Adolescent Well Care:
Making Every Opportunity Count
Michele Dritz, MD, MS
Adolescent Medicine Clinic
Wright-Patterson AFB Medical Center
Overview
• Background data on adolescent preventive care provision
• Adolescent preventive care guidelines
– Ohio and national statistics
– Current guidelines
• Setting the stage for providing quality care to adolescents
The rewards of caring for Adolescents
• Many adult chronic diseases have origins in childhood and
adolescence
• Most adolescent morbidity and mortality is preventable and
related to personal health behavior – unintentional injuries,
reproductive health issues, co-morbidities related to obesity
• Adolescence is a time of developing independence and
establishment of long-term health behaviors
Preventable problems
related to personal behaviors
where providers can help
make a difference!
Preventive Care Services
• Only 38% of adolescents had a preventive care
visit in the past year
• Only 35% of adolescents receive the
recommended preventive care services
• On average, adolescents have non-preventive care
visits 1-1.5 times per year, versus 0.15-0.28
times per year for preventive care visits
• Only 40% of adolescents had time alone with
their provider at their last preventive care visit
Adolescent Preventive Care Guidelines
• Lots of opinions…
– Guideline for Adolescent Preventive Services (GAPS)
• American Medical Association (AMA)
– Bright Futures (BF)
• American Academy of Pediatrics (AAP), Maternal & Child Health
Bureau (MCHB), US Public Health Services
– Guide to Clinical Preventive Services
• United States Preventive Services Task Force (USPSTF)
– Recommendations for Pediatric Preventive Health Care
• American Academy of Pediatrics (AAP)
– Age Charts for Periodic Health Examinations
• American Academy of Family Physicians (AAFP)
– Adolescent Immunization updates
• Advisory Committee on Immunization Practices (ACIP)
Not
always a
lot of
consensus
Elster, AB, “Comparison for Recommendations for Adolescent Clinical Preventive Services Developed by
National Organizations”, Arch Pediatr Adolesc Med, 1998, 152:193-198.
What’s a doctor to do?
Making the most of the visit
• Medical history
• Psychosocial history with screening and
counseling for high risk behaviors
• Adolescent exam and pelvic exam
• Screening and labs
• Immunizations
• Health guidance
Medical History
Medical History
• Chronic medical conditions
• Medications and supplements
– Prescription, Over-the-counter, nutritional supplements
• Past hospitalizations
– Medical, Psychiatric
• Surgical history
• Injury history
– Concussions, Sports injuries
• Family medical history
– Cardiovascular risk
– Psychiatric illnesses
– Substance abuse
• Mental health history
– Hospitalizations, counseling, suicide attempts, medications
• Review of systems
• Current concerns
Gynecological History
• Last Menstrual Period – An adolescent vital sign
• Age of menarche
– Median = 12.4 years
• Cycle length
– Mean length = 21-45 days
• Menstrual flow
– Normal length ≤7 days
– Typical menstrual products = 3-6 pads/tampons per day
• Ovulatory cycle symptoms
– Dysmenorrhea, headaches, PMS, PMDD
• Pregnancies and/or abortions
Psychosocial History
and
High Risk Behaviors
Taking a Psychosocial History
•
•
•
•
•
•
•
•
H: Home
E: Education and Employment
E: Eating
A: Activities
D: Drugs
S: Sexuality
S: Suicide and Depression
S: Safety from Injury and Violence
Eating Behaviors and Weight:
Ohio & National Statistics
• 33% of Ohio teens are overweight or obese
• Over ½ of female teens and ⅓ of male
teens use unhealthy weight control
behaviors such as skipping meals, fasting,
smoking, vomiting or using laxatives
• Eating disorders have the highest mortality
rate of any other mental illness
Eating Behaviors and Weight
• Important to screen both girls and boys
• Be cognizant of high risk categories for eating disorders:
– Involvement in weight-specific sports (wrestling, gymnastics, dance) and
competitive athletes
– Frequent dieters
– Recent or significant weight loss; or being overweight
– Diabetes and other chronic illnesses
– Co-morbid psychiatric and personality disorders
– Family history (eating disorder, obesity)
• Ask about typical meal intake, exercise, body image and diets/other
weight loss behaviors
• Plot BMI on a growth chart
• Ask about their weight goals and help develop with them healthy
weight plans
– Opportunity to engage in motivational interviewing
Drugs & Substance Use:
Ohio Statistics
• 29% report binge drinking (5 or more
alcoholic drinks within a few hours)
• 20% report having their first drink before
the age of 13
• 34% report using marijuana one or more
times in their life
• 22% report smoking in the
past month
Drugs & Substance Use
• Increased risk-taking behavior is
developmentally appropriate in adolescence,
but can still be dangerous and lead to
negative long-term consequences
• Screening tools developed to help providers
assess risk category
– CRAFFT (alcohol and drugs)
• Know your local resources
Sex and Sexuality:
Ohio Statistics
• 45% of Ohio teens have had sexual
intercourse
• 40% did not use a condom during their last
sexual encounter
• 5 to 6% of US students identify themselves
as gay, lesbian, bisexual or transgender
Sex and Sexuality
• Importance of asking questions and not assuming
anything
• In order to determine STD risk, you need to know what
and where to screen
– May need to be specific in your questions: kissing, touching,
oral sex, anal sex, penile-vaginal intercourse?
