ADOLESCENT MEDICINE
WHY ADOLESCENT MEDICINE?
Alain Joffe MD, MPH
Department of Pediatrics,
Johns Hopkins Medical Institutions, Baltimore, Maryland
Address
reprint requests to
Alain Joffe, MD, MPH
Park 307
Johns Hopkins Hospital
600 North Wolfe Street
Baltimore, MD 21287-2530
BACKGROUND
Adolescents aged 11 to 21 years old
made approximately 61.8 million office visits to physicians in 1994. Few of these
visits were to internists. According to data from the 1994 National Ambulatory
Medical Care Survey, only 5.3% of visits by 12- to 17-year-olds and 7.4% of
visits by 18- to 21-year-olds were to internists. [36]
Despite the fact that adolescents comprise 15.4% of the U.S. population, they
accounted for only 9.1% of office visits in 1994. The opportunity for internists
and all other physicians to increase the numbers of adolescents in their
practices exists. This situation may be especially true if the 14.1% of
adolescents who were uninsured in 1995 receive coverage through federally
funded state health insurance programs. Compared with adolescents with
insurance, uninsured adolescents are five times as likely to lack a usual
source of health care and twice as likely not to have had a physician contact
in the prior year. [23]
The opportunity to incorporate more
adolescents into practice, if realized, could prove challenging for internists.
Current Residency Review Commitee (RRC) guidelines for internal medicine state
only that “residents should be instructed in adolescent
medicine, which may include the following
topics: health promotion, family planning and human sexuality, sexually
transmitted diseases (STDs), chemical dependency, sports medicine, and school
health issues.” Although structured patient care experiences directed by
faculty experienced in the care of adolescents are desirable, they are
not required. Only 5% of the articles published in the Annals of Internal
Medicine in 1998 indicated adolescence as a key word for the
article.
RATIONALE FOR ADOLESCENT MEDICINE
Except for the newborn and early
infant years, no period of the human life span encompasses more dramatic
changes than does adolescence. Regardless of how one designates the age limits
for this period (e.g., ages 10 to 19, 12 to 21, 15 to 24 years), providing
optimal health care to individuals in this age group requires an in-depth
understanding of the biologic, cognitive, and sociocultural changes that occur,
their interrelatedness, and their potential impact on an adolescent’s health.
Applying this understanding to clinical practice defines the discipline of adolescent medicine.
A schematic representation of these changes is shown in Figure 1 (Figure Not
Available) . Throughout this article, the term puberty is used to refer
to the biologic changes that teenagers undergo, primarily during the second
decade of life. In contrast, the term adolescence refers more broadly to
the phase of human development encompassing the transition from childhood to
adulthood; this includes but is not limited to pubertal development.
Figure 1.
(Figure Not Available) The temporal relation between the biologic, psychologic,
and psychosocial events of adolescence. Age limits for the events and stages
are approximations and may differ from those used by other authors. The mean
age of onset of pubic hair development for boys (13.4 years) is likely too high
because of bias in the data collection method. These limits and the points indicating
the attainment of individual stages of puberty were chosen for consistency and
to reflect the earlier maturation of American versus British adolescents. B2,
B3, B4, B5, breast stage 2, 3, and so forth; G2, G3, G4, G5 genital stage 2, 3,
and so forth; PH2, PH3, PH4, PH5, pubic hair stage 2, 3, and so forth; PHV,
peak height velocity. ( From Joffe
A: Introduction to adolescentmedicine. In McMillan JA, DeAngelis CD, Feigen
RD, Warshaw J (eds): Oski’s Pediatrics. Principles and Practice, ed 2.
Philadelphia, Lippincott Williams and Wilkins, 1999, p 528; with permission.)
PUBERTY
Puberty starts well before any
physical changes are apparent to the adolescent or his or her parents. Approximately
2 years before the appearance of secondary sexual characteristics, there is
increased production of adrenal sex steroids. Higher levels of these hormones
are not, however, necessary for puberty to occur. In the earliest stages of
puberty, there is a sleep-associated increase in the pulsatile secretion (in
frequency and in amplitude) of gonadotropin-releasing hormone (GnRH),
follicle-stimulating hormone (FSH), and luteinizing hormone (LH). As puberty
progresses, these increases are detectable throughout the day. Consequently, if
measurement of GnRH, FSH, or LH were necessary as part of the evaluation of an
adolescent with delayed onset of puberty, it would be important to obtain
specimens during this early morning period.
Paralleling increases in GnRH, FSH,
and LH, serum levels of testosterone and estrogen rise in boys and girls. The
rise in estrogens gradually reaches the level to induce menarche in girls, but
it is not for at least several years after menarche that the regular midcycle
surge of estrogen leading to an LH surge and ovulation is established (positive
feedback system). Accordingly, most young women ovulate infrequently for
several years after menarche and do not have significant dysmenorrhea.
