look
at your watch.
• Disagree with adolescent. Each time he or she says something, challenge it.

Example:

Adolescent girl who have been sexually abused feel disgusted and dirty about herself.
Health care provider understands and feels for her.

Case Scenario-imagine you are a 15 years old girl who had been sexually abuse by your
father for the past 5 years. You decided to end this suffering by committing suicide. How do
you feel? (Get feedback from the participant)

The healthcare provider needs to listen to the adolescent when he or she expresses his or
her feeling. Listen to what is said as well as how it is said. Listen to the intonation of the
voice, stammering, or throat clearing. Observe the adolescent’s facial expression, hand
gestures and body language.

When the adolescent says, “My mother always compares me with others. I am always
useless and lazy….”

The adolescent may be feeling angry, or sad, or dissatisfied or even frustrated. Without
letting them continue and clarify, the healthcare provider will never know the true feeling.
This would hamper the empathizing process.

The healthcare provider may not need to respond verbally at times as empathy can be
expressed in the following ways:
• maintaining eye contact (be with them)
• gentle nodding of the head
• respond appropriately to their feelings

112
3.5.3 CONFIDENTIALITY

A. What is Confidentiality?

Usually refers to privacy of information shared between healthcare provider and the
adolescent and it extends beyond the session.

In the event that the case would need to be referred to other specialist, the healthcare
provider needs to obtain consent from the adolescent concerned.

B. How to Maintain Confidentiality?

It is encouraged that the Confidentiality statement is made when parents are also in the
room – as they also need to know. The parents need to understand that the adolescent has
his or her own right that needs to be respected.

C. When to Breach Confidentiality?

Everything is kept confidential unless there is significant concern

• When the adolescent may harm him/her self
• When others may be harmed
• When others may harm him/her
• When s/he give consent to disclose

ONLY relevant information pertaining to the above concern will be disclosed.

Example 1

16 years old Diabetic with multiple psychosocial problems (smoking, promiscuous, glue
sniffing and poor compliance to treatment) attempted suicide after suffering from depression
for 3 years. Referral to psychiatrist was made – How much information should be revealed?

Suggestion: Depression and suicide attempt

Example 2

Parents bring their adolescent to the clinic with complaints of abdominal discomforts. During
interview, the adolescent admitted to having regular unprotected sexual intercourse with
multiple male friends. She has been secretly treating herself for unresolved vaginal
discharge. Discussion of possibilities of sexually transmitted infection was done and further
investigations which include HIV screening was agreed upon. You’re the healthcare provider
managing this adolescent. How would you approach the parents? (Breaking news to
parents without breaching confidentiality)

Suggestion: Giving options to the adolescent on information to be shared, negotiates with

him/her on the level of disclosure and to include the adolescent when breaking the news in
which the healthcare provider facilitates the session.

113
Example of Verbal Confidential Contract (VCC):

“What we talk about is confidential, which means that I won’t discuss it with anyone else
without your permission. There are 3 exceptions to this which are if I am worried that you’re
at risk of harming yourself, harming others, or if you are being abused and are not saved. If
these things come up, we’ll need to deal with them and I’ll help you through this and involve
you in any decisions that need to be made around who we need to talk through.”

3.5.4 BUILDING TRUST

There’s nothing worse for a teenager than to find that you have a closed mind and can’t
listen to their view.

A. Definition

Adolescent have faith and confidence towards healthcare provider and able to share their
secret or concern freely.

Building trust is a crucial process to adolescent. It promotes effective engagement between

adolescent and health care provider. It is equally important that the health care provider
honour the trust placed upon them.

Factors that erode

• Absence of mutual trust
• Withholding information from adolescent
• Collaborating with parent /guardian without consent
• Showing disrespect towards adolescent
• Break the confidentiality
• Unethical behaviour e.g. taking advantage of the adolescent

“It is easier to lose trust than gaining it”

114
 APPENDIX 1

ICE-BREAKING ACTIVITIES

Activities Time Teaching/AV Outcome

Frame Materials
Line Up
1. Participants would be asked to position
themselves either along a line or on an
imaginary map based on their response to the
Participants
questions initiated by the facilitators.
would be able to
2. The participants later engage among
know each other
themselves to ask about things they’ll like to Large Space
in an informal
know from each other. 20 min Cordless
way without
3. Examples of questions are: Microphone
directly asking
a. Geographical Area
each other in a
b. Birth Month
fun way.
c. Time of Waking Up
d. Birth Order Among Siblings
e. Ownership of Pet, Shoes etc

Throw in Circle
1. Participants would be asked to stand in a circle
and share their experience as the ball is tossed
around. Upon receiving the ball, participants
are supposed to say a word/phrase on the
theme agreed. To be able to
Example of personal experience include: grasp
Ball/Yarnball/
a. Prior experience with Adolescence – participants’ prior
Crushed
Memorable contact with adolescents 20 min experience and
paper
b. Challenges faced in understanding understanding
Papers
adolescents about issues &
Markers
c. Specific experience with adolescents in the stereotypes in
clinic setting adolescence

*Facilitators will record the session and take note

on the remarks and comments shared by the
participants.

Sound, Music and Movement Participants

1. Participants would be divided to 4 groups by would be able to
having them count 1-4 repeatedly. No. 1s will be creative,
be Group 1, No. 2 Group 2 and so on. spontaneous and
2. Each participant to device or create a sound engage with their
using their own bodies based on their creativity. peers as part of
Present for
The participants will then join the sound the adolescent
30 min best group
together to make a rhythm for their group. culture
performance
3. Each group will take turns to show their
creation and each performance will be voted by To reduce
the rest. participants’
4. All of the groups would then join together to barrier to engage
make a new arrangement using their creation. freely

115
 APPENDIX 2

BUILDING TRUST ACTIVITIES

Activities Time Teaching/AV Outcome

Frame Materials

Set Up
1. Participants are not to observe set up. Use tea Participants
break to do this. would be able to
2. Set up a path of about 10 metres. Use strings learn that the
to mark off the border on both sides. Width of process of
the path should be around 5 metres. building trust is
3. Use chairs and strings to make obstacles by difficult due to
placing them randomly on the path. mis-
4. Mark the final point. Use a water bottle. Large Space communications,
5. Two representatives will be selected from each Tables distraction,
group. One is the Lost Blind Man and the other, 20 min Chairs multiple input as
the kind Samaritan. The rest will be the crowd. String well as stress.
6. The Blind Man puts up the eye cover at the Bottles
side led the room away from the obstacles and
is the led to the starting point by the facilitator. It is difficult for
7. The Samaritan takes his/her place at the side both the guide
of the pathway opposite the crowd. (Samaritan) and
8. The Crowd is allowed on the other side of the his/her care
pathway and to cheer or distract. (Lost Blind Man)
9. Instructions will be given separately to the Blind to build and
Man, Samaritan and Crowd. maintain the
trust. It’ll take
time to develop as
The Lost Blind Man they become
1. Participant is told that the task is to be the first more
to cross over from one side of the room to the comfortable and
others. 20 min Blindfold understand each
2. He/She will be blind-folded for the task. other better.
3. He/She is to try to rely and follow the
instructions of the kind Samaritan.

At the end of the

The Samaritan activities,
1. Participant told that the task is to give verbal participants will
instructions to the lost blind man to cross over be able to
from one side of the room to the other side Barrier develop good
safely through the obstacles either by avoiding, 20 min (Table, listening skill.
climbing over or crawling trough. Chairs, Communication,
2. He/She has to stay behind the barrier at all Strings) skill, empathy
times. and trust.
3. He/She can only communicate with the lost
blind man of his/her own group.

116
 Activities Time Teaching/AV Outcome
Frame Materials

The Crowd
1. Participants are instructed to stay on the
opposite side of the barrier from the Samaritan.
Barrier
2. Only the groups with representatives in the
(Table,
game can participate. 20 min
Chairs,
3. They cannot communicate directly with their
Strings)
team members but they can talk to the
opposing team.

The Game
1. The task is to cross over from one side of the
room to the other side while relying on remote Participants
instruction in the midst of the chaos created by would also be
others. able to deliver
2. At any one time, 2 groups will be competing- clear massages
Barrier
crowd members from the opposite group will try and support
(Table,
to sabotage their opponent’s effort. members in need
20 min Chairs,
3. Start the timer. of help despite
Strings,
4. Let the kind Samaritan gives the instruction to all obstacles.
Bottles)
the Lost Blind Man.
5. The facilitators will be the referee as well as
crowd controller and maintain safety at all
times.
6. The game is won when the lost blind man
reach the final point.

117
 APPENDIX 3

INSTRUCTIONS FOR ROLE PLAY (FACILITATOR)

Instructions to Facilitators:

a. Explain the objectives of this exercise.

i. Participant will be able to engage in Group Dynamics and share their experience
ii. Participant will be able to give feedback based on pictures/video clips on specific
issues – communication, body language, C’RET©
b. Explain to Participants that the exercise will be recorded for learning purposes.
c. Arrange the venue so that the groups are well-spaced out.
d. Assign a facilitator to each group.
e. Appoint a time keeper (either one of the facilitators or helper).
f. Mark time on the board to help participant manage their time.

Instructions to Participants:

For the following exercise, please read through each of the scenarios and take turns to role
play in your group as the healthcare provider, the adolescent and the observer. You have
about 30 minutes for each scenario. Spend about 2 minutes to brainstorm about the
scenario and choosing your role. You have 10 minutes to do the role play and after which
you will take 2 minutes to debrief alone and then 15 minutes in your group.

Use the following questions to help your discussion:

• How Do I Feel In My Role?
• How Do I Feel About the Other Role?
• What Was Successful?
• What Needs To Be Improved?

Use the Checklist C’RET© to Guide Your Observation (page 123)

Instructions for Recording:

a. Preparation before digital recording session includes:

i. Check the AV equipment the day before to ensure availability of recording tapes
and sound system.
ii. Battery fully charged and sufficient for 2 hours continuous recording.
iii. Memory capacity for the digital video camera and computer with a minimum of
2G.
iv. Both audio and video channel is functional – pre-tested before starting the
module.

b. Get a general overview of the group in action.

c. Then zoom into specific triads during their role-play.
d. Close-up view of the healthcare provider role on verbal and non-verbal communication
such as facial expression, hand gestures, eye contact, distance, intonation and manner
of engagement.
e. Repeat the steps for each group.
f. Editing of the recorded material is required and need to be made available for discussion
after that.

118
 APPENDIX 3

CONFIDENTIALITY

Case 1
An adolescent girl walked into your clinic making enquiries about contraception. As you
talked to her further, you found out that she is currently seeing a young man who is
pressuring her into having sexual intercourse to prove her love for him. You need to find out
more about her sexual history but she seems reluctant. You reassure her on confidentiality
and protecting her secrets.

Task for Participant:

• Identify important issues in this scenario.
• Demonstrate how you’ll assure her of confidentiality.

Task for Facilitator:

• Guide the participants to discuss about VCC with the adolescent.
• Guide the participants on the skills required to keep confidentiality.

Case 2
A 15 years old adolescent male came to the clinic alone with history of penile discharge and
burning sensation upon urinating. Additional history revealed that he had history of sexual
intercourse with a girl during one of his weekend rendezvous with his Mat Rempit gang.
Investigation confirmed gonorrhea (STD). He has been advised to bring his parents in for
discussion about his treatment. This boy requested you to conceal his revelation about
contacting STD.

Task for Participant:

• Identify important issues in this scenario.
• Demonstrate how you address issues on confidentiality.

Task for Facilitator:

• Guide the participants to discuss about VCC with the adolescent.
• Guide the participants on the skills required to break confidentiality.

RAPPORT

A Form Two boy was brought in by his mother for his serious acne problem. He kept quiet
throughout the interview while the mother complained about his “couldn’t care less” attitude
about proper skin care. You observed that this boy has low self esteem and you need to
engage with this boy.

Task for Participant:

• Identify important issues in this scenario.
• Demonstrate how you build rapport with the boy.

Task for Facilitator:

• Guide the participants to engage with the adolescent.
• Guide the participants on the skills required to build rapport.

Note: The role-play is between adolescent and healthcare provider alone – if this did not
happen, address the issue after the role-play.

119
 APPENDIX 3

EMPATHY

13 years old adolescent girl previously diagnosed to have Systemic Lupus Erythematous
(SLE) now presented with shortness of breath with increasing pallor and oedema. She was
later diagnosed to have end stage renal failure and in need of haemodialysis. Her parent
was in great distress and the adolescent was too shocked to react. Her parents were unable
to comply with the recommended management as they live in a remote Felda settlement.
Her condition is deteriorating. You are the health care provider who is presently attending
this family.

Task for Participant:

• Identify important issues in this scenario.
• Demonstrate how you express empathy.