– When was the last time they had sex?
• Asking about safe sex:
– Did they use a condom?
– Have they ever had an STD? Have they ever been tested?
• Contraception:
– Have they ever been pregnant or had an abortion?
– Are they trying to get pregnant?
Suicide & Depression:
Ohio Statistics
• 25% of teens report feeling depressed
• 13% of teens had suicidal ideations in the
past year
• 7% attempted suicide in the past year
• 91% of parents were unaware of their teen’s
suicide attempts
Suicide & Depression
• 2009 USPSTF recommendation for routine depression
screening if systems in place for treatment
• Use screening tools such as PHQ-9, SIGECAPS or BDI
to adequately assess risk
• Other important questions to ask:
–
–
–
–
–
History of counseling?
Psychiatric hospitalizations?
Recent suicidal ideation?
History of suicide attempt in past?
Non-suicidal self-injurious behaviors
• If concern, assess current safety, presence of reliable
adult support, if there are guns in the home
• Know your local resources
Safety, Violence and Injury:
Ohio Statistics
• 30% of teens said they were in a physical
fight in the past year
• 28% reported being harassed or bullied on
school grounds
• In Ohio, there were 47,444 confirmed cases
of child abuse or neglect – 26% higher than
the national average
• 23% of teen reporting riding in a vehicle
driven by someone who had been drinking
Violence and Injury
• Important to screen both boys and girls
– Either can be victim or perpetrator
• Screening tools available:
– FISTS
• Ask about history of physical or sexual abuse, dating
violence or witnessing domestic violence
• MVAs are the leading cause of morbidity in
adolescents and young adults ages 10 to 24
– Discuss use of seatbelts
– Discuss risks of drinking and driving or getting into car
with driver that has been drinking
High Risk Behaviors
• Most risks are taken by “multiple-risk” teens who have many
points of contact and therefore many possible intervention sites
• Nearly all teens, even multiple risk-taking adolescents
participate in positive behaviors
• So what should a physician do?
– Celebrate and praise teens who are avoiding high-risk
behaviors
– Encourage and support participation in positive behaviors,
especially in risk-taking teens
– Target the risk-taking behaviors as a whole and work with
the teen to minimize negative outcomes
Adolescent Exam
Physical Exam
• Vitals, including last menstrual period (LMP)
• Height, weight, BMI
–
–
–
–
Plot height, weight & BMI
Overweight = BMI 85th – 95th percentile
Obese = BMI ≥ 95th percentile
Underweight = BMI <5th percentile
• Comprehensive physical
• Importance of having teen change
into a gown to be able to do thorough
skin and genitourinary (GU) exam
Male GU Exam
• Determine Sexual Maturity Rating (SMR)
• Look for signs of STIs
– Penile discharge, warts, vesicles
• Examine testicles
– Hydrocele, hernia, varicocele, mass
Female GU Exam
• Determine Sexual Maturity Rating (SMR) – breast and genitals
• Look for signs of STIs
– Vaginal discharge, warts, vesicles
• Is a pelvic exam necessary?