The control of the onset of puberty
is not well understood. Most experts agree that GnRH secretion increases as the
hypothalamus becomes less sensitive to circulating levels of testosterone and
estrogen, but the mechanism by which this occurs has yet to be elucidated.
Because infants, even those born without functioning gonads, have relatively
elevated levels of gonadotropins that fall during early childhood, it is
hypothesized that puberty must also involve modulation of a direct inhibitory
process operating at the level of the central nervous system.
The orderly appearance of secondary
sexual characteristics, changes in body composition, and increase in stature
all mirror the hormonal changes that are occurring. Documenting that these
changes are occurring is as sensitive a measure of normal pubertal development
as would be repeated measures of testosterone or estrogen levels. The careful
records of Marshall and Tanner [20]
[21]
laid the groundwork for describing the appearance of secondary sexual
characteristics and the assigning of sexual maturity ratings or Tanner stages.
The various stages are assigned numbers from 1 to 5, with 1 representing no
pubertal development and 5 signifying full adult development. Boys and girls
are assigned a rating based on the degree of pubic hair development (PH1 to
PH5). Girls receive a separate rating for their stage of breast development (B1
to B5), whereas boys are assessed based on the volume of their testicles (G1 to
G5). Because these ratings represent separate physical characteristics, it is
inappropriate to assign a mean Tanner stage based on averaging the two
(e.g., a girl who has Tanner 2 breast development and Tanner 3 pubic hair does
not have an overall Tanner stage of 2.5).
Most events that occur during
puberty correlate better with Tanner stage than with chronologic age. In fact,
knowledge of Tanner stage is essential to avoiding errors in diagnosis. For
example, although gynecomastia is often associated with various diseases among
men, it is normal (and usually self-limited) during puberty, especially at
Tanner stage 2 or 3. Similarly, blood pressure levels correlate more closely
with height age and Tanner stage than with chronologic age: A 13-year-old with
a height age of 16 should be assessed according to normal blood pressure values
for a 16-year-old. Finally, in that hemoglobin levels in boys rise
progressively during puberty as testosterone levels increase, determination of
anemia should be based on sexual maturity rating, not age.
Marshall and Tanner’s studies
documented the orderly appearance of secondary sexual characteristics among
pubertal adolescents. [20]
[21]
Typically, girls develop breast buds as the first sign of puberty (although
about 15% develop pubic hair first). Approximately 1 year after breast budding,
girls reach their peak height velocity, and 1 year later menarche ensues. After
menarche, a girl usually grows only an additional 4 to 5 cm. Onset of puberty
in boys is heralded by an increase in testicular volume, followed by pubic hair
growth, then enlargement (length and circumference) of the penis. Peak height
velocity occurs 2 years after the onset of testicular enlargement. Adolescents
gain about 15% to 25% of their final adult height during the pubertal growth
spurt. Genetic factors aside, boys generally wind up taller than girls because
their peak growth velocity occurs after a longer basal period of growth and
because their peak height velocity is greater than that of girls.
This information can be used to
counsel and reassure adolescents about what to expect during the pubertal years
as well as guide follow-up. For example, because peak height velocity occurs
early in puberty and precedes menarche in girls, follow-up of a patient with
10° of scoliosis (which worsens during the growth spurt) would be more frequent
before menarche than after. Similarly a young woman with Tanner stage 2 breast
development can be counseled that menarche is likely to occur in about 2 years.
Girls experience a drop in body
self-image as they progress through adolescence. This decreased self-image may,
in part, be due to the natural increase in percent body fat and widening of the
hips that occur during puberty. Against a backdrop of media images that
emphasize slimness as the sole standard for female beauty, girls may interpret
these normal changes as evidence of their becoming fat. Discussions about these
normal changes early in puberty may afford the physician an opportunity to
discuss body image concerns with the adolescent, to reassure her about her
development, and to help her achieve a realistic set of expectations and goals
regarding her physical development.
Although the sequence of pubertal
events is generally invariable among boys and girls, the timing of onset and
progression is not. This observation gives rise to the concept of early,
average (or on-time), and late maturing adolescents. Typically, girls enter
puberty at approximately 11 years of age, but some, who are otherwise completely
normal, may not do so until age 13. Boys usually begin puberty about 6 months
later than girls, with the upper age limit of normal being 14. Recognizing this
broad range of normal guides the clinician in determining at which point an
evaluation for delayed onset of puberty is indicated.
Completion of breast development
averages 4 years, whereas pubic hair growth is completed in 2.5 years.
Comparable figures for boys are 3 years for testicular growth and 1.5 years for
pubic hair development. On average, puberty lasts 3 to 4 years; adolescents who
fail to progress through puberty should be thoroughly evaluated for the
presence of chronic illness, malnutrition, or other conditions that may affect
physical development.