Task for Facilitator:

• Guide the participants to empathise with the adolescent.
• Guide the participants on the skills required to express empathy.

TRUST

A female matriculation student came to see you for being stressed. She expresses her
anxiety about boy-girl relationship and her unexpected attraction towards her new male
course mate. She finds this experience scary and hard to handle. She had always presented
herself as tomboyish since early teens and find difficulty in relating emotionally to boys. By
the slip of the tongue, she blurted out, “All men cannot be trusted!” and suddenly stopped
talking.

Task for Participant:

• Identify important issues in this scenario.
• Demonstrate how you can gain trust.

Task for Facilitator:

• Guide the participants to engage with the adolescent again.
• Guide the participants on the skills required to build trust.

120
 APPENDIX 4

INSTRUCTIONS FOR ROLE PLAY (PARTICIPANT)

For the following exercise, please read through each of the scenarios and take turns to role
play in your group as the healthcare provider, the adolescent and the observer. You have
about 30 minutes for each scenario. Spend about 2 minutes to brainstorm about the
scenario and choosing your role. You have 10 minutes to do the role play and after which
you will take 2 minutes to debrief alone and then 15 minutes in your group.

Use the following questions to help your discussion:

• How Do I Feel In My Role?
• How Do I Feel About the Other Role?
• What Was Successful?
• What Needs To Be Improved?

Use the Checklist C’RET© to Guide Your Observation (page 123)

Scenario 1: CONFIDENTIALITY

Case 1
An adolescent girl walked into your clinic making enquiries about contraception. As you
talked to her further, you found out that she is currently seeing a young man who is
pressuring her into having sexual intercourse to prove her love for him. You need to find out
more about her sexual history but she seems reluctant. You reassure her on confidentiality
and protecting her secrets.

Or

Case 2
A 15 years old adolescent male came to the clinic alone with history of penile discharge and
burning sensation upon urinating. Additional history revealed that he had history of sexual
intercourse with a girl during one of his weekend rendezvous with his Mat Rempit gang.
Investigation confirmed gonorrhoea (STD). He has been advised to bring his parents in for
discussion about his treatment. This boy requested you to conceal his revelation about
contacting STD.

Your tasks are:

• Identify important issues in this scenario.
• Demonstrate how you address issues on confidentiality and reassuring your
patient.

121
 APPENDIX 4

Scenario II: RAPPORT

A Form Two boy was brought in by his mother for his serious acne problem. He kept quiet
throughout the interview while the mother complained about his “couldn’t care less” attitude
about proper skin care. You observed that this boy has low self esteem and you need to
engage with this boy.

Your tasks are:

• Identify important issues in this scenario.
• Demonstrate how you build rapport with the boy.

Scenario III: EMPATHY

13 years old adolescent girl previously diagnosed to have Systemic Lupus Erythematous
(SLE) now presented with shortness of breath with increasing pallor and oedema. She was
later diagnosed to have end stage renal failure and in need of haemodialysis. Her parent
was in great distress and the adolescent was too shocked to react. Her parents were unable
to comply with the recommended management as they live in a remote Felda settlement.
Her condition is deteriorating. You are the health care provider who is presently attending
this family.

Your tasks are:

• Identify important issues in this scenario.
• Demonstrate how you express empathy.

Scenario IV: TRUST

A female matriculation student came to see you for being stressed. She expresses her
anxiety about boy-girl relationship and her unexpected attraction towards her new male
course mate. She finds this experience scary and hard to handle. She had always presented
herself as tomboyish since early teens and find difficulty in relating emotionally to boys. By
the slip of the tongue, she blurted out, “All men cannot be trusted!” and suddenly stopped
talking.

Your tasks are:

• Identify important issues in this scenario.
• Demonstrate how you can gain trust.

122
 APPENDIX 4

CHECKLIST C’RET©

Please tick the appropriate column.

YES NO
CONFIDENTIALITY
VCC To Adolescent
VCC To Parents
Breaking Confidentiality
Mutual trust
Withholding information from adolescent

RAPPORT
Comfortable environment
Greeting and Introduction of Self
Address adolescent appropriately (by name/nickname)
Bringing self to adolescent’s level
Allow adolescent to test the situation

Body language
Facial expression (includes smiling)
Posture
Tone of voice
Gesture
Distance
Hand movement
Eye contact

Attitude
Be honest, warm and friendly
Genuine interest to help
Flexible
Showing respect towards adolescent
Sensitive to adolescent’s need
Calm and patient
Distracted
Uninterested
Judgmental
Imposing personal value
Domination
Threatening

SKILLS (EMPATHY & TRUST)

Active listening
Bringing self to adolescent level
Consistency in behaviour, thought and feeling
Congruent (correlation between verbal and non-verbal)
Unethical behaviour e.g.: taking advantage of the situation

123
 APPENDIX 5

EVALUATION ACTIVITIES

Activities Time Teaching/AV Outcome

Frame Materials

Pre- & Post (Role Play)

1. Participants will perform a role-play which 5 min Digital Participants will
is typical of their current clinic scene during x4 recording of be able to
revision/introduction. the role observe their
plays, LCD mistakes and
2. Participants will perform role-play with projector model the
different CRET© scenarios during the skill 8 min correct
sessions. x4 behaviour.

Ear of The Day

1. 3 participants will be given the opportunity Throughout Notepad Participants are
to be facilitator’s ear for the day the given a chance
Session to air their views
2. They will listen for comments on the through their
module (content, presentation, appointed
organization, experience) from their representatives.
fellow participants and report their
observation at the end of the day.

Smiling Board
1. Participants will be given Post-It to draw End of Post-It Participants can
any of these smileys ☺ which Each Mood track their own
best describes their experience for each Activity Meter emotion through
activity. (15 secs) Board/Wall the activities and
provide a
2. Participants will post their response on the feedback on their
allocated boards. experience.

Post Mortem
1. Participants will be given the ISO Participants and
Evaluation Sheet at the end of the module End of Whiteboard / organisers can
Summary Flip Chart share lesson
2. Facilitator will also conduct a roundtable (30 min) learnt and
discussion on the participants’ reflection identify areas
and suggestions on the module. that need more
work.

124
 APPENDIX 6

FACILITATOR’S GUIDE - Snippets from DVD C’RET©

No Snippet Scene Soft Skills Identified Discussion

ADOLESCENT CULTURE

1 Sepet Two female • Respect adolescent • Update on adolescent current

adolescents culture interest, culture and jargon.
having a
conversation • Maintain rapport • One adolescent’s interest can
vary greatly from another.
about idols • Situation where
while waking health care provider
amongst may need to play
crowd in town “friend to friend” role.

Sepet Two female • Appropriate eye • Addressing adolescent by the

adolescents contact name he/she is comfortable
happroaching with.
a male • Avoid derogatory/
adolescent sarcastic remarks • Appropriate ways of engaging
adolescents – nonverbal
working at a • Be sensitive to
roadside CD communication
adolescent culture
stall
• Respect individuality
• Avoid being
Judgmental
• Appropriate body
language – Look but
do not stare or flirt.

Sepet Family having • Non effective • Everybody talking and not

dinner at communication listening
home
• No respect • Family environment influences
demonstrated adolescent’s stress and
behaviour
• Different value system between
generations as well as of
different upbringing.
• Adolescent felt neglected and
unimportant
• Family members are not aware
of adolescent’s activities

125
 No Snippet Scene Soft Skills Identified Discussion

DEALING WITH THE ADOLESCENT

2. Grey’s Medical • Inability to share • Express discomfort in dealing

Anatomy personnel fear/anxiety with with adolescents
directed by the superior about
boss to hold • Ways to overcome personal
working with
discussion limitations
adolescents
with a few • Our past experience may
adolescents • Acknowledge
influence our attitude to
personal limitations
adolescent
• Discuss with colleagues about
difficulties to assist problem
solving

Grey’s Two female • Awareness of own • Learn to be comfortable with

Anatomy adolescents body language and adolescent
trying to have verval responses
a discussion • Relate positively help to
with the male • Relate effectively establish a working relationship
with adolescent by
physicians on • Adolescents’ views should be
their dying being comfortable
acknowledged and respected;
friend’s wish and respectful, as
even when one doesn’t agree.
for a birthday well as using
party examples familiar to • A cooperative approach where
them there’s equal participation from
both side can bring forth a
• Suggest alternatives
Later, a much better solution for all.
with disagreeing
colleague was
able to relate • Skills in negotiating
to the with adolescents
adolescents
and have a
meaningful
discussion
which left
everyone
happy and
satisfied

126
 No Snippet Scene Soft Skills Identified Discussion

RAPPORT

3. Gilmore Girl Adolescent, • Need to • Most of the time, adults talk

grandfather acknowledge the without acknowledging the
and his friend presence of adolescent’s presence. They
having a adolescent by may even feel that they have
conversation showing respect and succeeded because they had a
at include her in the good time.
grandfather’s conversation
house • Adolescent feels loss and has
• Do not pretend to be difficulty fitting in – this may
interested in the lead to frustration and
adolescent’s view rebellious behaviour.
only to cut her short
• It is important for our action to
and dismiss it.
match our words and feelings
• Using too simple because others can sense it
and childish when we are not sincere /
language makes one congruent
feel disrespected
• Passive agreement may mimic
• Effective obedience but can also be
communication silent protest.
involves both verbal
and non-verbal

Gilmore Girl Conversation • Engage in an • Adolescents express concern

between an effective and worry about many issues;
adult and communication sometimes even those that
adolescent in (verbal and non- don’t concern them
a park verbal)
performing • Adult can encourage
community • Active listening continuous expression of
feeling and thought in
service. • Maintain good bye
adolescent by displaying
contact
interest and listening intently
• Make adolescent
• Silence can facilitate effective
feel important by
communication
asking opinion from
adolescent • By talking about things, it helps
adolescent to think better and
• Ask opinion from
arrive at own conclusion.
adolescent
• Show respect
• Acknowledge the
feeling of the other
person

127
 No Snippet Scene Soft Skills Identified Discussion

EMPATHY

4. Sepet Boy and • Encourage • Important to assess

mother having adolescent to adolescent’s relationship with
conversation express feeling parents to identify the famile
regarding the dynamics and possible stressor
poem recited • Enjoying the
by the boy conversation • Ability to share and express
enhance positive feelings in adults model healthy
communication coping for adolescents
• Avoidance of • Bonding time with adolescent is
judgmental attitude important
• Situation where • Adult should show non
health care provider judgmental attitude towards
need to play “parent adolescent’s view/feelings
– child” role
• Empathy is experienced more
• Make adolescent as a feeling and behaviour than
feel important in it is as a thought
what’s being said
despite trivial
• Active listening
• Maintain good eye to
eye contact
• Acknowledge the
feeling of the other
person
• Non-threatening
approach of criticsm

Sepet Boy being • Demonstrate • When adolescent is feeling

comforted by empathy trough non- down do not provoke or
mother at verbal behaviour- question
home intonation, touch,
• Sometimes it is difficult to get a
feeling
response especially when one
• Show caring attitude is sad/depressed
with appropriate
• Expressing one’s concern and
body language
stating the availability and
• Acknowledge the readiness to listen and help
feeling gives assurance about caring
others
• Situation where
health care
providers (HCP)
need to play
“mother-child” role

128
 No Snippet Scene Soft Skills Identified Discussion

CONFIDENTIALITY

5. Health Nurse • Protection of privacy • Sometimes it is human nature

Clinic eavesdropping extends beyond the to be curious. Therefore it is
doctor-patient important to have clear
relationship and the guidelines for all staffs
limit of the
consultation room
• Staffs need to
remind each other
about professional
conduct

Nurse • Written information • When staff behaves

gossiping in the case notes are inappropriately, it may lead to
about also confidential miscommunication or mistrust
adolescent materials
• One has to be aware of one’s
• Staffs should own conduct and value system
respect the privacy
• Insensitivity can be expressed
of the clients and be
in many different ways
sensitive to them
• Staffs should remind
each other about
professional conduct

129
130
131
132
133
134
3.7 REFERENCES

CHETNA. Empowering Adolescent girls: Learning about Life; 2002. p. 34

Institut Kesihatan Umum dengan kerjasama Bahagian Pembangunan Kesihatan Keluarga,

Kementerian Kesihatan Malaysia. Adolescent Health Care. Adolescent Health Needs;
1997.

Mc Kee N, Salas MA, Shahzadi N & Tillman HJ. Visualisation in Participatory Programmes
(VIPP): Taking stock of its diffusion and impact.

Ng, LO. Lecture series on psychology. Unpublished paper.

Sanci, LA et al. Confidental health care for adolescents: reconciling clinical evidence with
family values. Med J Aust. 2005; 183(8): 410-414

Visualisation in Participatory Programmes (VVIP). UNICEFF Bangladesh; 1993.

