Bright Futures for Adolescents:
What’s New in 2015?
National School-Based Health Care Convention
Session E4
Thursday, June 18, 2015 3:45-5:00 PM
Barbara Frankowski MD, MPH, FAAP
Jane Bassewitz MA
Speaker Disclosures
Barbara Frankowski MD, MPH, FAAP
In the past 12 months,
I do not have any
Financial Disclosures
I do not intend to discuss an
unapproved/investigative use of a
commercial product/device in my
presentation.
Jane Bassewitz MA
In the past 12 months,
I do not have any
Financial Disclosures
I do not intend to discuss an
unapproved/investigative use of a
commercial product/device in my
presentation.
2
Bright Futures: Mission
The mission of Bright Futures is to
promote and improve the health,
education, and well-being of infants,
children, adolescents, families, and
communities.
Bright Futures is the health promotion/disease
prevention component of the medical home.
At the heart of the medical home is the relationship
between the clinician and the family or youth.
What are the Bright Futures Guidelines?
Comprehensive health supervision guidelines:
• Developed by multidisciplinary child health experts providers, researchers, parents, child advocates
• Provide framework for well-child care from birth to
age 21
• Present single standard of care based on health
promotion and disease prevention model
• Include recommendations on immunizations, routine
health screening, and anticipatory guidance
• Replace the former AAP Guidelines for Health
Supervision
2000 & 2002
…is a set of principles,
strategies and tools that
are theory - based,
evidence - driven, and
systems - oriented, that
can be used to improve
the health and wellbeing of all children
through culturally
appropriate
interventions that
address the current and
emerging health
promotion needs at the
family, clinical practice,
community, health
system and policy levels.
Affordable Care Act: Section 2713
…requires all health plans to cover, with no cost-sharing
“with respect to infants, children, and adolescents,
evidence-informed preventive care and screenings
provided for in the comprehensive guidelines supported
by the Health Resources and Services Administration,”
the services are outlined in Bright Futures: Guidelines for
Health Supervision of Infants, Children, and Adolescents,
3rd Edition (Hagan J, Shaw JS, Duncan PM eds.)
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Periodicity Schedule
Available at: www.aap.org/en-us/professionalresources/practice-support/Pages/PeriodicitySchedule.aspx
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A Brighter
Future for All
Children and
Their Families
Bright Futures: Goals
Bright Futures has four goals that will allow it to carry out its
mission of improving the health of our nation’s children,
families, and communities. These goals are to:
 Work with states to make the Bright Futures approach the
standard of care for infants, children, and adolescents;
 Help health care providers shift their thinking to a
prevention-based, family-focused, and developmentallyoriented direction;
 Foster partnerships between families, providers, and
communities; and
 Empower families with the skills and knowledge to be
active participants in their children’s healthy development.
Bright Futures Guidelines, 3rd Edition
How does the 3rd Edition differ from previous editions?
Part I: Themes
 10 chapters highlighting key health promotion themes
 Emphasizes “significant challenges” - mental health and healthy
weight
Part II: Visits
 Rationale and evidence for screening recommendations
 31 age-specific visits
 5 health supervision priorities for each visit
• Designed to focus visit on most important issues for child that age
• Includes: health risks, developmental issues, positive reinforcement
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Bright Futures Guidelines: 10 Themes
 Promoting Family Support
 Promoting Child Development
 Promoting Mental Health
 Promoting Healthy Weight
 Promoting Healthy Nutrition
 Promoting Physical Activity
 Promoting Oral Health
 Promoting Healthy Sexual Development & Sexuality
 Promoting Safety and Injury Prevention
 Promoting Community Relationships and Resources
Bright Futures Guidelines: History
Supported and funded by federal government’s Maternal
and Child Health Bureau (MCHB) in the Health
Resources and Services Administration, Department of
Health and Human Services
• 1st edition was published in 1994