Changes in body composition that occur
during puberty can have profound implications for adult health status.
Adolescents accrue 40% of their adult bone mass during puberty. Girls who
complete puberty having failed to develop adequate bone density, as can be seen
secondary to anorexia nervosa or because of exercise-induced amenorrhea, may
not subsequently be able to catch up. [34]
If so, these young women complete puberty being relatively osteopenic and may
be at significant future risk for osteoporosis and hip fractures. Ensuring that
adolescents maintain regular menses and ingest at least 1300 mg of calcium per
day is essential for optimal bone development during adolescence and for
prevention of a common adult morbidity.
Adolescence is one of two critical
periods for the development of obesity. During puberty, body fat increases in
girls (from a baseline of about 16% to a peak of 26%), whereas it decreases in
boys. Because of differences in how adipose tissue is deposited, obese boys are
at greater risk for adult mortality, but obese girls are more likely to remain
obese as adults. The risk for being obese as an adult, with its known
complications, is increased for adolescents who remain obese at the completion
of puberty. [30]
These facts highlight the role of nutritional counseling during this period of
growth.
COGNITIVE AND DEVELOPMENTAL CHANGES
Adolescence is characterized by an
emerging capacity to reason in an increasingly more sophisticated manner. [24]
Younger teens are relatively concrete in their thinking and have difficulty
with abstract concepts. They also tend to have little in the way of a future
time orientation. During middle and late adolescence, the ability to reason
abstractly, to handle multiple concepts simultaneously, and to use a what if
approach emerges. These older teens are capable of taking another person’s
perspective and are better able to project themselves into the future and
reflect about events that may be remote in time. This capacity to reason more
abstractly does not occur as an all-or-none process. Under periods of stress,
adolescents may revert to more concrete levels of thinking.
These differences have significant
implications for health care encounters. For example, counseling younger teens
about smoking is more likely to have an impact if the focus is on the immediate
consequences of smoking (bad breath, yellow teeth, and decreased exercise
performance) rather than on long-term (and fairly abstract) conditions (lung
cancer or emphysema). Terms such as cancer or emphysema may be too abstract to
have an impact on their decision regarding smoking.
Early adolescents tend to be
self-centered in their thinking and preoccupied with their own needs. During
the initial stages of puberty, this focus is on body changes (“am I
normal?”) and may prompt physician visits largely for reassurance about
their development. A classic example is the adolescent boy with gynecomastia
who presents to a physician for evaluation of chest pain. Adolescents do not
always express concerns about their physical development. A teenager may be too
embarrassed to ask for acne therapy or to inquire whether her breast asymmetry
(a common finding in early puberty) is permanent.
Because of their developmental
level, adolescents have a sense of uniqueness and personal invulnerability.
Negative health outcomes, such as unintended pregnancy, a serious injury, or a
sexually transmitted disease, happen to other teenagers but not to them. This
sense of personal invulnerability, coupled with a desire to test and master
their newly emerging physical and mental capabilities, may provide one
explanation for the risk-taking behaviors observed during this age period.
Viewed within this context, behaviors that are perceived as risky by adults can
be seen as meeting important developmental needs for adolescents.
Adolescence is customarily divided
into three stages: early (age 11 to 14 years), middle (age 14 to 17 years) and
late (age 17 to 21 years). Early adolescence is characterized by a focus on the
physical changes that accompany puberty and by concrete thinking. Separation
from parents and the rise in peer group influence begins during this stage but
is not prominent. During middle adolescence, peer group influence and conflicts
with parents peak. Risk-taking behaviors, such as cigarette smoking, drinking,
and sexual intercourse become more common. Concerns about one’s developing sense
of self and autonomy become increasingly important. By late adolescence, the
focus shifts to developing the capacity for intimacy in relationships and
defining one’s career goals and place in society. Generally, peer group
influence lessens, and a rapprochement with parents occurs. Older
adolescents are often idealistic and may be highly critical of traditional
institutions.
SOCIOCULTURAL CHANGES
The development of adolescents
cannot be viewed in isolation from the world around them. Although adolescent medicine
rightly emphasizes the primacy of the adolescent, peers, parents (family),
community, and culture all have a powerful impact on the adolescent’s behavior
and health status. For example, current societal expectations are that young
people postpone marriage and the age of childbearing to complete the added
years of schooling necessary to achieve economic self-sufficiency in today’s
marketplace. Yet over the last 150 years, the age at which adolescents begin
puberty and are able to bear children has dropped substantially. Menarche
currently occurs at approximately 12.5 years, in contrast to 16 or 17 years in
the 1860s. [22]
Teenage pregnancy is of much greater concern now than it was in the 1800s.