Video-Recording of Participants

Yeo, A. Counselling a problem-solving approach, APECA Publication, India;1993

135
 

136 
 
 

UNIT 4

USING HEADSS

137 
 
 

138 
 
 UNIT 4:

USING HEADSS

TABLE OF CONTENTS PAGE

4.1 Instructions to Facilitators 140

4.2 Introduction 141

4.3 Time Frame 141

4.4 Objectives 141

4.5 Suggested Activities 141

4.6 Suggested Timetable 142

4.7 Teaching Outline (Framework) 143-151

4.8 Appendices

Appendix 1 Pre and Post Test 152

Appendix 2 HEADSS Notes 153-158

Appendix 3 PowerPoint Presentation on Engaging Adolescent 159-166

Appendix 4 HEADSS’s Case Note

167-171
Appendix 5 HEADSS - Examples of Questions
172-175
Appendix 6 Role Play
176-177
Appendix 7 Client Satisfaction Form
178

4.9 References 179

139
4.1. INSTRUCTIONS TO FACILITATORS

1. Participants to do self-evaluation pre-test (Appendix 1). [Page 152] The pre-test to be

kept with participants.

2. Distribute HEADSS Notes to participants (Appendix 2). [Page 153 - 158]

3. Ask participants to read the handout (Appendix 2). [Page 153 - 158]

4. Explain objectives [Page 141] to the participants.

5. Go through the activities timetable [Page 142].

6. Lead discussion on handout (Appendix 2). [Page 153 - 158]

7. Distribute lecture’s note and give lecture on Engaging Adolescent using the
PowerPoint presentation provided (Appendix 3). [Page 159-166]

8. Distribute HEADSS’s Case Note and explain its usage (Appendix 4). Page 167 -171]

9. Show the participants the video clip on ‘Engaging Adolescent’.

10. Do activities accordingly (4.1: TEACHING OUTLINE (FRAMEWORK). [Page 143-151]

a) For the video clips;
i. Tell participants the title of the film(s) (director, producer-optional).
ii. Short description about the scene(s).

11. Distribute example questions on HEADSS (Appendix 5). [Page 172 - 175]

12. Ask participants to read again HEADSS Notes in preparation for the role plays
(Appendix 2). [Page 153 - 158]

13. Role Play (Appendix 6). [Page 176 - 177]

14. Participants to do self-evaluation post-test (Appendix 1). [Page 152]

15. Explain to participants regarding ‘Assessment of adolescent’s satisfaction’ form

(Appendix 7) [Page 178]. Participants to administer to adolescents during the third
visit to participant’s clinic. Participants to self-evaluate strength and weaknesses
base on comment(s) from clients.

140
4.2. INTRODUCTION

This unit provides the knowledge and practical skills to healthcare providers regarding the
HEADSS Psychosocial Framework and practical approaches on how to apply the framework
during the interview with adolescents.

4.3. TIME FRAME

355 minutes.

4.4. OBJECTIVES

• To impart knowledge and skills to the Health Care Providers in engaging

adolescents by using the HEADSS framework.
• To enhance confidence among Health Care Providers in assessing and
identifying adolescent health issues.

4.5. SUGGESTED ACTIVITIES

Time
No. Programme Teaching Materials
Frame

1. Preamble;
a. Introduction to HEADSS 15 min. • Handout

b. Engaging Adolescent 45 min. • PowerPoint presentation (Lecture)

2. Video clip 20 min. • Video clip

3. Activities 6 hours
a. Brainstorming • Video clips
• Notebook computer
b. Group discussions • DLP/LCD projector
• Answer sheet HEADSS
c. Role Play • Marker pen
• Flip-chart/Mahjong paper
d. Discussion • Checklist for observer
• Case scenario
• Case note

4. Evaluation (Pre and Post) 30 min. • Questionnaire

141
4.6. SUGGESTED TIMETABLE

Time Activities

08:00 – 08:15 Pre-test

08:15 – 09:15 Preamble;

1. Introduction to HEADSS - Discussion on handout
2. Engaging Adolescent – Lecture

09:15 – 09:35 Video clip HEADSS

09:35 – 10:30 Brainstorming and group discussion

10:30 – 10:45 Tea break

10:45 – 12:45 Brainstorming and group discussion

12:45 – 14:00 Lunch break

14:00 – 15:00 Brainstorming and group discussion

15:00 – 16:45 Role Play

16:45 – 17:00 Post-test

17:00 – 17:15 Tea break

17:15 Dismiss

142
 4.7. TEACHING OUTLINE (FRAMEWORK)

PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME

ASSESSMENT MATERIAL FRAME (For Facilitator Use)

H - HOME Objective: 25 min. Example of Questions

• Explore home situation, family life,
relationships and stability. • Where do you live?

Activity 1:
• What type of house you live in?
• Video clips • Who lives at home with you?
(Mother controlling; Meal time; Nagging) • Who is in your family (parents, siblings, extended
• Questions pertaining H - Home family)?
• What language is spoken at home?
Activity 2:
• Set up a small group (5 - 7 group members)
• Do you have your own room?
discussion. • How much time you spend at home?
• Brainstorm on examples of questions to be • Have there been any recent changes in your
asked. home environment (moves, departures etc.)?
• Discussions. • How do you get along with mum and dad and
other members of your family?
Teaching Materials:
• Video clip
• Who could you go to if you needed help with a
problem?
• Notebook computer
• DLP/LCD projector • What kinds of things do you and your family
• Marker pen argues about the most? What happens in the
• Flip-chart/Mahjong Paper house when there is a disagreement?
• Is there anything you would like to change about
your family?

143
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

E - EDUCATION/ Objective: 25 min. Example of Questions

EMPLOYMENT • To explore sense of belonging at
school/work and relationships with • Which school do you go to? What
teachers/peers/workmates; changes in form are you in? Any recent changes
performance. in schools?
• What do you like/not like about
Activity 1: school (work)? What are you good
• Video clip(Bully) at/not good at?
• Questions pertaining E - Education; • How do you get along with teachers
employment. /other students/workmates?
• How do you usually perform in
different subjects?
Activity 2: • How much school did you miss last
• Set up a small group (5 - 7 group members) /this year?
discussion. • Some young people experience
• Brainstorm on examples of questions to be bullying at school, have you ever
asked. had to put up with this?
• Discussions. • What are your goals for future
education/employment?
Teaching Materials: • What do you do for daily living?
• Video clip • Are you satisfied with your current
• Notebook computer job? If not, why?
• DLP/LCD projector • Any recent changes in employment?
• Marker pen
• Flip-chart/Mahjong Paper

144
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

E - EATING Objective: 25 min. Example of Questions

and • To explore how they look after themselves;
EXERCISE eating pattern and exercise. • What do you usually eat for breakfast/lunch/
dinner?
Activity 1: • Sometimes when people are stressed they can
• Set up a small group (5 - 7 group members) overeat or under eat. Do you ever find yourself
discussion. doing either of these?
• Brainstorm on examples of questions to be • Are you concerned about your figure? (If
asked. screening more specifically for eating disorders
• Discussions. you may ask about body image, the use of
laxatives, diuretics, vomiting, excessive exercise
Teaching Materials: and rigid dietary restrictions to control weight.)
• Marker pen • Do you like to do exercise?
• Flip-chart/Mahjong Paper • What do you do for exercise?
• How frequent do you exercise?
• Do you think you are the right weight for your
height?
• How much times have you gone on a diet for this
year?
• Have you ever taken slimming pills?

145
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

A - ACTIVITIES Objective 90 min. Example of Questions

and PEER • To explore their social and interpersonal
RELATIONSHIPS relationships, risk taking behaviour, as well • What sort of things do you do in your free time
as their attitudes about themselves. out of school/work?
• What do you like to do for fun?
Activity 1: • Do you have best friends (at school/out of
• Video clips (Computer; Phone; Gang) school)? Who are they?
• Questions pertaining A - Activities. • Who do you go to when you have problem?
• Where to you hang out? Alone or with your
Activity 2: friend?
• Set up a small group (5 - 7 group members) • How do you get on with others your own age?
discussion. • How do you think your friends would describe
• Brainstorm on examples of questions to be you?
asked. • What are some of the things you like about
• Discussions. yourself?
• What sort of things do you like to do with your
Teaching Materials: friends?
• Video clip • How much time do you spend on television/
• Notebook computer video games/internet/mobile phone/phone per
• DLP/LCD projector day?
• Marker pen • What’s your favourite music?
• Flip-chart/Mahjong Paper • Are you involved in sports/hobbies/clubs, etc?
• Do you read for fun? What do you read?
• Have you ever been involved with the police?
Have you ever been charged? Do you belong to
a group/gang?

146
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

D - DRUG USE/ Objective 25 min. Example of Questions

CIGARETTES/ • Explore the context of substance use (if
ALCOHOL any) and risk taking behaviours. Many young people at your age are starting to
experiment with cigarettes/drugs/alcohol.
Reminder:
• Stress on confidentiality issue. • Have any of your friends tried these or other
drugs like marijuana, injecting drugs, other
Activity 1: substances (glue and other inhalants)?
• Video clip(Cigarettes) • How about you, have you tried any? – explore.
• Questions pertaining D - Drug use; • Have you ever used a needle?
cigarettes; alcohol. • How much are you taking and how often?
• Set up a small group (5 - 7 group members) • What effects does drug taking or smoking or
discussion. alcohol, have on you?
• Brainstorm on examples of questions to be • Has your use increased recently?
asked. • What sort of things do you (& your friends) do
• Discussions. when you take drugs/drink?
• How do you pay for the drugs/ alcohol?
Teaching Materials: • Do other family members take drugs / drink?
• Video clip • Do you or your friends drive when you have been
• Notebook computer drinking?
• DLP/LCD projector • Have you ever been in a car accident or in
• Marker pen trouble with the law, and were any of these
• Flip-chart/Mahjong Paper related to drinking or drugs?

147
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

S - SEXUALITY Objective 25 min. Example of Questions

• To explore their knowledge, understanding,
experience, sexual orientation and sexual • Do you have a boyfriend / girlfriend?
practices. • Many young people your age become interested
in sexual relationships. Have you ever had a
Reminder: sexual relationship with a boy or a girl (or both)?
• Stress on confidentiality issue. - explore.
• How do you feel about relationships in general or
Activity 1: about your own sexuality?
• Video clips • What do you know about contraception and
(Sex education; Forced to kiss) protection against STDs?
• Questions pertaining S - Sexuality. • Has anyone ever touched you in a way that has
made you feel uncomfortable or forced you into a
Activity 2: sexual relationship?
• Set up a small group (5 - 7 group members) • Have you ever been pregnant or had an
discussion. abortion?
• Brainstorm on examples of questions to be • Have you ever had a discharge or sore that you
asked. are concerned about? Have you ever been
• Discussions. checked for a sexually transmitted disease?
Knowledge about STDs and prevention?
Teaching Materials: • Have you ever had a pap smear?
• Video clip • Do you have any concerns about Hepatitis or
• Notebook computer AIDS?
• DLP/LCD projector • If someone abused you, whom would you talk to
• Marker pen about this? How do you think you would react to
• Flip-chart/Mahjong Paper this?

148
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

S - SUICIDE/ Objective 25 min. Example of Questions

SELF-HARM/ • To explore risk of mental health problems,
DEPRESSION/ strategies for coping and available support. • People sometimes feel down or sad. How about
MOOD you? When did you last feel like this?
Reminder: • What do you do if you are feeling sad, angry or
• Stress on confidentiality issue. hurt?
• How do you feel in yourself at the moment on a
Activity 1: scale of 1 to 10?
• Video clip • How often do you feel this way?
(Depressed) • Who can you talk to when you’re feeling down?
• Questions pertaining S - Suicide; self-harm; • How well do you usually sleep? (Assess on
depression; mood. changes in sleeping and eating patterns).
• Have you ever felt hopeless or worthless?
Activity 2: • Sometimes when people feel really down they
• Set up a small group (5 - 7 group members) feel like hurting, or even killing themselves. Have
discussion. you ever felt that way? Have you ever tried?
• Brainstorm on examples of questions to be • If yes, how did you try to harm/kill yourself?
asked. • What happened to you after that?
• Discussions. • What prevented you from going ahead with it?

Teaching Materials:
• Video clip
• Notebook computer
• DLP/LCD projector
• Marker pen
• Flip-chart/Mahjong Paper

149
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

S - SAFETY Objective 25 min. Example of Questions

• To explore issues on the safety of the
adolescent. • Are you afraid of violence in your school? In your
neighbourhood? At home?
Activity 1: • Do your friends carry weapons? What about
• Video clips you?
(Kidnap; Riding motorcycle) • Have you have any history of abuse?
• Questions pertaining S - Safety. • Have you ever been a victim of violent crime?
• Do you have a car / motorcycle – use seat belt /
Activity 2: helmet?
• Set up a small group (5 - 7 group members) • Have you ever been involved in illegal racing?
discussion.
• Brainstorm on examples of questions to be
asked.
• Discussions.