– AAP: All sexually active females
– ACOG: Not necessarily at 1st visit, but with annual STD screen
– GAPS: No, can do STD screening via vaginal or urine sample for females,
urine sample for males
– Bright Futures: If “clinically warranted”
• Do a pelvic exam if:
– Symptomatic
• Vaginal symptoms, abdominal or pelvic pain, abnormal bleeding
– Question about pubertal development or primary amenorrhea
– Due for a pap smear
• Current ACOG recommendations, 21 years or older
• Pelvic exam includes external exam, speculum and bimanual
Screening and Labs
Screening and Labs:
Ohio Statistics
• 26% of US female adolescents had at least
one of the most common STIs (HPV,
Chlamydia, Trichomonas, HSV)
• Syphilis rates in Ohio teens have more than
tripled since 2005
• Approximately 10% of US teens have
elevated cholesterol levels
• The incidence rate of Type II Diabetes in
Cincinnati children has increased 10-fold
Screening and Labs
• Sexually Transmitted Infections:
Gonorrhea Chlamydia Trichomonas HIV
(Females) (Females) (Females)
Abstinent
Sexually
active
High Risk1
MSM2
WSW3
Syphilis Pap smear4 Pharyngeal Rectal
(HPV)
& Rectal
Chlamydia5
(Females) Gonorrhea5
Once
Yearly
Yearly
(Males)
(Males)
(q 3-6 mo) (q 3-6 mo)
Yearly
Yearly
1High
Yearly
Yearly
At age 21
(Yearly)
Yearly
(Yearly)
At age 21
(prn)
(prn)
(q 3-6 mo)
(q 3-6
mo)
(q 3-6
mo)
At age 21
(prn)
(prn)
Yearly (anal pap)
(yearly) At age 21
Yearly
prn
Yearly
prn
(Yearly)
Yearly
yearly
Risk = >1 sex partner in past 6 months, history of STI, IV drug use, sex for money,
homeless, sex with high risk partner
2MSM = men who have sex with men
3WSW = women who have sex with women
4Pap Smear = ACOG: 21 yo; American Cancer Society: 3 years after sex or by 21 yo
5Based on risk due to sexual practices
Screening and Labs
• Sexually Transmitted Infections:
– If asymptomatic:
• Males:
– Urine GC/CT NAAT (“1st catch” urine)
• Females:
– Vaginal GC/CT NAAT (self-obtained) – preferred method
» urine GC/CT NAAT also option (“1st catch” urine)
– Trichomonas vaginal swab (can be self obtained)
– If symptomatic:
• Male:
– Urine GC/CT NAAT (“1st catch” urine)
• Female:
– Endocervical, Vaginal or urine GC/CT NAAT
– Trichomonas vaginal swab (physician obtained)
– Pelvic exam with bimanual
Screening and Labs
• Tuberculosis:
– PPD
• Recommendation: Selective screening based upon risk factors
–
–
–
–
–
–
–
–
–
–
–
–
–
Suspected contact with TB
Clinical or radiographic findings suspicious for TB
Emigration from TB endemic area
Travel to TB endemic countries or close contact with travel to those areas
Live in high prevalanceTB area as determined by local health department
HIV positive
Live with someone who is HIV positive
Incarcerated adolescents
Exposure to HIV positive individuals, homeless persons or nursing home
residents
Institutionalized adolescents
Illicit drug use
Migrant farm worker
Exposure to high-risk adult
Screening and Labs
• Dyslipidemia:
– Fasting lipid panel
• No recommendation for universal screening, but selective
screening by most guidelines
• Concern is that targeted screening misses up to ½ of all affected
teens, but recommended intervention is typically only diet and
exercise
• Selective screening if any of the following:
–
–
–
–
–
–
–
Family history of premature CHD (<55 yo)
Parent with total cholesterol of > 240 mg/dl
Family history unknown
Obesity
High blood pressure
Diabetes
Heart disease
• If results normal, repeat every 3-5 years
Screening and Labs
• Diabetes:
– Fasting plasma glucose:
• No recommendation for universal screening and no pediatric