Evidence continues to accumulate
concerning the role of parents in promoting the health of adolescents. Results
from the National Longitudinal Study of Adolescent Health show that adolescents
who feel connected to their families are at reduced risk for engaging in a wide
variety of health-risking behaviors. [27]
Adolescents who report satisfaction with their relationship with their mothers
and who perceive their mothers as having made clear statements against sexual activity
during adolescence are more likely to be abstinent or to have sex less often
than their peers; they are also more likely to use contraception if they choose
to have intercourse. [16]
Parental monitoring of adolescents (e.g., after school or at night) has been
associated with a decreased risk for behaviors such as drug use and violence. [28]
[30]
Although parents are important in the lives of adolescents, fewer and fewer
parents, particularly single parents, are able to spend the necessary amount of
time with their children. This situation may be one explanation for why parents
tend to underestimate the prevalence of risk behaviors among their adolescents.
[35]
Results from the National Health
and Nutrition Examination Survey (NHANES III) indicate that more than one fifth
of children and adolescents in the United States are obese; this represents an
increase of more than 30% since 1980. Although the cause of this increase is
uncertain, it does not appear that changes in caloric intake alone can account
for all the observed increase. The proportion of calories derived from fat
among adolescents in the United States has decreased over the last few decades.
In contrast, a decrease in exercise, especially among girls, has been noted.
Throughout high school, approximately 50% of boys participate in vigorous
physical activity. For girls, there is a 50% reduction in the proportion that
exercise, from 30% at entry to high school to 15% in twelfth grade. Other
studies document the association between the number of hours of television
watched per day and increased risk for obesity. [13]
The choices in electronic entertainment now available to adolescents (each of
which promotes a sedentary lifestyle) continue to expand. Television watching
may contribute to adolescent obesity in other ways. Advertisements for food are
the most common commercials on television, and the food promoted is often high
in calories, fat, or both; these foods are often consumed by adolescents while
watching television.
Television and other forms of media
may promote unhealthy lifestyles in a number of other ways. When adolescents
view images in which adolescents or adults smoke cigarettes, drink, engage in
sexual intercourse (usually without mention of contraception), and commit acts
of violence, they come to perceive these activities as being socially
acceptable or normative behaviors. These perceptions may, in turn, influence
their behavior. [3]
[32]
Research studies have shown that to the extent teenagers perceive various
behaviors as normative among their peers, the more likely they are to engage in
similar behaviors. [17]
Advances in health care have
enabled many children with once fatal childhood diseases to survive into
adolescence and young adulthood. Other adolescents develop chronic illnesses,
such as inflammatory bowel disease, during the second decade of life. In both
cases, internists are likely to encounter a growing number of adolescents in
their practices with chronic illness. Some diseases, such as cystic fibrosis or
certain forms of congenital heart disease, may be ones that internists have
previously only rarely encountered.
The impact of chronic disease on
adolescent development may be significant. Illnesses that result in visible
deformity or limitations in activity are likely to be problematic for teens,
who desire to fit in with peers. Compliance with drug regimens may also be
difficult if side effects of medications result in physical changes, as is the
case with prednisone therapy. Chronic illness may also interfere with the
normal separation from parents that occurs during adolescence. Parents may be
reluctant to grant autonomy to their child for fear that he or she will not
adequately manage the illness.
Although fewer adolescents with
chronic illnesses or disabling conditions may engage in risky behaviors than
their peers, a substantial number still do so. [2]
Because many of these adolescents suffer from social isolation and may lack
credible sources of information about risky behaviors, it is essential that physicians
screen all adolescents for these behaviors.
HEALTH STATISTICS OF ADOLESCENCE
In the aggregate, health statistics
for adolescents have improved in the 1990s. Nonetheless, significant numbers of
adolescents continue to engage in health-risking behaviors that result in
appreciable morbidity and mortality. Although each risk behavior is discussed
separately, current research indicates that many adolescents who engage in one
such behavior often engage in others (co-vary).
In contrast to adult mortality
figures, the leading causes of death among adolescents are behavioral in
origin. In 1997, among 15- to 24-year-old males of all races, motor vehicle
accidents were the most common cause of death (38.1 per 100 000), followed by
homicide (28.2) and suicide (18.9). For similarly aged females of all races,
leading causes of death were motor vehicle accidents (17.1), homicide (4.7),
and malignant neoplasms (3.7). Suicide is the second leading cause of death for
15- to 24-year-old white males (19.5), whereas homicide is the leading cause of
death for African-American males (113.3) and females (13.3) as well as for
Hispanic males (42.7).
Drug use by adolescents has
declined in the last few years, after peaking in the mid-1990s. According to
the 1998 Monitoring the Future Survey of more than 50,000 students across the
United States, use of any illicit drug in the 12 months before the survey
declined for the second year in a row among eighth graders and for the first
time in the 1990s for tenth and twelfth graders (http://www.isr.umich.edu/src/mtf/index.html).
Declines in marijuana use accounted for much of the decrease, although 22% of
eighth graders and 49% of twelfth graders reported having tried marijuana.