Teaching Materials:
• Video clip
• Notebook computer
• DLP/LCD projector
• Marker pen
• Flip-chart/Mahjong Paper

150
 PSYCHOSOCIAL ACTIVITES/TEACHING TIME OUTCOME
ASSESSMENT MATERIAL FRAME (For Facilitator Use)

S - SPIRITUALITY Objective 90 min. Example of Questions

• To explore the adolescents’ spirituality and
beliefs as protective factors. • What helps you relax?
• What gives you a sense of meaning?
Activity 1: • Do you believe in God?
• Video clip • What religion do you practice?
(Reciting Qur’an) • Do you practice the teachings of
• Questions pertaining S - Spirituality. your religion?

Activity 2:
• Set up a small group (5 - 7 group members)
discussion.
• Brainstorm on examples of questions to be
asked.
• Discussions.

Teaching Materials:
• Marker pen
• Flip-chart/Mahjong Paper

Activity 3:
• Role Play.
• Using Scenario given to the group.

Teaching Materials:
• Role play scenario (Appendix 6)
• Checklist for observer (Appendix 6)
• Case note (Appendix 4)

151
 APPENDIX 1

PRE / POST TEST ON PERCEPTION AND UNDERSTANDING OF HEADSS

FRAMEWORK

Name:
Designation:
Place of Work:

Date:

Instruction
This questionnaire is to help us to evaluate our training module. Please answer ALL
questions with a ( ) in the appropriate box.

Things that I usually do when engaging adolescent in my clinic are;

No. Items Yes Sometimes No

1. I ask for permission from the adolescent before
assessing them.

2. I explain regarding confidentiality before starting

the interview.

3. I told them that they are not obliged to answer any

questions if they feel uncomfortable.

4. I see the adolescent separately even if they are

accompanied by parents/guardian.

5. I ask about relationships among the family

members.
6.
I ask how they get along in school.
7.
I enquire regarding their leisure activities.
8. I do not talk about sexual issues during the
interview.

9. I ask regarding their understanding about

substance use.

10. I give feedback about issues identified during the

interview.

My level of confidence in dealing with adolescents’ health issues;

1 2 3 4 5
Very low Low Moderate High Very high

152
 APPENDIX 2

HEADSS NOTES

Introduction

Psychosocial, behavioural and lifestyle problems are the major causes of adolescent
morbidity and mortality. Yet adolescents rarely choose to see Health Care Providers for
psychosocial issues such as drug use, sexual health, mental health, school or family
problems. Adolescents often present with relatively minor complaints. By exploring beyond
the presenting complaint, the Health Care Providers can assess the young person’s
psychosocial background and detect underlying health concerns and risk factors. This
increases the chance of providing timely intervention and preventive education.

The HEADSS Assessment

The HEADSS screening tool is a structured framework for conducting a comprehensive

biopsychosocial assessment of the young person. It provides information about the young
person’s functioning in key areas of their life:

H – Home
E – Education / Employment / Eating and Exercise
A – Activities and Peer Relationships
D – Drug Use / Cigarettes / Alcohol
S – Sexuality
S – Suicide / Self-Harm / Depression / Mood
S – Safety
S – Spirituality

The HEADSS assessment gives the Health Care Providers a structure for;
• developing rapport with the young person while systematically gathering information
about their world – their family; peers, school and inner world
• performing a risk assessment and screening for specific risk behaviours
• identifying areas for intervention and prevention
• developing a picture of the young person’s strengths and protective factors
• assessing the progress of the young person’s psychosocial problems post intervention

153
 APENDIX 2

ENTRY POINT FOR USING HEADSS

Referred Adolescent or RESPONSIBILITY

walk-in 

Assistant Medical Officer

Screening Form Clinical Staff Nurse
1
SKR I & II Presentations Community Nurse
Medical Officer
1
Garispanduan
Assessment Pelaksanaan
Perkhidmatan
Kesihatan Remaja di
Peringkat Kesihatan
Primer 
Yes No
2
Problem  2
Reproductive Health
Mental Health
Nutritional Health
Risk Behaviour
Physical Health 

HEADSS Health
Promotion TCA 6/12 to 1 year

3
3
Suspected / sexual
URGENT  abuse / rape
Yes
Suicidal
Anorexia / Bulimia

No Refer MO/FMS/COUNSELOR

Counselling
AMO/SN

1 to 3 weeks
depending on severity
Appointment of conditions
Date 

154
 APPENDIX 2

PREPARING FOR THE INTERVIEW

Summary of steps in HEADSS

1. Introduce yourself to adolescents and then parents/family carers

2. Engage respectfully with concerns of parent

3. Negotiate for time with adolescent alone

4. Engage with how the adolescent feels about being there

5. Discuss confidentiality
Everything is kept confidential unless there is significant concern of their life or
someone else’s life being at risk of serious harm:
• Suicide or self harm
• Homicide
• Risk of sexual or physical abuse
Interviewing Tips

1. Listening skills.

2. Assists the adolescent explore their agenda with you.

3. Ask permission before exploring into sensitive areas.

4. Adolescent have the right if they don’t want to answer any question.

5. Compliment them.

6. Positively reframe their lives.

7. DON’T ARGUE with them – STAY ONE DOWN.

8. Use HUMOUR if it is your style (as long as not sarcastic and be yourself).

9. Suggest an explanation and invite them to agree or disagree…

• ‘You may disagree with this but it seems to me that you feel abused…’

10. TALK ABOUT OTHERS FIRST before you turns attention on them…
• Many young people your age are starting to experiment with
drugs/cigarettes/alcohol have any of your friends tried these things?...how about
yourself?’
• ‘Tell me what it’s like for teenagers these days…’

155
11. LET THEM TEACH YOU A FEW THINGS…
• ‘Tell me what it’s like at parties these days…’
• ‘What do you mean by ‘hanging out’?’

12. THE MULTIPLE CHOICE QUESTIONS…

• ‘Did that make you feel confused, angry or sad?’
• ‘Have you tried other drugs such as ecstasy, cocaine, speed…’

13. EFFECTS & REGRETS…

• ‘What effects did getting drunk have on you?...’
• ‘Any regrets about this?...’

Sometimes when people get drunk or high, something happens that they wish
hadn’t happened…
• Has that ever happened to you?

14. SCALING QUESTION.

• How do you feel in yourself, at school, at home?...

0-----------------------5-----------------------10☺

Rates how up or down you feel most of the time if ten is great and one is really
really down;
• Do you ever get lower than that? When do you feel as low as that?
• Do you ever get higher than that? When do you feel like that?
• Was there a time you remember when most of the time you felt happier than you
do now?

15. OFFER HOPE e.g. for depressive illness

• ‘You may not believe this now but I’ve seen many young people in your position
and they have got better – you can get better from this…’
*do not offer “false hope”

156

ADOLESCENT DEVELOPMENTAL STAGES
Early (10 – 14 years)
“Am I normal?”
• coming to terms with
puberty
• struggle for autonomy
commences
• same sex peer
relationships all important
• mood swings
• anxieties about body
shape and changes
• comparison with peers
• still fairly concrete
thinkers
• less able to understand
subtlety
• daydreaming common
• difficulty identifying how
their immediate behaviour
impacts on the future
Middle (15 – 17 years)
CENTRAL QUESTION
“Who am I?”
“Where do I belong?”
MAJOR DEVELOPMENTAL
ISSUES
• new intellectual powers
• new sexual drives
• experimentation and risk-
taking
• relationships have self-
centred quality
• need for peer group
acceptance
• emergence of sexual
identity
MAIN CONCERNS
• influence of peers
• tensions between family
and individual over
assertions of autonomy
• balancing demands of
family and peers
• prone to fad behaviour
and risk taking
• strong need for privacy
• maintaining ethnic identity
while striving to fit in with
dominant culture
COGNITIVE
DEVELOPMENT
• able to think more
rationally
• concerned about
Individual freedom and
rights
• able to accept more
responsibility for
consequences of own
behaviour
• begins to take on
greater responsibility
within family as part of
cultural identity
157
APPENDIX 2
Late (> 17 years)
“Where am I going?”
• independence from
parents
• realistic body image
• acceptance of sexual
identity
• clear educational and
vocational goals, own
value system
• developing mutually
caring and responsible
relationships
• self-responsibility
• achieving economic
independence
• developing intimate
relationships
• longer attention span
• ability to think more
abstractly
• more able to synthesise
information and apply it to
themselves
• able to think into the
future and anticipate
consequences of their
actions
 PRACTICE POINTS
• Reassure about normality • Address confidentiality • Ask more open-ended
• Ask more direct than concerns questions
open-ended questions • Always assess for health • Focus interventions on
• Make explanations short risk behaviour short & long term goals
and simple • Focus interventions on • Address prevention
• Base interventions short to medium term more broadly
needed on immediate or outcomes
short-term outcomes • Relate behaviours to
• Help identify possible immediate physical and
adverse outcomes if they social concerns – e.g.
continue the undesirable effects on appearance;
behaviour relationships
 

158
 Appendix 3

POWERPOINT PRESENTATION ON ENGAGING ADOLESCENT

159
160
161
162
163
164
165
166
 Appendix 4

HEADSS’s CASE NOTE

 
  H E A D S S P sy c hosoc ial A ss ess ment
D ru gs /C ig ar e tt es /A lc oho l
 
 
 
 
 
 
Suic ide /S elf -H a r m /D e pre s s ion/M oo d
 
 
 
 
 
 
 
Se x ua lity
 
 
 
  Sa fe ty /S pirit ua lity

 
 
 

167 2
 Appendix 4

Boys 2 – 18 Date of Birth:____________

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

168

10 3
 Appendix 4

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

169

4 9
 Appendix 4

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

170

8 5
 Appendix 4

Girls 2 – 18 Date of Birth:____________

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

171

6 7
 APPENDIX 5
EXAMPLE OF QUESTIONS
Psychosocial Assessment HEADSS

Framework Example of Questions

H – HOME • Where do you live?

• What type of house you live in?
Objective: • Who lives at home with you?
• Who is in your family (parents, siblings, extended family)?
Explore home
• What language is spoken at home?
situation, family life,
relationships and
• Do you have your own room?
stability. • How much time you spend at home?
• Have there been any recent changes in your home
environment (moves, departures etc.)?
• How do you get along with mum and dad and other
members of your family?
• Who could you go to if you needed help with a problem?
• What kinds of things do you and your family argues about
the most? What happens in the house when there is a
disagreement?
• Is there anything you would like to change about your
family?

E – EDUCATION/ • Which school do you go to? What form are you in? Any
EMPLOYMENT recent changes in schools?
• What do you like/dislike about school (work)? What are you
good at/not good at?
Objective: • How do you get along with teachers/other students/
workmates?
To explore sense of • How do you usually perform in different subjects?
belonging at school/ • How much school did you miss last/this year?
work and
• Some young people experience bullying at school, have you
relationships with
ever had to put up with this?
teachers/peers/
• What are your goals for future education/employment?
workmates;
changes in • What do you do for daily living?
performance. • Are you satisfied with your current job? If not, why?
• Any recent changes in employment?

E – EATING and • What do you usually eat for breakfast/lunch/dinner?

EXERCISE • Sometimes when people are stressed they can overeat or
under eat. Do you ever find yourself doing either of these?
Objective: • Are you concern about your figure? (If screening more
specifically for eating disorders you may ask about body
To explore how image, the use of laxatives, diuretics, vomiting, excessive
they look after exercise and rigid dietary restrictions to control weight.)
themselves; eating
pattern and
exercise.

172
 Framework Example of Questions
• Do you like to do exercise?
• What do you do for exercise?
• How frequent do you exercise?
• Do you think you are the right weight for your height?
• How much times have you gone on a diet for this year?
• Have you ever taken slimming pill?

A – ACTIVITIES • What sort of things do you do in your free time out of

and PEER school/work?
RELATIONSHIPS • What do you like to do for fun?
• Do you have best friends (at school/out of school)? Who are
Objective: they?
To explore their • Who do you go to when you have problem?
social and • Where do you hang out? Alone or with your friend?
interpersonal • How do you get on with others your own age?
relationships, risk • How do you think your friends would describe you?
taking behaviour, • What are some of the things you like about yourself?
as well as their • What sort of things do you like to do with your friends?
attitudes about • How much time do you spend on television/video
themselves. games/internet/ mobile phone/phone per day?
• What’s your favourite music?
• Are you involved in sports/hobbies/clubs etc?
• Do you read for fun? What do you read?
• Have you ever been involved with the police? Have you
ever been charged? Do you belong to a group/gang?