• Updated in 2000 (2nd edition)
• In 2002, AAP was selected by MCHB to implement the next
phase of the initiative
• 3rd edition was released in October 2007
• In 2007, AAP was awarded a second cooperative
agreement to address implementation
• In Spring 2015, 4th Edition will undergo Public Review
• In 2016, the 4th Edition will be released
Bright Futures Guidelines: Update
Bright Futures Guidelines, 4th Edition: Revision
Considerations
Focus Areas
• Areas that change Universal
or Selective Screening
• Medical Screening,
Psychosocial, Anticipatory
Guidance
• Implementation Projects
Lessons Learned
• Review current recommendations
by Expert Panels
• Identify existing related guidelines
(eg, USPSTF) and systematic
reviews (eg, Cochrane)
• Evidence collection
– Including nomination by expert
panels and Bright Futures Partners
• Integration of new evidence
• Transparency around Evidence
Synthesis
– Recommendations & Rationale
• Internal AAP/External Review
Process
Bright Futures:
Implementation
for Adolescents
Bright Futures Priorities
Visit Priorities
Bright Futures Tools
• Patient concerns and
• Previsit Questionnaires
questions
• Physical Growth and
• Documentation Forms
Development
• Social/academic competence
• Patient/Parent Handouts
• Emotional wellbeing
• Risk reduction
• Violence and injury
prevention
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Quality Measures for
Adolescent Preventive Services
• Yearly Visit (Use Recall and Reminder systems)
• Parental/Youth questions and concerns
• Screening and Follow-Up
–
–
–
–
–
–
–
Risk Assessment
Developmental Tasks of Adolescents
BMI Percentile
Dyslipidemia
Depression
Chlamydia
HIV
• Anticipatory Guidance
– Including counseling on nutrition and physical activity
• Immunizations (TdaP, HPV, Meningococcal, Hep A, Flu)
• Physical Exam
• Strength-based Approaches
Screen for Dyslipidemia
The National Heart, Lung and Blood Institute (NHLBI) and endorsed by the
American Academy of Pediatrics (AAP) recommend that all children be
screened for high cholesterol at least once between the ages of 9 and 11
years, and again between ages 17 and 21 years.
Age:
2-8 years
9-11 years
12-16 years
17-21 years
Recommendation:
Obtain fasting lipid profile only if family history is positive (+), parent with
dyslipidemia, any other RFs (+), or high-risk condition
Obtain universal lipid screen with nonfasting non-HDL = TC – HDL, or
fasting lipid profile → manage per lipid algorithms as needed.
Obtain fasting lipid profile if family history newly (+), parent with
dyslipidemia, any other RFs (+), or high-risk condition; manage per lipid
algorithms as needed.
Obtain universal lipid screen once in this time period with nonfasting nonHDL-C or fasting lipid profile → Review with patient; manage with lipid
algorithms as needed.
Table adapted from NHLBI: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children
and adolescents: full report. 2012. Available at: http://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf 17
Screen for Depression
AAP recommends that patients are screened for
depression at every health supervision visit,
yearly, starting at age 11.
•
•
•
•
•
•
Annual well child exams
Mental health related visits
Sports physicals
Chronic illness visits/management
Other routine office visits
Sick visits
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Screen for Chlamydia
• All sexually experienced adolescent females should be
tested at least annually for Chlamydia infection, even if
no symptoms are present or barrier contraception is
reported.
• Sexually experienced adolescent males should be annually
screened if high risk (MSM).
• Annual screening for sexually active males who have sex
with females may be considered in settings with high
prevalence rates (jails, juvenile correction facilities, National
job training programs, STI clinics, high school clinics, and
adolescent clinics for patients who have a history of
multiple partners).
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Screen for HIV
• AAP recommends that routine screening be offered to ALL
adolescents at least once by 16 through 18 years of age.
• Adolescents with behaviors that increase risk of HIV
acquisition (eg, multiple sex partners, illicit drug use) should
be screened annually.
• HIV antibody tests can be performed on samples of blood
or oral fluid.
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What Makes a
Bright Futures Visit?