Alcohol use decreased for eighth graders for the second year in a row and
declined for the first time among tenth and twelfth graders. Nonetheless, 8.4%
of eighth graders, 21% of tenth graders, and 33% of twelfth graders reported
being drunk at least once in the 30 days preceding completion of the survey.
Rates of cigarette smoking, which
had shown a steady rise until 1996, began to decline in 1997; 19% of eighth
graders, 27.6% of tenth graders, and 35% of twelfth graders reported smoking in
the 30 days before the survey. Prevention of smoking during the adolescent
years is essential and has both short-term and long-term payoffs. Among adults
who smoke daily, 89% began any use of cigarettes and 71% began smoking
regularly by the age of 18. [19]
Preventing adolescent smoking would reduce greatly the tobacco-related
morbidity and mortality (emphysema, lung cancer, coronary artery disease) so
prevalent among adults.
In the 1990s, rates of sexual
activity among adolescents have stabilized and perhaps even begun to decrease,
whereas use of condoms has increased. [31]
In combination, these two observations provide some explanation for the
sustained drop in adolescent pregnancy rates that has occurred since the
mid-1990s. Although these trends are encouraging, adolescents aged 15 to 19
years have the highest rates of Neisseria gonorrhoeae and Chlamydia
trachomatis infection of any other age group in the United States. [8]
It is estimated that one fourth of the 12 million cases of sexually transmitted
diseases diagnosed annually in the United States occur among adolescents.
Approximately 5% of adolescents
have a major depressive disorder, and nearly one fourth of students in a
national survey reported having seriously considered killing themselves in the
last year. In the same survey, 17.7% of students had made a plan, 8.7% had
attempted to do so, and almost 3% reported needing treatment from a physician
or nurse for the injury. Approximately 1% of white girls of middle to upper
socioeconomic status have anorexia nervosa, and it is estimated that two to
five times that many meet diagnostic criteria for bulimia nervosa.
HEALTH VISITS FOR ADOLESCENTS
Given all the changes that occur
during adolescence, the prevalence of risky behaviors among this population,
and the possibility for the internist to promote healthy lifestyles that can
provide short-term and long-term benefits, health visits occurring during this
age period assume critical importance. The goals of the health visit are
threefold: (1) to reassure the adolescent that his or her development is normal
or identify any problems that may require further evaluation or treatment; (2)
to assess the adolescent and his or her family for factors that may predispose
to or protect against the adolescent’s pursuit of health-risking behavior, and
(3) to promote a healthy lifestyle that will continue throughout adulthood.
In a time of rapid and sweeping
change in the health care industry, there is much discussion about how best to
achieve these goals in an efficient and cost-effective manner. In the 1990s, a
consensus as to the scope and content of preventive services for adolescents
has emerged. Five sets of comprehensive recommendations are now available,
promulgated by public and private national organizations. [7]
All five emphasize risk assessment and anticipatory health guidance as being as
important as physical examination and laboratory testing. Several sets
recommend that although assessment and counseling occur annually, physical
examinations need occur only every other year or less often. A health visit at
11 to 12 years of age, at which time immunizations can be updated, can serve as
the inaugural adolescent visit. At this time, the physician can set the ground
rules for future visits so that the adolescent and parents know what to expect.
These rules center around the physician’s spending most of the visit with the
adolescent alone and issues of confidentiality.
There is much confusion concerning
the principles of consent and confidentiality as they pertain to adolescent
health care. Consent is a function of the adolescent’s capacity to
understand treatment choices presented to him or her, including the risks and
benefits, and to choose among them. Confidentiality refers to the
control and protection of health information shared between the adolescent and
the physician. Beginning in the 1970s, states have generally granted
adolescents younger than 18 years of age the right to seek confidential health
care services and to consent to treatment on their own in a number of
health-related areas. These are reproductive health care (including pregnancy
testing and contraceptive services), diagnosis and treatment of sexually
transmitted diseases, and assessment and treatment for drug and alcohol
problems. Many states permit older adolescents to seek care for mental health
problems on their own. Because the exact nature and wording of these statutes
vary from state to state, internists should become familiar with the statutes
governing care in their own state.