173
 APPENDIX 5

Framework Example of Questions

D – DRUG USE/ Many young people at your age are starting to experiment with
CIGARETTES/ cigarettes/drugs/alcohol.
ALCOHOL
• Have any of your friends tried these or other drugs like
Objective:
marijuana, injecting drugs, other substances (glue and other
Explore the context inhalants)?
of substance use (if • How about you, have you tried any? – explore.
any) and risk taking • Have you ever used a needle?
behaviours. • How much are you taking and how often?
• What effects does drug taking or smoking or alcohol, have
on you?
• Has your use increased recently?
• What sort of things do you (& your friends) do when you
take drugs/drink?
• How do you pay for the drugs/alcohol?
• Do other family members take drugs/drink?
• Do you or your friends drive when you have been drinking?
• Have you ever been in a car accident or in trouble with the
law, and were any of these related to drinking or drugs?

S – SEXUALITY • Do you have a boyfriend/girlfriend?

• Many young people your age become interested in sexual
Objective: relationships. Have you ever had a sexual relationship with
To explore their a boy or a girl (or both)? – explore.
knowledge, • How do you feel about relationships in general or about your
understanding, own sexuality?
experience, sexual • What do you know about contraception and protection
orientation and against STDs?
sexual practices. • Has anyone ever touched you in a way that has made you
feel uncomfortable or forced you into a sexual relationship?
• Have you ever been pregnant or had an abortion?
• Have you ever had a discharge or sore that you are
concerned about? Have you ever been checked for a
sexually transmitted disease? Knowledge about STDs and
prevention? Have you ever had a pap smear?
• Do you have any concerns about Hepatitis or AIDS?
• If someone abused you, whom would you talk to about this?
How do you think you would react to this?

S – SUICIDE/ • People sometimes feel down or sad. How about you? When
SELF-HARM/ did you last feel like this?
DEPRESSION/ • What do you do if you are feeling sad, angry or hurt?
MOOD • How do you feel in yourself at the moment on a scale of 1 to
10?
Objective: • How often do you feel this way?
To explore risk of • Who can you talk to when you’re feeling down?
mental health • How well do you usually sleep? (assess on changes in
problems, sleeping and eating patterns).

174
 Framework Example of Questions
strategies for • Have you ever felt hopeless or worthless?
coping and • Sometimes when people feel really down they feel like
available support. hurting, or even killing themselves. Have you ever felt that
way? Have you ever tried?
• If yes, how did you try to harm/kill yourself?
• What happened to you after that?
• What prevented you from going ahead with it?

S – SAFETY • Are you afraid of violence in your school? In your

neighbourhood? At home?
• Do your friends carry weapons? What about you?
Objective: • Have you have any history of abuse?
To explore issues • Have you ever been a victim of violent crime?
on the safety of the • Do you have a car/motorcycle – use seat belt/helmet?
adolescent. • Have you ever been involved in illegal racing?

S – SPIRITUALITY • What helps you to relax?

• What gives you a sense of meaning?
• Do you believe in God?
Objective: • What religion do you practice?
To explore the • Do you practice the teachings of your religion?
adolescents’
spirituality and
beliefs as protective
factors.

175
 APPENDIX 6
ROLE PLAY

Instructions:
1) Participants will be grouped in fives. Each group consists of 5 characters;
a. Mother: Read the ‘Scenario’ below. Use the HEADSS’s Case Note (Appendix
4) [Page 167 - 141] to note down information gathered by the
‘Counsellor’ during the interview.
b. Father: Read the ‘Scenario’ below. Use the HEADSS’s Case Note (Appendix
4) [Page 167 – 171] to note down information gathered by the
‘Counsellor’ during the interview.
c. Adolescent: Read the ‘Scenario’ below. Act accordingly.
d. Counsellor: DO NOT read the ‘Scenario’ below. Use the HEADSS’s Case
Note (Appendix 4) [Page 167 – 171] to note down information
gathered during the interview. You may use example questions on
HEADSS (Appendix 5) [Page 172 - 175] as guide.
e. Observer(s): DO NOT read the ‘Scenario’ below. Use the CHECK-LIST FOR
OBSERVER (ROLE PLAY) form (Appendix 6) [Page 176] to note
down the ‘Counsellor’s’ conduct during the interview. You will
have to give feedback to the ‘Counsellor’ base on the check-list.
2) Participants are given 15 minutes to explore the issues.
3) At the end of the role play, there will be discussion about it.

Scenario

A 16-year-old girl, a student, came to the clinic complaining of per vaginal discharge. Both
parents are working. Her father, who is a businessman, often works outstation. Her mother
is a nurse who is working shift duty at a private hospital. The girl is the only child, and close
to her father. They have no maid or any other companion at home.

She is not interested in her studies. Her friends are the ‘out going’ type. They like to hang
out after school at various spots. She’s a smoker and has many boyfriends. She often
sneaks out at night, when her parents not at home, to nightclubs and has experimented with
‘ecstasy pills’.

She has had sexual intercourse with some of her boyfriends (multiple partners), which were
occasionally unprotected. Currently, her menses are regular and her last menstrual period
was 2 weeks ago.

176
 APPENDIX 6

CHECK-LIST FOR OBSERVER (ROLE PLAY)

Participant’s Name:

Instruction
Please identify whether the following items have been used during the role play. Tick
( ) in the appropriate box.

No. Items Done

1. Greeting adolescent first and introduction.
2. Negotiate with the parents/guardian for time with adolescent alone.
3. Ask for permission from the adolescent before assessing them.
4. Explain regarding confidentiality before starting the interview including
the three exceptions (self-harm; harming others; being harm by others).
5. Telling the adolescent that they are not obliged to answer any questions
if they feel uncomfortable.
6. Using open-ended questions during interview.
7. Starting from less sensitive to more sensitive issues.
8. Using third person approach in addressing sensitive issues.
9. The following have been covered during the interview:
a. H – home
b. E – education; employment; exercise; eating
c. A – activities; peer relationships
d. D – drugs; cigarette smoking; alcohol; substance use
e. S – sexuality
f. S – suicide; self-harm; depression; mood
g. S – safety; spirituality
10. Give them opportunity to express any concern not covered.
11. Ask for feedback about the interview.
12. Wrapping-up:
a. Provide feedback.
b. Outline and negotiate management plan.
c. Liaise with other health providers/agencies if required (permission if
needed to talk to others).

NOTE: The above can be use as guide during interview with adolescent.

177
 APPENDIX 7
CLIENT SATISFACTION FORM

Penilaian Kepuasan Pelanggan Remaja

Assessment of Adolescent’s Satisfaction

Arahan:
Instruction:

Soal selidik ini adalah untuk membantu kami menilai perkhidmatan kami. Sila jawab SEMUA
soalan dengan menandakan ( ) di kotak yang sesuai.
This questionnaire is to help us to evaluate our service. Please answer ALL questions with a
( ) in the appropriate box.

Saya berpuas hati dengan perkhidmatan di klinik remaja ini pada tahap berikut:
My level of satisfaction with the adolescent’s health clinic session:
1 2 3 4 5
Sangat rendah Rendah Sederhana Tinggi Sangat tinggi
Very low Low Moderate High Very high
 
 
Perkara
No. 1 2 3 4 5
Items

1. Adakah anda selesa dengan anggota kesihatan

yang menemuramah anda?
Are you comfortable with the interviewer?
2. Adakah anda faham perkara yang dibincangkan?
Do you understand what he / she is talking about?
3. Adakah anda berasa selesa memberitahu anggota
kesihatan maklumat mengenai diri anda?
Do you feel comfortable in sharing information with
him / her?
4. Adakah anda akan datang semula untuk temujanji
seterusnya?
Would you like to come again next session for
follow-up?
5. Adakah anda akan mencadangkan kawan anda
untuk datang ke klinik ini sekiranya beliau
bermasalah?
Would you recommend your friend that you think is
having problems to come to this clinic?

Cadangan untuk penambahbaikan klinik ini:

Recommendation for further improvement:

_______________________________________________________________________

178
 4.9 REFERENCES

Chown P, Kang M, Bennett D, Sanci L. Adolescent Health. A Resource Kit For GPs.
Sydney, NSW: NSW Centre for the Advancement of Adolescent Health, the
Children’s Hospital at Westmead.

Goldenring J M, Cohen E. 1988. Getting into adolescents’ heads. Contemporary Pediatrics.

1998 July .p.75-90.

Sanci L, Young D. 1995. Adolescent Health: Engaging the adolescent patient. Australian
Family Physician. 1995;11:2027-2031.

Video clip edited from “Interviewing Adolescent Series”. Written and Directed by
Sanci L, Cahill H. Centre for Adolescent Health, Royal Children”s Hospital,
Melbourne, Australia; 1998

Video clip edited from “I Not Stupid” Directed by Neo J. Medicacorp Raintree
Pictures Pte. Ltd, Singapore’ 2002.

Video clip edited from “I Not Stupid Too”. Directed by Neo J.Medicacorp Raintree Pictures
Pte. Ltd, Singapore;2006.

Video clip edited from “Sepet”. Directed by Yasmin A.MHZ Film Sdn Bhd, Malaysia.
.

179
 

180 
 
 

UNIT 5

FACE YOUR FEARS

181 
 
 

182 
 
 UNIT 5:

FACE YOUR FEARS

TABLE OF CONTENTS PAGE

5.1 Teaching Outline (Framework) 184-187

5.2 Introduction 188

5.3 Time frame 188

5.4 Objective 188

5.5 Contents:

5.5.1 Fearing The Teenager 188-189

5.5.2 Types Of Fear 189-191

5.5.3 Self Awareness 191-192

5.5.4 Active Listening 192-193

5.5.5 Common Mistakes in Thinking 193-194

5.6 Teaching Method and Materials

5.6.1 Face Your Fears 194-196

5.6.2 Self Awareness 197-200

5.6.3 Relating to Adolescents 201-203

5.6.4 Managing Self in Relation to Fears 204-206

5.6.5 Maintenance Practice 207-209

5.7 Appendices

Appendix 1 Child Act 2001 210-212

Appendix 2 Consent and Confidentiality 213-214

Appendix 3 PowerPoint Presentation 215-216

ƒ Fearing the Teenagers: How to Cope
ƒ Self - Awareness

5.8 References 217

183
 5.1 TEACHING OUTLINE (FRAMEWORK)

Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time

Objectives (participants) Materials Evaluation
(min)

1. To identify and 1. Why fear teenagers? Lecture on fear in Generate list of • Ball of yarn Fear Scale 40
normalise relating with personal fears in (Before/After
• Managing self- • Marker pen
personal fears teenagers (20 mins) dealing with Activity)
doubt
in dealing with
Activity: Web of Fear
teenagers • A4 Paper Agreement
teenagers in
health care To normalize • Laptop check for
normalization
interview common fears in • Flip chart of fear
settings dealing with
teenagers (20 mins) • LCD
(Fears) Projector
• Lecture
handouts
Check that all
2. To create 1. Prerequisites to Lecture on topics: Reaction to • A4 Paper 80
participants
awareness and managing fear: picture of
recognise that
Lecture: Self-
teenagers profile • Laptop are aware that
• Awareness of awareness (20 min) they have
fears can lead
self – values,
– report projected • LCD personal
to difficulties in Workshop: Personal feelings and Projector
beliefs and judgement (60 min) judgment in
managing self- personal
emotions in
responses
responses • Pictures of handling
Facilitate self- teenagers’ teenagers.
handling the • Breaking awareness activity
interview with barriers of profile
and discussion.
teenagers positive Give impression • Lecture Check that
thoughts Show how perception according to handouts participants
(Self- can cloud judgement HEADSS are aware that
awareness) of issues • Worksheet
s

184
 Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time
Objectives (participants) Materials Evaluation
(min)
personal
judgement can
affect
HEADSS
interview

1. To be aware 1. Managing personal Teach the use of the Reaction to video • A4 Paper Assessment 60
of personal prejudices in thought diary (5 clips of teens’
values and relating to mins) positive and • Laptop by facilitator on
participants’
responses in /interacting with
Facilitate discussion
negative • LCD awareness of
relating to teenagers behaviours Projector
on personal values self
teenagers /culture (3
and beliefs relating to
common • Video clips
(Relating) participants’ of
responses to
responses in the teenagers
difficult situations
thought diary – rights (6 clips –
silence/
and wrongs, should
depressed, 1 male & 1
and shouldn’t
crying, anger/ female)
Show how these defiant)
values could interfere • Thought
Record diaries
with the process of
responses in a
interacting with the • Handouts
thought diary that
teen while using
includes situation,
HEADSS
thoughts,
(55 mins) feelings,
behaviour
reaction and
reflections.