specific recommendations by any of the adolescent guidelines
• Concern is due to increasing rates of adolescent obesity and
associated co-morbidities and insulin resistance
• American Diabetes Association “consensus statement” for
screening adolescents:
– Overweight/Obese PLUS 2 OF THE FOLLOWING:
» 1st or 2nd degree relative with Type 2 DM
» Native American, African American, Hispanic American,
Asian/South Pacific Islander
» Signs or conditions associated with insulin resistance (PCOS,
acanthosis nigricans, HTN, dyslipidemia)
– Retest every 2 years
Screening and Labs
• Anemia:
– High prevalence of iron deficiency anemia due to poor diet, rapid
growth and menstrual losses
– Only recommended by AAP
– Hemoglobin or Hematocrit
• With 1st visit, end of puberty or both
• Vision Screen:
– Mixed opinions
– Recommendation:
• At initial visit, and then every 2-3 years
• Hearing Screen:
– Mixed opinions
– Recommendation:
• At least once during adolescence
Immunizations
Immunizations
• 2011 Advisory Committee on Immunization
Practice (ACIP) update:
Immunizations
• Adolescent Specific:
– Tdap:
• Recommendation: 11-12 years
• Catch-up: 13- 18 years
• Booster: Td booster every 10 years
– MCV4:
• Recommendation: 11-12 years
• Booster: at age 16 years
• Catch-up:
– HPV:
– 1 dose at age 13-18 years
– Dose 1 at 13-15 years, booster at 16-18 years
– 1 dose if previously unvaccinated college freshman living in dorm
• HPV4 (Gardasil) – HPV 16, 18, 6, 11 – females and males
• HPV 2 (Cervarix) – HPV 16, 18 – females only
• Recommendation: 3 shot series at 11-12 years
Immunizations
• Childhood Catch-up:
– Varicella
• Recommendation:
– 2 dose series if no clinical immunity and no previous immunization
– 1 dose due for catch-up if previously received only single dose
– Hepatitis B:
• Recommendation: 3 dose series if not previously vaccinated
– Hepatitis A:
• Recommendation: 2 dose series if MSM or other high risk group
– Catch-up for any other recommended childhood vaccines
• IPV, MMR
• Continuous:
– Influenza:
• Recommendation: Yearly
Health Guidance
Health Guidance
• Guidance for parents:
– Normative adolescent development
• Physical, emotional and sexual development
– Discussing health-related behaviors with their
teens
– Acting as positive role models
– Methods to help teens avoid potential injuries:
• Safe driving
• Avoiding weapons at home
• Monitoring their teen’s activities
– Maintaining open communication with their teen
Health Guidance
• Guidance for adolescents:
– Normative development
• Physical, emotional and sexual development
– Importance of becoming actively involved in their health
care and medical decisions
– How to avoid potential injury:
•
•
•
•
Safe driving
Use of safety devices (helmets, seatbelts, etc)
Healthy interpersonal relationships
Avoiding weapons
– Promotion of physical activity and healthy dietary habits
– Responsible sexual behavior including abstinence, condom
use, contraception, and STI screening.
– Avoidance of tobacco, alcohol, drugs and anabolic steroids
Health Guidance
• Mixed Opinions:
– Breast self-exam (BSE)
• USPSTF recommended against routine BSE (2009)
• ACOG still recommends
• Still recommended in all adolescent preventive services
guidelines except GAPS (AMA)
– Testicular self-exam (TSE)
• USPSTF recommended against routine TSE and
physician testicular exam for testicular cancer screening
(2004)
• American Cancer Society does not recommend
• Still recommended in all adolescent preventive services
guidelines except GAPS (AMA)
So how do we go
from here…
to there?