An emerging body of research
underscores the need for the clinician to discuss confidentiality with the
adolescent at the start of the visit. Many adolescents would forgo health care
if parents might find out; the proportion is highest among adolescents with
health concerns they wished to keep private. [4]
In a randomized trial, assurances of confidentiality increased the number of
adolescents who were willing to disclose sensitive personal information and
increased their willingness to seek health care in the future. [10]
Confidentiality, however, cannot be unconditional in that some information
(e.g., sexual abuse) must be disclosed by law and other information (e.g.,
suicidality) is of sufficient potential harm to the adolescent that the
principle of first do no harm supersedes the principle of
confidentiality. The nature and limits of confidentiality should be explained
at the beginning of the visit. In one study of California physicians, 16.5% of
internists did not discuss confidentiality at all with their adolescent
patients, and three fourths of the ones who did promised unconditional
confidentiality. [9]
Although confidentiality is an
essential component of adolescent health care, most adolescents are part of a
family system. Teenagers, especially younger ones, are often accompanied to a
visit by one or both parents or another adult guardian. Although it is
essential that the adolescent perceive that he or she is the central focus of
the visit and that the physician is primarily focused on the adolescent’s
concerns, some interaction with parents is desirable and necessary. Parents can
provide important details about the adolescent’s prior medical history and the
family history. Parents should also be queried about their own health
behaviors, such as seat belt use, personal use of drugs and alcohol, or mental
health problems, because these can have a significant impact on the
adolescent’s well-being. Parents can corroborate that things are going well for
the adolescent or provide important clues when the adolescent’s level of
functioning has begun to deteriorate. This parental input may be particularly
applicable regarding substance abuse because denial that a problem exists is a
prominent component of the disease process. There are numerous ways to involve
parents during the visit. The author prefers, at new patient visits, to meet
with the family together at the outset, then with the teenager alone for most
of the visit, then with the parents alone toward the end. At subsequent visits,
the nature of the visit and the preference of the adolescent dictate the
necessity for interaction with parents. At age 18, adolescents are entitled to
the full legal protections due to any competent adult.
Figure 2 (Figure Not Available)
contains recommended content for the well adolescent health maintenance visit.
The recommendations are derived and modified from a variety of sources,
including the preventive service guidelines highlighted by Elster. [7]
In an asymptomatic adolescent, the physical examination (excluding, perhaps,
the pelvic examination in sexually active young women) is unlikely to detect
any significant abnormalities. Because much of the morbidity and mortality that
occur during adolescence and young adulthood is behavioral in origin, a
thorough and wide-ranging history is most likely to reveal pertinent positives,
and most of the time allotted for the visit should be devoted to this task.
Figure 2.
(Figure Not Available) Recommended content for routine adolescent visit. (
From Joffe A: Introduction to adolescentmedicine. In McMillan JA, DeAngelis CD, Feigen
RD, Warshaw J (eds): Oski’s Pediatrics. Principles and Practice, ed 2.
Philadelphia, Lippincott Williams and Wilkins, 1999, p 535; with permission.)
Many mnemonics have been developed
as a means to remind the physician to survey all of the pertinent aspects of an
adolescent’s level of functioning. One example is the HEADSS assessment:
H–homelife; E–education; A–activities; D–drugs
(including alcohol); S–sexuality; and S–suicide (depression).
In addition to a discussion of confidentiality, many other strategies can be
used to maximize the probability of obtaining accurate information.
The interview is the essential
component of the adolescent visit. It helps to build rapport and a sense of
trust between the adolescent and the clinician and is the primary medium for
gathering information about the adolescent’s overall health. The interview must
be conducted in a manner that maximizes the likelihood that all pertinent
information will be collected. Adolescents may not understand the need for
physicians to ask questions pertaining to each of the aforementioned domains,
especially if they have been previously accustomed to more narrowly focused
medical interviews. Explaining that each domain relates to the adolescent’s
overall level of functioning and can affect the adolescent’s health helps place
the questions in the proper context. “I ask these questions of all my
patients” reassures the adolescent that he or she is not being targeted
for any particular reason of dress or hairstyle. Inquiries about personal
behaviors may require different strategies and additional reassurance and explanation.
Questions about drug abuse should first be directed toward ascertaining use of
nonprescription (but legal) and then prescription medications. These can be
followed by inquiring about friends’ use of illicit substances, then the
adolescent’s own use. Follow-up to positive responses with use of the CAGE (see
the section on drugs in Fig. 2) (Figure Not Available) or CRAFFT *
questionnaires helps keep the interview focused on the health
consequences of drug use and avoids battles about how much drinking or drug use
is too much. [18]
Questions about sexual behaviors
should not suggest that any one standard of behavior is the norm. Prefacing
inquiries about sexual intercourse with the comment, “Some young people
your age are having sex; others have chosen to be abstinent,” indicates
that the clinician is open to either a yes or no response. Asking a boy if he
has a girlfriend (or a girl about boyfriends) suggests that heterosexual
relationships are the norm. A more open-ended line of questioning (“Have
you ever had a sexual relationship with anyone?” followed by “Do you
have sex with men, women, or both?”) signals to a gay or lesbian youth
that he or she can be open about relationships.
During the interview, it is
important to elicit any negative consequences the adolescent may have
experienced as a result of health-risking behaviors. These might include
citations for driving while intoxicated, a decrease in exercise performance
after initiation of smoking, a pregnancy scare, or an act of vandalism or
physical violence that occurred while the adolescent was intoxicated. This
information can be useful in encouraging the adolescent to modify his or her
behavior.