185
 Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time
Objectives (participants) Materials Evaluation
(min)

4. To impart and 1. Engaging the teen Facilitate exercise in Workshop: • Marker pen Assess the 40
generate – active listening, managing fears in level of
appropriate appropriate dealing with teens
Brainstorm ways • A4 Paper participants’
to handle
responses to responses with (from 1and 3)
personal fears in • Flip chart improvement
manage fears regards to problem knowledge
and to behaviours
Discuss responses in dealing with • Mahjong about
relation to biased teenagers. paper list
minimise managing their
interpretations – give from
inappropriate Identify mistakes fears in dealing
handouts (40 min) Activity 1
reactions in thinking from with teenagers
(Managing self
given situations • Thought (Likert scale)
derived from diaries
in relation to
Activities 1 and 3
fear) – • Handouts –
something to Common
take back Mistakes in
Thinking
• Handouts -
Active
listening
and
appropriate
responses

186
 Learning Contents Activities (trainer) Activities AVA/Teaching Assessment/ Time
Objectives (participants) Materials Evaluation
(min)

5. To maintain 1. Planning of Facilitate small group Reflect and plan • Paper Not Applicable 20
practice in self- maintenance of discussion on future future methods of
awareness of acquired self- planning in maintaining fear- • Pen
personal fears management skills maintaining practice reducing skills
in dealing with and appropriate of generating fear-
teenagers, behaviour in reducing skills.
appropriate handling teenagers
Summary of planning
behavioural in a health interview
by facilitator (e.g.
responses to setting.
who to contact for
teenagers and
further reference,
managing
support group,
personal fears
continuing education,
(Maintenance etc.)
Practice)
(20 min)

TOTAL TIME 4 Hrs

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5.2 INTRODUCTION

The main idea of this Unit consolidates the four previous units with regards to the application
of HEADSS in interviewing teenagers. This unit recognises that teenagers can be a difficult
bunch to handle. Many health professionals find dealing with teenagers discomforting. The
use of the HEADSS module can also lead to difficult situations between the professional and
the teenager. These difficult situations usually bring about negative feelings among the
professionals who deal with teenagers. These negative feelings include anger, frustration,
guilt and feelings of threat. As such, dealing with teenagers can be discouraging and at
times, even fearful. It is known that fear is the underlying emotion of all negative feelings
such as anger, frustration, avoidance, feelings of threat (to the ego/expose weakness), and
general interpersonal discomfort. It is, therefore important to help identify and manage the
health professional’s personal fear in relating to teenagers.

5.3 TIME FRAME

240 mins (4 hours)

5.4 OBJECTIVES

• To identify and normalise personal fear in dealing with teenagers

• To create awareness and recognise that fears can lead to difficulties in managing self-
emotions in handling the interview with teens
• To be aware of personal values and responses in relating to teens
• To impart and generate coping skills to manage fears and minimise inappropriate
reactions
• To maintain practice in self-awareness of personal fears

5.5 CONTENTS

• Fears: Fearing the teenagers and types of fears

• Awareness of self (values, beliefs, responses, breaking barriers of positive thought)
• Managing personal prejudice
• Managing self in relation to fear
• Maintenance practise

5.5.1 FEARING THE TEENAGER

A. What’s the issue?

• Interacting with teenagers can be difficult for the adult
• Difficulties due to fear of handling teenager
• Fear examples (See Note 2)

B. Why is it important?
• Difficult to interview with fear
• Fear can lead to mistaken assumption
• May discourage patient from answering or disclosing further

188
 C. How does it relate to the use of HEADSS?
• HEADSS is interview-based
• Need to overcome fear to maximize information from HEADSS

D. Where does this fear come from?

• Self-doubt
• Values clash
• Negative expectation/thinking
• Lack of skills

E. What can we do?

• Self-awareness
• Interact with teens often
• Professional training
• Improve medical knowledge

F. How do we do it?
• See next lecture

5.5.2 TYPES OF FEAR

The types of fear with regards to relating to teens include:

A. Self-doubt

Self-doubt comes from a lack of self-confidence arising from:

i. Perceived or actual lack of knowledge and skills on:

Knowledge Skills
• Adolescent health problems • Communication
• Bio psychosocial developmental • Conflict management
stages • Counselling skills
• Substance use and abuse • Crisis management
• Deliberate self-harm • Management of intrusion
and manipulation by parents,
teachers, VIPs and others
ii. Unfamiliarity with teen issues (e.g. developmental, education, sexuality, spiritual,
medical, mental health, culture, trends)
iii. Fear of being too rigid or too liberal with regards to personal values
iv. Perceived or actual inability to control self-behaviour
v. Mistakes in thinking that leads to inaccurate judgment or barriers of healthy
judgement:
• Black/White Thinking
• Jumping to conclusions
• Mind-reading
• Predicting the future – over/under-expectation
• Filtering out the positives

189
 • Personalisation
• Overgeneralization – always, never, cannot, should,
• Labelling
• Self-criticism
• Minimising/maximising the problem

B. Negative Self-expectations

Negative self-expectations bring about fear of uncertainties and coping by predicting a

negative future.

C. Fear of Personal Prejudice

Being afraid of making biased judgement based on first impressions alone, such as:
i. Behaviour - smoking, stealing, harsh speech, withdrawn
ii. Appearance - tattoos, piercing, smell, dressing, mannerisms
iii. Physical discomfort - environmental difficulties, 5 senses – “too trendy”, smelly, loud,
dirty, vomit, diarrhoea, picking nose, clearing throat, spitting, farting, burping,
salivating, under influence of substances

D. Fear of inadequate interpersonal skills in engaging the teen

Possible Problems

i. Language barrier
ii. Silence/non-responsive client
iii. Crying
iv. Extreme emotions – anger outburst
v. Threats of suicide/emotional blackmail
vi. Possible negative feedback:
• You are like my mother/father/teacher/ustaz(ah)/preacher/pastor – you think you
know everything – you think you can change me
• You don’t understand me
• You’re too young/old to know
vii. Physical touch or clinginess
viii. Personal safety, aggression, violence
ix. Abnormal behaviour – e.g. psychotic, inability to express emotions, personality
disorder, removing clothing/stripping
x. Attraction/attachment by client
xi. Refusal to leave clinic
xii. Manipulation of harassment by teen

E. Lack of management and structural facilities to cater for adolescents’

needs

i. Lack of networking/resources – human resources/material/NGO

ii. Lack of Standard Operational Procedures (SOP) for – indication of referral flow –
support from organizational/administration structure and roles within profession
iii. Insufficient time for assessment of teenagers

190
 F. Inadequate medico-legal knowledge

i. Lack of knowledge on policies, legislations and processes related to health services

for teenagers (refer to Appendix 1 – Child Act 2001)
ii. Lack of knowledge in handling disclosure of abuse (neglect/physical/sexual/
abuse/drugs) (refer to Appendix 2 – Consent and Confidentiality)
iii. Ethical dilemma – to report or not to report – legal issues vs. confidentiality

5.5.3 SELF- AWARENESS

A. What’s the issue?

i. Part of overcoming fear in relating to teenagers is to understand the self through self-
awareness
ii. The lack of self-awareness leads to discomfort in dealing with teenagers
iii. Knowing the self in relation to the teenager helps us to understand personal
responses and values
iv. Personal values and belief system can interfere with interviewing

B. Why is it important?

i. Self-awareness is needed to understand fear in relating to teenagers

ii. Self-awareness leads to self-acceptance
iii. Self-acceptance leads to comfort

C. How does it relate to the use of HEADSS?

i. In HEADSS, the interviewer needs to encourage answers

ii. Poor self-awareness can discourage answers
iii. Self-awareness training can help health care professionals/providers in being more
efficient in obtaining information
iv. How do we improve self-awareness?
v. Stay for the workshop

Self-awareness – the key to understanding people is to understand yourself, and how

you relate to other people

Knowing the self has many advantages in counselling:

• Knowing how you react to certain interactions
• Knowing what you are sensitive to
• Knowing you values and your limits
• Knowing personal motives in helping others
This is to minimise personal idiosyncrasies that can interfere with counselling process

Day (1995) found 3 common motivations:

• To do for others what someone has done for me
• To do for others what I wish had been done for me
• To share with others certain insights I have learned

191
Motives can be use negatively and may be detrimental in the long run if personal awareness
is not strong for:
• Competence – negative self-image or poor self-esteem may be projected to the
client
• Power – can be misused to have a power over someone, to play God, possibly
ending up in a struggle or on the other hand, be over submissive.
• Intimacy – personal need/fear for/of intimacy may lead to fear of rejection/closeness,
affecting therapeutic relationship with client. – e.g. filtering out certain information due
to intimacy-laden content.

Attachment theory – type of childhood attachment can affect adulthood behaviour and
personality.

It’s important to know your own attachment style and be able to accept your own
tendencies. You then decide if and when you want to change. This paves the way for
personal insight and experience cognitive restructuring within yourself, making it easier to
empathise with clients. Note feelings and thoughts when changing or attempting change.

Some issues affecting helpers include your own personal preference, value, attitudes and
beliefs towards diversity. Diversity could include:
a. differences in personal preference (e.g. as music, fashion, sexual) or practices
b. differences in individual differences (e.g. ethnicity, gender, age, socioeconomic
status, intelligence level, personality, disability)
c. roles in society (e.g. ill person, criminal, religious authority, drug users, police,
teacher)

5.5.4 ACTIVE LISTENING

A. Listening Responses

i. Clarification – to encourage elaboration, check accuracy, get meaning – be useful!

ii. Paraphrase – to mirror and highlight content, to show understanding
iii. Reflection – to mirror and highlight feelings to show empathy, emotional awareness
iv. Summarisation – to bring together client-stated ideas and reflecting back to client,
the theme/pattern of the process, to get feedback

B. Focus on:

i. Person, rather than problem

ii. Present, rather than past/future
iii. Feelings, rather than thought/behaviour
iv. Understanding, rather than explaining

192
 v. Accepting, rather than correcting
vi. Child’s direction, rather than therapist’s instruction
vii. Child’s wisdom, rather than therapist’s knowledge
viii. Possible negative feedback:
• You don’t like me
• I’m your worse patient
• You can’t get me well
• You want to get rid of me
• You don’t want to hear my problems
• You’re going to hospitalise me aren’t you?
• I’m boring you
• You don’t understand me
• You act as though you know more about what I’m feeling than I do
• You are always trying to put words in my mouth
• You’re too old to know
• You are a not a doctor, I’m not telling you

5.5.5 COMMON MISTAKES IN THINKING

A. Black and White Thinking

Problem: Either good or bad only
Solution: Think good enough for now

B. Labelling and Mislabelling

Problem: Labelling leads to overgeneralization
Solution: Be aware of stereotypes and personal responses

C. Overgeneralization
Problem: The use of “always”, “never”, “cannot”, “all the time”, “everyone”
Solution: Use “sometimes”, “not able to now”, “some people”

D. Jumping to Conclusions
Problem: Assuming something that may not be true
Solution: Check for evidence

E. Predicting the Future

Problem: Telling the outcome of the future, usually in a negative manner, without
any evidence
Solution: Be aware that the future has not happened and tell yourself that you have
some control over what might happen, but you can deal with it when it
comes. Pessimism can prevent personal development.

F. Self-criticism
Problem: Criticism of self to the point of getting a negative self-concept
Solution: While criticisms of self serves to push us towards improving ourselves, too
much of it can kill our self-esteem. One way to overcome this is to
affirm yourself that you have strengths too, and focus on those things you
are good at so that you do not become consumed by self-criticisms.

193
 G. Magnification / Minimisation
Problem: Making an issue bigger than it actually is
Solution: Reassess the situation. Most of the time, while something is distressing, it
is not necessary to “catastrophise” or “awfulise” the situation. It helps to
keep calm and functioning so that a solution can be thought of.

H. Negative Filter: Disqualifying the Positives

Problem: Tendency to see only negative elements in self and others, turning
away any positive observations or attributes. This can lead to depression.
Solution: Take the effort to acknowledge and affirm positive elements and nature in
self and others. This helps to reduce begative feelings in yourself and
others.

I. Personalising
Problem: Taking things personally when an event or person causes distress
Solution: Reassess whose problem the distressing event or person is. More often
than not, the problem that is in the event or person is not necessarily
one’s own.

J. Emotional reasoning
Problem: Acting on an emotion that may lead to the distortion of rational thought.
Feeling distressed and acting distressed, leading to poor outcomes.
Somewhat a self-fulfilling prophecy.
Solution: Reassess the issue and differentiate between feelings and personal
ability, and the problem solve based on rational thinking and affirmation of
own capabilities that can contribute to seeking a solution.