Bright Futures Tool and Resource Kit
•
It helps you provide standardized care
– All the forms are closely linked to Bright
Futures visit components and priorities,
making clinical activities and messages
consistent throughout
– Completed Documentation forms help
you track care over time, ensuring that
all patients receive recommended
exams, screenings, and immunizations
• AND it helps you provide individualized
care
– Forms allow parent/patient priorities and
concerns to surface, giving you
opportunities to tailor care and
anticipatory guidance, using a strengthbased approach
Core Tools: Integrated Format
 Previsit Questionnaires
–
Allows healthcare provider to
gather pertinent information without
using valuable time asking
questions
 Documentation Forms
–
Enables Provider to document all
pertinent information and fulfill
quality measures
 Parent/Patient
Handouts
–
Provides Parental Education all
the Bright Future Priorities for the
visit
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Core Tool: Previsit Questionnaire
• Parent/adolescent patient fills
out before seeing practitioner
• The questionnaires:
– ask risk-assessment
questions, thereby triggering
recommended medical
screening
– ask about Bright Futures 5
priority topics for that agebased visit
– allow parent/patient to note
any special concerns
– gather developmental
surveillance information
The Previsit Questionnaire will be updated to match the Bright Futures Guidelines, 4th Edition currently being revised
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Questionnaires
Paper
Electronic
 At the visit in the waiting
or exam room
 At home (via email)
Make appointment time
15 minutes earlier
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Setting the agenda
Medical Screening
PRIORITIES
Setting the agenda
Physical growth and development
Social and academic competence
Emotional well-being
Risk reduction
Violence and injury prevention
Developmental Tasks
of Adolescence
Core Tool: Documentation Form
• Practitioner uses during visit to
document activities
• Forms guide practitioner on
what questions to ask/issues to
address based on child’s age
and visit priorities
• Forms include sections for
each component of visit:
– History
– Surveillance
– Physical exam
– Screening
– Immunizations
– Anticipatory guidance
The Documentation Form will be updated to match the Bright Futures Guidelines, 4th Edition currently being revised
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Pre-visit
Questionnaire
Reviewed
Documenting
Parental Concern
Bright Futures
Priorities
Psychosocial Risk
Assessment
Screening
Screening
Core Tool: Educational Handouts
These handouts will be updated to match the Bright Futures Guidelines, 4th Edition currently being revised
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Bright Futures and the
Electronic Health Record (EHR)
• The templates, questionnaires, handouts, and
forms from the Bright Futures Resource and Tool
Kit form a structured knowledge base that can be
used in EHRs.
• Depending on your specific EHR system, import the
documents or use them as a guide in setting up
customized health supervision visit templates and
previsit questionnaires
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Case Study: Tiffany
Meet Tiffany!
• Tiffany is 17
• Living in 5th Foster
Home
• 12th Grade, failing math
• Past H/O tobacco, etoh,
marijuana use
• Currently sexually
active w/o protection
with one male partner
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Using the Questionnaire
• Tiffany was in a juvenile detention facility for a couple
of weeks three months ago.
• She is sexually active.
• Her diet was almost exclusively vegetarian and
sometimes she didn’t really have enough to eat when
she was “couch surfing”. She took no vitamins or iron
• Her PHQ-9 score = 3
• She has a history of alcohol and drug use.
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CRAFFT Questions
Vermont Department of Health
Health Screening Recommendations for Children & Adolescents
Adolescent Substance Use: Screening and Counseling Guidelines
Ask the patient: “Have you ever tried alcohol? Marijuana? Any other drug?”
Yes
No
Congratulate and encourage to continue
choosing healthy behaviors.
The CRAFFT Questions:
A Brief Screening Test for Adolescent Substance Abuse
Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?
Do you ever use alcohol/drugs while you are by yourself, ALONE?
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Do you ever FORGET things you did while using alcohol or drugs?
Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CRAFFT Q uestions c ourtesy of J. Knight, MD, Center for Adolescent Substance Abus e Research, Children’s Hospital Boston.
Source:
CRAFFT Questions courtesy of J. Knight, MD, Center for Adolescent Substance Abuse Research, Children’s Hospital, Boston.
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Developmental Surveillance
37
Search Institute
Search Institute
The Banks Building
615 First Avenue NE, Ste 125
Minneapolis, MN 55413
800/888-7828
www.search-institute.org/
Circle of Courage, by Lakota Artist George D Bluebird, Sr.
Brendtro LK, Brokenleg M, Van Bockern S. (1990, republished in 2004). Reclaiming youth at risk: Our hope for the future. Bloomington, IN: National Education Service.
Circle of Courage & Adolescent Development
Generosity
– Demonstrating honesty &
caring; contribute to family,
community; empathy
Independence
– Establish an identity and sense
of self-efficacy; practice
independent decision making
Belonging
– Develop healthy interactions
and relationships within and
beyond the family
Mastery
– Find something meaningful
to do in life
– Learn and maintain good
health habits
Brendtro LK, Brokenleg M, Van Bockern S. (1990, republished in 2004). Reclaiming youth at risk: Our hope for the future.
Bloomington, IN: National Education Service.
40
HEADDSSS
Home
Belonging (Connection)
Education
Mastery (Competence)
Activities
Generosity (Contribution)
Diet
Drugs
Independent decision making
Safety
Sexual Activity
Suicide
Coping, Resilience, Self-confidence
Reif, CJ, Elster, AB, Adolescent Preventive Services. Primary Care: Clinics in Office Practice, Vol 25, No 1, March 1998, WB Saunders,
Philadelphia. Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5(7):75-90.
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Search for Strengths
• Risks need to be identified.