Adolescents may often use terms
that are unfamiliar to the physician. It is better for the clinician to ask for
clarification rather than pursue a line of questioning based on an incorrect
interpretation of a response. Conversely, physicians need not use slang in an
attempt to relate to adolescent patients. Although it may occasionally be
necessary to use nonmedical terms to clarify a question, surveys of adolescents
indicate that the qualities they value most in a health care provider include
honesty, being treated with respect, and the physician’s being knowledgeable. [12]
Alternatives to personal interviews
include questionnaires or computerized health assessments. Questionnaires for
adolescent visits have been developed by the Maternal and Child Health Bureau
as part of its Bright Futures Initiative (www.brightfutures.org) and as part of
the Guidelines for Adolescent Preventive Services (GAPS) developed by the
Department of Adolescent Health at the American Medical Association. [8]
[14]
Computer-assisted visits can be cost-effective and are often preferred by
adolescents. [25]
[26]
Relatively few routine laboratory
tests are indicated for the healthy adolescent (Fig. 2) (Figure Not Available)
. With the current availability of effective antiretroviral agents, screening
for and early detection of human immunodeficiency virus (HIV) infection has
become increasingly important.
At the end of the visit, physician
counseling should focus on encouraging the adolescent to adopt health-promoting
behaviors and to reduce identified risk behaviors. The nature and extent of the
counseling is tailored to the individual adolescent, based on information
elicited during the history, physical examination, and, when indicated,
laboratory testing. Health promotion focuses on such behaviors as wearing seat
belts, using a bicycle helmet, establishing a regular exercise program, and
adopting a prudent diet that contains no more than 30% of calories from fat.
Promoting abstinence or, for sexually active adolescents, consistent use of
condoms is important for prevention of sexually transmitted diseases.
Discussions about effective means of contraception should occur with sexually
active adolescents at risk for pregnancy or fathering a baby. Now that
combination estrogen-progestin and progestin-only regimens have been approved
by the U.S. Food and Drug Administration for emergency contraception
(previously referred to as the morning-after pill), women should
routinely be counseled about and offered this additional method of pregnancy
prevention.
Reduction of risky behaviors
includes smoking cessation, avoiding drinking and driving (or driving after
smoking marijuana), limiting one’s number of sexual partners, and not swimming
while intoxicated. The ideal method for promoting a reduction in risk behaviors
has not been established. Motivational interviewing, used widely in the field
of substance abuse treatment, may be an effective means. [1]
This approach relies on direct feedback to the adolescent, based on information
gathered during the interview, regarding the negative health consequences he or
she has experienced as a result of health-risking behaviors. For example, an
adolescent smoker can be reminded that the frequent colds he or she has had
over the last year are due to the deleterious effects cigarette smoke has on
the protective mechanisms of the lungs. Reminding an adolescent that he or she
has occasionally thought about needing to cut down on drinking may be enough
motivation for the adolescent to try a period of abstinence. The motivational
interviewing approach avoids physicians and patients from being locked in
discussions about whether risky behaviors are good or bad.
Efforts to update immunizations
should occur at each visit. Adolescents 11 years old and older should receive
an adult booster dose of diphtheria and tetanus toxoids (Td), depending on the
time elapsed since their last one, and a second dose of measles-mumps-rubella
vaccine if they have not previously had one. Three doses of hepatitis B vaccine
should be administered over a 6-month period. Adolescents without a clinical
history of varicella should receive one (if younger than age 13) or two (if age
13 or older) doses of varicella vaccine. The Advisory Committee on Immunization
Practices (ACIP) and the American College Health Association recommend that
“those who provide medical care to this group [college freshmen dormitory
residents] give information to students and their parents about meningococcal
disease and the benefits of vaccination.”
Which components of preventive
services for adolescents and young adults are effective and whether physician
counseling can affect patient behavior are currently under study. [11]
Some services, such as immunizations, screening for sexually transmitted
diseases, Papanicolaou smears, smoking cessation counseling, and counseling to
wear seat belts, have been shown to be effective. Strategies such as framing
the counseling to match a patient’s perceptions, being specific in the advice
given, suggesting small rather than large changes, and getting a commitment
from the patient can help increase the internist’s effectiveness. [33]
Adolescents generally recognize physicians as reputable sources of health
information. Because the cause of health-risking behaviors is complex, no
single approach alone is likely to achieve this goal. Health promotion efforts
by physicians in conjunction with community-level interventions are most likely
to be successful. [5]
CONCLUSION
Adolescence and young adulthood
represents a period of the human life span during which enormous change takes
place. Most threats to the health of adolescents are behavioral in origin and
stem from the interaction among the biologic, psychologic, and sociocultural
changes that occur. The specialty of adolescent
medicine recognizes the significance of
these changes and uses an understanding of the factors underlying them to
promote the optimal current and future physical and mental health of
adolescents.