5.6 TEACHING METHOD AND MATERIALS

5.6.1 FACE YOUR FEARS (40 MINS)

Training Objective: To identify and normalise personal fears in dealing with teenagers in a
health care interview setting

Contents: Focused on acknowledging personal fears and handling self-doubt when dealing
with teenagers.

Materials:

1. Ball of yarn
2. Marker pen
3. A4 Paper
4. Laptop
5. Flip chart
6. LCD Projector
7. Lecture handouts

194
Procedure :

1. Lecture: Fearing the Teenager (20 min)

2. Activity: Web of Fear (20 min)

a. Break participants into 4 groups

b. Facilitator brief activity instructions to participants
c. Facilitator will throw a ball of yarn to a participant at random. That participant has
to say out a fear he/she has in dealing with teenagers.
d. The facilitator will write the participant’s fear on the worksheet.
e. The rest of the participants who share that same fear will put their hands up.
f. The participant with the ball of yarn will throw the yarn to whoever who has
his/her hand up, while holding on to the beginning of the string.
g. The person who receives the yarn will, twine the string around his/her finger and
repeat what the first participant did but with a different fear.
h. This continues until time is up.
i. The facilitator will then collate all lists of fears and transfer them onto the
flipchart to show the number of shared fears of the participants.
j. Facilitator will then normalise fear in dealing with teenagers by showing
the group the list of fears that have been written down during the course
of the game. Normalising involves letting the participants know that they
are not alone in having fear when dealing with teenagers, and that these fears
are common among health care providers.

3. Assessment and Evaluation (To be compiled into one single evaluation form to be
given at the end of training).
• Check that participants are aware that fear of handling teenagers is a normal
feeling.

“Is feeling fear towards teenagers in a health care interview setting a normal
feeling?”
Yes/No

• Procedure; Rapport: subjective units of fear (Not fearful at all 0 – 10

extremely fearful) rated for before and after the activity.

Please rate your feelings in handling teenagers at your workplace BEFORE this workshop:
Circle one number only.

Not fearful Extremely

at all 1 2 3 4 5 6 7 8 9 10 fearful

Please rate your feelings in handling teenagers at your workplace AFTER this workshop:
Circle one number only.
Not fearful Extremely
at all 1 2 3 4 5 6 7 8 9 10 fearful

195
 For Participants

FACE YOUR FEARS

LIST OF FEARS

FEARS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

196
5.6.2 SELF AWARENESS (80 MIN)

Training Objective: To create awareness and recognise that fears can lead to difficulties in
managing self-emotions in handling the interview with teenagers

Contents: Focus on the prerequisites to managing fear, which are awareness of self
(values, beliefs and responses) and breaking barriers of positive thoughts.

Materials:

1. A4 Paper
2. Laptop
3. Flip chart
4. LCD Projector
5. Pictures of teenagers’ profile
6. Lecture handouts
7. Worksheets

Procedure:

1. Lecture: Self-awareness (20 min)

2. Activity: Personal Judgements (60 min)

a. Break participants into 4 groups

b. Facilitator brief activity instructions to participants
c. Facilitator will give four profile pictures of teenagers (2 males and 2 females)
portraying typical variety of teenagers to each group. These four pictures are the
same for each group.
d. Participants are instructed to analyse each profile based on HEADSS (Refer to
Worksheet)
e. At the end of HEADSS analysis, each group will present their findings with
regards to:
i. Their personal judgements of each picture.
ii. Their realisation of the purpose of the exercise
e. Facilitator provides summary and feedback on personal judgement towards
teenagers.
f. Facilitator provides take home tips on awareness of personal values affecting
judgement.

3. Assessment and Evaluation (To be compiled into one single evaluation form to be
given at the end of training).

• Check that all participants are aware that they have personal judgement in
handling teenagers.
- Based on each groups presentation [e(i)]. If presentations show awareness,
than participants are aware (objective met).

197
 • Check that participants are aware that personal judgement can affect
HEADSS interview.
- Based on each groups presentation [e(ii)]. If presentations show
awareness, than participants are aware (objective met).

Assessed by the Facilitators on Participants Awareness;

Participants are aware that they have personal

judgement in handling teenagers. YES / NO
- Based on each group’s presentation
(Their personal judgement of each picture)

Participants are aware that they have personal

judgement can affect HEADSS interview. YES / NO
- Based on each group’s presentation
(Their realization of the purpose of the exercise)

198
 For Participants
SELF-AWARENESS

HEADSS ON TEENAGERS’ PROFILE

Write down what you think might be issues the pictured teenager may have with regards
to HEADSS. It is important that you comment based on your first impressions.
Please refer to picture 1-4 in PowerPoint Presentation.

PICTURE 1 PICTURE 2 PICTURE 3 PICTURE 4

199
 For Facilitator

SELF AWARENESS

Assessed by the facilitators on participants’ Awareness

Please circle only one: YES / NO / PARTIALLY AWARE

Participants are aware that they have

personal judgment in handling teenagers. YES
- Based on each group’s presentation
[e.(i)]. Saying that they do have an NO
automatic reaction to the
presentation of teenagers having a PARTIALLY AWARE
certain look or behaviour with
regards to personal values.

Participants are aware that personal

judgment can affect HEADSS interview.
- Based on each group’s presentation YES
[e.(ii)]. Report of insight that the way
they perceived the teens can NO
influence the way they ask
questions, or comment during a PARTIALLY AWARE
HEADSS interview.

200
5.6.3 RELATING TO ADOLESCENTS (60 MIN)

Training Objective: To be aware of personal values and responses in relating to teenagers

Contents: Focus on managing personal prejudices in relating to/interacting with teenagers.

Materials:

1. A4 Paper
2. Laptop
3. Flip chart
4. LCD Projector
5. Thought Diaries
6. Video clips of 4 teenagers (silence, crying, angry, defiance)
7. Worksheets

Procedure:

1. Activity: Thought Diaries on Profiles (60 min)

a. Facilitator brief activity instructions to participants

b. Facilitator will show four video clips of teenagers portraying various problematic
behaviours (angry, defiant, silent and crying).

c. Participants are divided into four groups, each with an individual facilitator.

d. Each group facilitator leads discussion of the participants’ reflections described

in the thought diary.

i. Identify the positive and negative interactions (thoughts, feelings and

behaviour responses)
ii. Identify barriers to engaging teenagers in using HEADSS.
iii. Discuss the rights and wrongs, should and shouldn’t in relating with
teenagers while using HEADSS based on personal thought diaries.

e. Group facilitator provides summary and feedback on personal responses

towards teenagers.

201
 2. Assessment and Evaluation (To be compiled into one single evaluation form to be
given at the end of training).

a. Check that all participants are confident in using the thought diary for their daily
management of personal responses towards teenagers in health care interview
setting (i.e. HEADSS). (Likert scale)

b. Check for commitment in using the thought dairy in future self-management of

responses to teenagers (Y/N).

Please rate your confidence level in using the thought diary to manage your responses to
teenagers:

Circle one number only.

Not at all Extremely

confident 1 2 3 4 5 6 7 8 9 10 confident

Will you use the thought diary for your

management of personal responses YES / NO
towards teenagers

202
 For Participants

RELATING

THOUGHT DIARY

Situation Thoughts Feelings Behaviour Reflection

Describe the Write Write Write Write what you

situation you thought(s) feeling(s) behaviour(s) think of your
were in which you had which you had which you had in responses
in this in this situation this situation
situation.

E.g. E.g. E.g. E.g. E.g.

Patient – girl Aiyo! What to Nervous Looked around. I feel very

was silent. do? She Anxious Smiled at the uncomfortable
I didn’t know doesn’t want to A bit angry at girl. with silence in my
what to do. talk. Am I not the girl Tapped my interview session.
friendly pen. I wish someone
enough? would come in
Can anyone and help me.
help me? I don’t like doing
Why won’t you this.
talk?

203
5.6.4 MANAGING SELF IN RELATION TO FEAR (40 MIN)

Training Objective: To impart and generate appropriate responses to manage fears and to
minimise inappropriate reactions

Contents: Focus on engaging the teen with active listening, appropriate responses with
regards to fear.

Materials :

1. A4 Paper
2. Flip chart
3. Mahjong paper list from Activity 1
4. Thought diaries
5. Handouts – Common Mistakes in Thinking

Procedure:

1. Activity: Handling Personal Fears (40 min)

a. Facilitator brief activity instructions to participants

b. Facilitator will lead recall of fears from Activity 1 and 3

c. Participants are divided into four groups, each with an individual facilitator.

d. Each group brainstorm ways to manage fears from list in Activities 1 and 3. The
use of thought diaries is encouraged

e. Identify mistakes in thinking from given situations derived from Activities 1 and 3

f. Group facilitator provides summary and feedback on managing personal fears

towards teenagers.

g. Group facilitator provides tip sheets on managing thoughts, active listening and
appropriate responses.

204
 2. Assessment and Evaluation (To be compiled into one single evaluation form to be
given at the end of training).

a. Assess the level of participants improvement knowledge about managing their

fears in dealing with teenagers (Likert scale).

Please rate your level of knowledge in managing your personal fears in dealing with
teenagers BEFORE this workshop:

Circle one number only.

Not at all 1 2 3 4 5 6 7 8 9 10 Extremely

knowledgeable knowledgeable

Please rate your level of knowledge in managing your personal fears in dealing
ith teenagers AFTER this workshop:

Circle one number only.

Not at all 1 2 3 4 5 6 7 8 9 10 Extremely

knowledgeable knowledgeable

205
 For Participants

MANAGING SELF IN RELATION TO FEAR

LIST OF MANAGEMENT STRATEGIES FOR FEARS

MANAGEMENT STRATEGIES
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

206
5.6.5 MAINTENANCE PRACTICE (20 MIN)

Training Objective : To maintain practice in self-awareness of personal fears in dealing with

teenagers, appropriate behavioural responses to teenagers and managing personal fears.

Contents: Focus on planning of maintenance of acquired self-management skills and

appropriate behaviour in handling teenagers in a health interview setting.

Materials:

1. Pen
2. A4 Paper

Procedure:

1. Activity: Maintenance Practice Discussion (20 min)

a. Facilitator brief activity instructions to participants

b. Participants are divided into four groups.

c. Each group discuss ways to maintain skills acquired from previous workshops.

d. Group leaders present their discussion outcomes.

e. Facilitator provides summary and feedback on maintaining acquired skills.

207
Assessment and Evaluation:

Assess the improvement of participants knowledge in facilities, services and medico-

legal issues related to teenagers health (Likert scale).

Please rate your level of knowledge in facilities, services and medico-legal issues related to
teenagers health BEFORE this workshop:

Circle one number only.

Not at all 1 2 3 4 5 6 7 8 9 10 Extremely

knowledgeable knowledgeable

Please rate your level of knowledge in facilities, services and medico-legal issues
related to teenagers health AFTER this workshop:

Circle one number only.

Not at all 1 2 3 4 5 6 7 8 9 10 Extremely

knowledgeable knowledgeable

Assess the participant’s opinion on the content of “Services and facilities available in
MOH”

Please rate your opinion on the content of “Services and facilities available in MOH”.

Circle one number only.

Extremely 1 2 3 4 5 6 7 8 9 10 Extremely
Inadequate Adequate

Assess the participant’s opinion on the content of “Medico-legal Issues in Health

Care Management pertaining to Teenagers”

Please rate your opinion on the content of “Medico-legal Issues in Health Care Management
pertaining to teenagers”.

Circle one number only.

Extremely 1 2 3 4 5 6 7 8 9 10 Extremely
Inadequate Adequate

208
 For Participants

MAINTENANCE PRACTICE

PLAN OF ACTION IN MAINTAINING SELF-MANAGEMENT PRACTICE

PLAN
1

10

11

12

13

14

15

209
 APPENDIX 1

CHILD ACT 2001 - RELEVANT HIGHLIGHTS

The Child Act 2001 is an Act to consolidate and amend the laws relating to the care,
protection and rehabilitation of children. It has come into force in Malaysia since 1 August
2002.

Interpretation of terms:

• “Child”: a person under the age of 18 years.

• “Hospital”: any Government hospital or any teaching hospital of a University.
• “Medical officer”:a registered medical practitioner in the service of the Government,
including a registered medical practitioner in the teaching hospital of any University.
• “Registered medical practitioner”: a practitioner registered under the Medical Act
1971
• “Protector”: the Director-General, Deputy Director General, Division of state
Director of Social Welfare officer appointed by notification in the Gazette to exercise
the powers on perform the duties of a Protector under the Act.