• BUT don’t forget that STRENGTHS are an
essential part of health.
• Look for Resiliency and Strengths: ask about
strengths at every encounter!
• Promoting strengths will enhance interactions
with adolescents and parents.
Strength-based Approaches
• Support mastery.
• Identify strengths.
• Start with what is right.
• If a behavior change is needed, use shared
decision making or motivational interviewing.
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Case Study (cont.): Strengths
• Cares about friends &
boyfriend, helps them out
• Knows how to take care of
herself, get to appointments, at
grade level
• Makes many healthy decisions
on her own
• Sense of belonging with foster
family, case worker, friends
• No tobacco, etoh, drugs
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Use Strengths and Shared Decision
Making to Encourage Change!
You’re worried about her risky
sexual behaviors.....
• SHARE STRENGTHS
• Ask permission. . . .
• Do you really want to have a baby?
• What choices can you make?
Consequences?
• Make a plan
• Follow up
Case Study: Rochelle
Meet Rochelle!
•
•
•
•
Rochelle is 14 years old
9th Grader, gets all A’s
BMI increasing since 5th grade
Diet “OK”, some fruits & veggies,
2% milk, loves cheese, drinks
soda at school
• No basketball this year –
babysits younger brother after
school, helps him with homework
• More than 3 hours screen time
Case Study (cont.)
Rochelle
• Denies the use of tobacco, alcohol, marijuana,
other drugs.
• Not interested in romantic relationships at this
time. Sort of had a boyfriend in 8th grade,
never sexually active.
• Always wears seatbelt.
• Gets sad sometimes
– Score on PHQ 9 = 8, but has never considered
hurting herself.
– Conflict with her mother about weight
• Wants to be a nurse practitioner.
Use Strengths and Shared Decision
Making to Encourage Change!
•
•
•
•
•
•
Share Strengths
Identify problem
Options
Consequences
Choose a Plan
Follow-up
Case Study: Warren
What about Warren?
• 17-year-old Junior
• Had been good student,
but now “tardy” a lot, Cs &
Ds
• One joint was found in
his locker
• Scheduled for an
“evaluation” at the SBHC
• “I don’t want my little
brothers to find out”
Case Study (cont.)
Warren
• H – Lives at home with Mom and 3 younger
siblings; dad left last year.
• E – School is important, but watches siblings
while mom works nursing evening shift. He
want to be an EMT
• A – Not much time, doesn’t want friends to
know he “babysits.”
• D – Occasionally smokes weed to relax & fit in
with friends in his neighborhood.
• S – Sexually active, uses condom
• PHQ 9 score = 14, but not suicidal
Case Study (cont.): Strengths
What are Warren’s Strengths?
•
•
•
•
Belonging/Relationships
Mastery/Competence
Independent Decision Making
Generosity/Caring
What would you do next?
Strength-based Approaches
• What do youth need to say “yes” to?
• “What’s right with you is more powerful than
anything wrong with you.” (Henderson)
• “Someone pointed out my strengths to me,
when I really didn’t think I had any.” (Youth in
foster care)
• “I’ve moved from the ‘sage on the stage’ to the
‘guide on the side.’ It has increased my job
satisfaction!” (Primary care provider)
Additional Helpful Resources
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References
•
•
•
•
•
•
•
Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for
Health Supervision of Infants, Children and Adolescents, Third Edition. Elk
Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. Bright Futures Tool and Resource Kit [CDROM]. Duncan PM, Shaw JS, Gottesman MM, Swanson J, Hagan JF, Pirretti
AE, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
Duncan P and Pirretti A. Using Bright Futures with Adolescents Adolescent
Updates AAP News American Academy of Pediatrics November 2009.
Duncan PM, Garcia AC, Frankowski BL et al. Inspiring healthy adolescent
choices: A rationale for and guide to strength promotion in primary care. J Adol
Health. 41(2007);525-535.
Ginsburg KR. Engaging Adolescents and Building on their Strengths. Adol
Health Update. 2007;19(2).
Frankowski B, Leader I, Duncan P. Adolescent Strength Based Interviewing
Adolescent Medicine State of the Art Reviews. April 2009, p352.
Brendtro LK, Brokenleg M, Van Bockern S. (1990, republished in 2004).
Reclaiming youth at risk: Our hope for the future. Bloomington, IN: National
Education Service.
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Contact Information
American Academy of Pediatrics
Bright Future National Center
Jane Bassewitz, MA
Manager, Bright Futures National Center
Phone
847-432-4326
E-mail
brightfutures@aap.org
Web site
brightfutures.aap.org