Setting the Stage
Setting the Stage
• Capturing every opportunity at every visit
• Honoring confidentiality
• Asking the right questions to gather a thorough
psychosocial history
• Fostering behavior change through motivational
interviewing
Capturing Every Opportunity
• Develop processes that automatically allow the
right thing to happen every time
– Immunization standing orders
– “Best Practice” reminders
• Consider the use of screening tools to optimize
both the reliability of care and use of time
– Risk behaviors, depression, substance use
• Have health education tools readily accessible for
patients and create a teen-friendly environment
• Take a team approach and consider developing a
quality improvement team
• Track your practices performance over time
Honoring Confidentiality
• Recognize an adolescent’s legal right to confidential services
– Ohio law:
• Can consent: STI counseling & treatment, HIV testing, substance abuse
evaluation and treatment, limited mental health evaluation and treatment,
emergency treatment, sexual assault services, adoption
• Cannot consent: abortion, psychiatric medication, inpatient psychiatric
hospitalization, HIV treatment
• No law either way: contraception including emergency contraception,
pregnancy testing, prenatal care
• Making confidentiality a part of the discussion from the
beginning
– “New Patient” letter
– Website
– Initial and subsequent visits
Honoring Confidentiality
• Discussing confidentiality with both teens and parents
– Stressing importance of open communication
– Data showing importance of confidentiality in adolescents seeking care
– Stress that both you and parent have the same interest – to keep their teen
healthy and safe
• Discussing the limits of confidentiality
– Concern for harm to self or others, or harm done to them
– Areas of possible disclosure (i.e. insurance billing, mental health records)
• Acting on that promise
– Seeing the teen alone for part of the visit
– Getting alternative contact info for teen in case necessary (i.e. cell phone)
Asking the Right Questions
• Don’t be afraid to ask…but realize it is up to you to
create a safe environment for them to be able answer
honestly
• Small talk matters in building a relationship of trust
• Consider using screening tools to stream line data
collection
– GAPS Initial Adolescent Preventive Services Form, GAPS
Parent/Guardian Questionnaire, topic-specific screening
tools
• If time is short, focus on high risk behaviors that need to
be addressed immediately and then have them follow-up
• If you feel you are out of your element, ask for help
Fostering Behavior Change
• Strong evidence regarding using motivational interviewing to facilitate
positive behavior changes
• Motivational interviewing techniques natural fit for adolescent
developmental stages:
–
–
–
–
–
Collaborative approach to health priorities
Gives adolescents a voice in the decision process
Allows for proactive problem solving
Helps build self-efficacy and self-esteem
Creates opportunity for frequent follow-up
• Motivation is the driver of behavior change –
so understanding what motivates your patient is key
• Consider behavior changes for your clinic as well
– Utilizing newer technologies to better serve adolescents needs
– “Meeting teens where they are”
In the end…
• The majority of adolescents move successfully from
childhood to adulthood with the help and support of:
– Families, Friends, Communities, Social institutions, Physicians
•
•
•
•
•
•
More than ¾ volunteered in the past year
Nearly ½ feel they can make a difference in their communities
Over ⅓ say religion plays a large role in their life
More than 90% of teens are enrolled in school or employed
87% of young adults completed high school
More than ¾ felt they could go to their parents
for advice and guidance in time of need
• There has been a 29% increase in the proportion
of teens choosing healthy behaviors over
health-risk behavior
You play a key role in helping teens navigate
adolescence successfully…
And that creates a solid
foundation not just for their
health today, but for their
tomorrows to come
Bibliography
•
Youth Risk & Behavior Surveillance, Ohio Executive Summary, Ohio Department of Health, 2007.
•
National Longitudinal Study of Adolescent Health, 2001, http://www.cpc.unc.edu/addhealth.
•
National Health and Nutrition Examination Survey (NHANES), 2003-2004,
http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/nhanes03_04.htm .
•
Ohio Department of Health, http://www.odh.gov.
•
South Carolina Department of Mental Health, Eating Disorder Statistics,
http://www.state.sc.us/dmh/anorexia/statistics.htm.
•
Neinstein, LS, Adolescent Health Care: A Practical Guide, 4th Edition, Lippincott Williams &
Wilkins, 2002.
Mangione-Smith, R et al, “The Quality of Ambulatory Care Delivered to Children in the United
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Developed by National Organizations”, Arch Pediatr Adolesc Med, 1998, 152:193-198.
•
•
•
•
Bibliography
•
•
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•
•
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Elster, A., “Guidelines for Adolescent Preventive Services”, UpToDate, Sept 2010 ,
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Bibliography
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US Preventive Services Task Force, “Screening for Testicular Cancer Recommendation
Statement”, 2004.
American Congress of Obstetricians and Gynecologists, “Response of The American College
of Obstetricians and Gynecologists to New Breast Cancer Screening Recommendations from
the U.S. Preventive Services Task Force”, 2009.
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