CHILDREN IN NEED OF CARE & PROTECTION (SEC 17)

Categories of children in need of care and protection under this Act include the
following:

a. A child who has been physically or emotionally injured or sexually abused by his
parent or guardian or member or his extended family, or child at risk of such
abuse or injury. This includes a child who has suffered emotional injury resulting
from conflict between himself and his parent or guardian.

b. A child or risk of injury or abuse described under (a) whose parent or guardian has
failed to protect or is unlikely to protect him from such injury or abuse.

c. A child whose parent or guardian is unfit, has neglected to or is unable to exercise

proper supervision and control over the child.

d. A child whose parent or guardian has neglected to or is unwilling to provide

adequate care, food, clothing, or shelter.

e. A child who has been abandoned or who has no parent or guardian.

f. A child whose parent or guardian refuses medical examination, investigation or

treatment which a child needs to restore or preserve his health.

g. A child who behaves in a way that may harm himself or others whose parent or
guardian is unable to or unwilling to take remedial action.

h. A child who is used for begging or any illegal activity (e.g. gambling, hawking),
which is detrimental to his health and welfare.

210
 APPENDIX 1

PROVISIONS FOR THE MEDICAL EXAMINATION AND TREATMENT OF A CHILD

NEED OF CARE AND PROTECTION

(SECTION 20 TO 26)

a. The Act provides for a Protector or police officer to bring such a child, if
appropriate, to a medical officer and leave him in hospital for medical
examination and treatment.

b. The Protector or police officer may also direct the person having care of such a
child to bring him to hospital for medical examination and treatment.

c. The Act also provides for a medical officer to take into temporary custody in the
hospital any child suspected to be a victim of physical, emotional or sexual
abuse until custody is handed over to a Protector or police officer.

d. The medical officer may with the authorization of the Protector / police officer
conduct a medical examination and necessary tests or procedures for diagnosis,
as well as provides treatment for any minor illness or injury.

e. If the child has a serious illness or injury, which requires surgery or psychiatric
treatment, the medical officer should inform the Protector or police officer to
contact the parent or guardian for authorization of treatment.

f. If there is immediate risk to the health of the child, the medical officer should
certify this in writing, The Protector may then authorise treatment only under any
of the following circumstances:

● The parent or guardian unreasonably refuses or withholds consent

● The parent or guardian is unavailable or cannot be found in time
● The Protector believes on reasonable grounds that the parent or
guardian has abused or neglected the child

g. The medical officer who examines or treats the child is exempted from any
liability for doing this under the above provisions (Section 21 to 24)

h. The medical officer is however not exempt from other forms of liability which he
would be subject to under normal circumstances when parental consent is
available (e.g. relating to duty of diligence and care)

211
 APPENDIX 1

DUTIES OF A MEDICAL OFFICER OR MEDICAL PRACTITIONER

Mandatory reporting

a. A medical officer or registered medical practitioner is required to inform the

Protector of any child that he examines or treats whom he suspects to be victim
of abuse.

b. The penalties for failure to comply include a fine of up to RM 5 000 and/or a

prison sentence of to two years.

CHILDREN BEYOND CONTROL (SEC 46)

There may be occasions where a parent seeks assistance or advice regarding a child over
whom he is unable to exercise proper control.

This section of the Act provides for such a child to be detained in an approved place under
the authority of the Court for Children if the parent or guardian makes a request for this in
writing.

The parent or guardian should refer to the district Social Welfare department for advice and
assistance with the relevant procedures.

212
 APPENDIX 2

CONSENT AND CONFIDENTIALITY

1. CONSENT – ISSUE OF CONSENT IN MANAGEMENT OF CHILDREN AND

ADOLESCENT

A) GUIDELINES FOR GOOD PRACTICE CONSENT

• Parents and young people need to be informed and involved as much as possible
in treatment decisions.

• Treatment can proceed with the consent of a parent/guardian and the young
person’s agreement.

• If either the parent or young person refuses, treatment should be delayed for
more discussion, modification of the treatment plan or to obtain the opinion of
another specialist.

• Treatment may proceed with the consent of one parent. If any dispute occurs,
attempts should be made to negotiate and if that fails, the local welfare authority
may be consulted.

• If there is or guardian, willing to consent to necessary action or treatment

programme for a child who is not competent, consult the local welfare authority.

• If neither parent is competent to give consent, consult the local welfare authority.

• Overruling the refusal of any young person should be considered only if:
a Attempts to discuss and modify the treatment have failed
b The parents are in favour, or consent from the relevant authorities (court,
social welfare) is obtained);
c The young person is more likely than not to suffer significant harm without
treatment.

• Before treating a young person against his or her will:

a The reasons for the decision should be recorded in the notes
b Record the consent from the parent, guardian or relevant authorities.

• Parents or the young person can withdraw consent at any time.

213
 APPENDIX 2

B) POINTS TO CONSIDER IN TAKING CONSENT

• The need for consensus/agreement

- Do the parents and child understand the illness and the treatment options
available?
- Does more explanation or information need to be provided for consent?
- Is more time needed for consideration?
- Is a second opinion required?

• The risks and benefits of the treatment

- What are the risks of treatment versus no treatment?

• The nature of the illness

- How disabling, chronic or life threatening?

2. CONFIDENTIALITY

A guide for cases where confidentiality is an issue

● Issues regarding confidentiality need to be explained to a child in a way that he

can understand.

● A child should be informed in situations where his right to confidentiality may be

limited and the reasons for this should be explained. Potential areas where the
confidentiality of the interview may be broken (e.g. disclosure of abuse) should
be explained to the child at the outset.

● In other situations, a decision to breach confidentiality can be guided bay answers

given to the following questions:
- Is there a significant risk of physical harm to either the child or others if
disclosure to the relevant authorities is not made?
- Is there a legal requirement to report to the authorities?
- What is the accepted practice among the professionals in this area?

4. Consult a more experienced colleague when unsure of what to do.

214
 APPENDIX 3
POWERPOINT PRESENTATION ON
FEARINF THE TEENAGERS: HOW TO COPE

215
 APPENDIX 3

POWERPOINT PRESENTATION ON
SELF AWARENESS

216
5.8 REFERENCES

Cormier s, Hackney HL. Counseling strategies and intervention. 7th ed. Allyn & Bacon.
2007

Division of Family Development and Department of Psychiatry, Kuala Lumpur, Ministry of

Health Malaysia. Child and Adolescent Mental Health Training Module for Specialist,
2003.

Ellis A. Overcoming destructive beliefs, feeling and behaviors: New directions for
Rational-Emotive Behavior Therapy. Prometheus Books; 2000.

McKay M. Fanning P. Self-esteem. Oakland, CA:New Harbinger; 2000.

217
ACKNOWLEDGEMENTS
The Family Health Development Division, Ministry of Health would like to express our thanks to the
following individuals for their contributions to this training module:

Advisors : Dr. Safurah bt. Haji Jaafar

Director
Family Health Development Division
Ministry of Health Malaysia

: Dr. Mymoon bt. Alias

Deputy Director
Family Health Development Division
Ministry of Health Malaysia

Contributors :
1. Dr. Nik Rubiah bt. Nik Abdul Rashid
Senior Principal Assistant Director
Family Health Development Division
Public Health Department
Ministry of Health
7. Assoc. Prof. Dr. Khairani bt. Omar
Family Medicine Specialist and Lecturer
Department of Family Medicine
Faculty of Medicine, UKM Medical Centre

2. Dr. Fauzi bt. Ismail 8. Dr. Alvin Ng Lai Oon

Consultant Child and Adolescent Clinical Psychologist / Senior Lecturer in
Psychiatrist Clinical Psychiatric
Department of Psychiatry Faculty of Allied Health Sciences,
Selayang Hospital UKM

3. Assoc. Prof. Aili bt. Hashim 9. Dr. Nazrila Hairizan bt. Nasir
Consultant Child and Adolescent Family Medicine Specialist
Psychiatrist Department of Psychological Pandamaran Health Clinic
Medicine, Klang, Selangor
University Malaya Medical Centre

4. Dr. Hj. Mohd Nizam b. Abd Ghani
Consultant Child and Adolescent
Psychiatrist
Sultanah Nor Zahirah Hospital
Kuala Terengganu
10. Dr. Iskandar Firzada b. Hj. Osman
Family Medicine Specialist
Jaya Gading Health Clinic
Kuantan, Pahang

5. Dr. Aminah bt. Kassim 11. Dr. Husni b. Hussain

Consultant Child and Adolescent Family Medicine Specialist
Psychiatrist Putrajaya Health Clinic
Hospital Kuala Lumpur Putrajaya
Kuala Lumpur

6. Assoc. Prof. Dr. Harlina Halizah bt. Hj 12. Dr. Eni Rahaiza bt. Md. Ramli
Siraj Consultant Child and Adolescent Psychiatry
Consultant Obstetric and Gynaecologist Taiping Hospital
Department of Medical Education, Perak
Faculty of Medicine, UKM Medical Centre
218 

 
  

13. Dr. Zubaidah bt. Jamil Osman
Clinical Psychologist / Senior Lecturer
Department of Psychiatry
Faculty of Medicine and Health Sciences,
UPM
21. Dr. Azah bt. Abdul Samad
Family Medicine Specialist
Tanglin Health Clinic
Department of Health, FT Kuala Lumpur

14. Dr. Hargeet Kaur a/p Basant Singh 22. Dr. Rohayah bt. Ismail
Consultant Paediatrician Family Medicine Specialist
Department of Paediatric, Jinjang Health Clinic
Selayang Hospital, Selangor Department of Health, FT Kuala Lumpur

15. Dr. Siti Aishah bt. Saidin Consultant 23. Dr. Salmah bt. Nordin
Paediatrician Family Medicine Specialist
Department of Paediatric Taman Ehsan Health Clinic
Taiping Hospital, Perak Gombak, Selangor

16. Dr. Saidatul Norbaya bt. Buang 24. Dr. Siti Zaleha bt. Suleiman
Principal Assistant Director Family Health Family Medicine Specialist
Development Division Public Health Merlimau Health Clinic
Department Jasin, Melaka
Ministry of Health Malaysia

17. Dr. Fauziah bt. Mohd Noor 25. Dr. Selva Ratnasingam
Senior Lecturer/ Lawyer International Consultant Child and Adolescent
Islamic University Malaysia (UIAM) Psychiatrist
Gombak, Selangor Permai Hospital
Johor Bharu, Johor

18. Dr. Aminah Bee bt. Mohd Kassim
Senior Principal Assistant Director
Family Health Development Division
Public Health Department
Ministry of Health Malaysia
26. Dr. Noor Ani bt. Ahmad
Public Health Physician
Institute for Public Health
Ministry of Health Malaysia

19. Dr. Wan Fadhilah bt. Wan Ismail 27. Pn. Hashimah bt. Abd Razak
Family Medicine Specialist Senior Counsellor
Klinik Kesihatan Tampoi Division of Service Management Ministry of
Johor Bahru, Johore Health Malaysia

20. Dr. Zil Falillah bt. Mohd Said 28. Ms. Yang Wai Wai
Family Medicine Specialist Clinical Psychologist / Lecturer Department
Kerteh Health Clinic of Paediatric
Kemaman, Terengganu Faculty of Medicine,
UKM Medical Centre

219 

 
  

29. En. Hairol Kamal Abd. Rahman 34. Hj. Mohd Jamal Nasir b. Sohaimi
Senior Counsellor Senior Assistant Medical Officer
Ipoh Hospital, Perak Putrajaya Health Clinic
Putrajaya

30. En. Lee Boon Hock 35. Dr. Aida Harlina Abdul Razak
Counsellor Assistant Director
Kuala Lumpur Hospital Family Health Development Division
Ministry of Health Malaysia

31. Pn. Nurizah bt. Zakaria 36. Pn. Athiyah Shaik Omar
Counsellor Matron
Health Management Institute Family Health Development Division
Kuala Lumpur Ministry of Health Malaysia

32. Pn. Husna bt. Zainal 37 Hj. Mohd Lazim Kadir

Counsellor Senior Assistant Medical Officer
Putrajaya Hospital, Putrajaya Family Health Development Division
Ministry of Health Malaysia

33. En. Mohd Zamry b. Yazid

Assistant Medical Officer
Umbai Health Clinic
Jasin, Melaka

220 

 
EDITORS

1. Dr. Nik Rubiah Nik Abdul Rashid 3. Pn. Athiyah Shaik Omar
Senior Principal Assistant Director Matron
Family Health Development Division Family Health Development Division
Ministry of Health Malaysia Ministry of Health Malaysia

2. Dr. Noor Ani Bt Ahmad 4. Hj. Mohd Lazim Kadir

Public Health Physician Senior Assistant Medical Officer
Institute for Public Health Family Health Development Division
Ministry of Health Malaysia Ministry of Health Malaysia

221 

 
 
136