References
1. Bien TH,
Miller WR, Tonigan JS: Brief interventions for alcohol problems: A review.
Addiction 88:315, 1993 Abstract
2. Britto
MT, Garrett JM, Dugliss MAJ, et al: Risky behavior in teens with cystic
fibrosis or sickle cell disease: A multicenter study. Pediatrics 101:250, 1998
Abstract
3. Brown
JD, Greenberg BS, Buerkel-Rothfuss NL: Mass media, sex and sexuality. Adolesc
Med 4:511, 1993
4. Cheng
TL, Savageau JA, Sattler AL, et al: Confidentiality in health care: A survey of
knowledge, perceptions, and attitudes among high school students. JAMA
269:1404, 1993 Abstract
5. DiClemente
R: The psychological basis of health promotion for adolescents. Adolesc Med
10:13, 1999 Abstract
6. Division
of STD Prevention: Sexually Transmitted Disease Surveillance, 1997. U.S.
Department of Health and Human Services, Public Health Service. Atlanta,
Centers for Disease Control and Prevention (CDC), 1998
7. Elster
AB: Comparison of recommendations for adolescent clinical preventive services
developed by national organizations. Arch Pediatr Adolesc Med 152:193, 1998
Abstract
8. Elster
AB, Kuznets NJ (eds): AMA Guidelines for Adolescent Preventive Services (GAPS):
Recommendations and Rationale. Baltimore, Williams & Wilkins, 1994
9. Ford CA,
Millstein SG: Delivery of confidentiality assurances to adolescents by primary
care physicians. Arch Pediatr Adolesc Med 151:505, 1997 Abstract
10. Ford
CA, Millstein SG, Halpern-Felsher BL, et al: Influence of physician
confidentiality assurances on adolescents’ willingness to disclose information
and seek future health care: A randomized controlled trial. JAMA 278:1029, 1997
Abstract
11. Gans
JE, Alexander B, Chu RC, et al: The cost of preventive medical services for
adolescents. Arch Pediatr Adolesc Med 149:1226, 1995 Abstract
12. Ginsburg
KR, Menapace AS, Slap GB: Factors affecting the decision to seek health care:
The voice of adolescents. Pediatrics 100:922, 1997 Abstract
13. Gortmaker
SL, Must A, Sobol AM, et al: Television viewing as a cause of increasing
obesity among children in the United States, 1986-1990. Arch Pediatr Adolesc
Med 150:356, 1996 Abstract
14. Green M
(ed): Bright Futures: Guidelines for Health Supervision of Infants, Children
and Adolescents. Arlington, VA, National Center for Education in Maternal and
Child Health, 1994, p 195
16. Jaccard
J, Dittus PJ, Gordon W: Maternal correlates of adolescent sexual and
contraceptive behavior. Fam Plan Perspect 28:159, 1996
17. Kinsman
SB, Romer D, Furstenberg FF, et al: Early sexual initiation: The role of peer
norms. Pediatrics 102:1185, 1998 Abstract
18. Knight
J, Shrier LA, Bravender T, et al: A new brief screen for adolescent substance
abuse. Arch Pediatr Adolesc Med 153:591, 1999 Abstract
19. Lynch
BS, Bonnie RJ (eds): Growing Up Tobacco Free: Preventing Nicotine Addiction in
Children and Youth. Washington, D.C., National Academy Press, 1994, p 5
20. Marshall
WA, Tanner JM: Variations in the pattern of pubertal changes in girls. Arch Dis
Child 44:291, 1969
21. Marshall
WA, Tanner JM: Variations in the pattern of pubertal changes in boys. Arch Dis
Child 45:13, 1970 Citation
22. Neinstein
LS, Kaufman FR: Normal physical growth and development. In Neinstein LS
(ed): Adolescent Health Care: A Practical Guide, ed 3. Baltimore, Williams
& Wilkins, 1996, p 36
23. Newachek
PW, Brindis CD, Cart CU, et al: Adolescent health insurance coverage: Recent
changes and access to health care. Pediatrics 104:195, 1999 Abstract
24. Orr DP,
Ingersoll GM: Adolescent development: A biopsychosocial review. Curr Probl
Pediatr 18:441, 1988 Citation
25. Paperny
DM, Aono JY, Lehman RL, et al: Computer-assisted detection and intervention in
adolescent high-risk health behaviors. J Pediatr 116:456, 1990 Abstract
26. Paperny
DMN, Hedberg VA: Computer-assisted health counselor visits: A low-cost model
for comprehensive adolescent preventive services. Arch Pediatr Adolesc Med
153:63, 1999 Abstract
27. Resnick
MD, Bearman PS, Blum RW, et al: Protecting adolescents from harm: Findings from
the National Longitudinal Study on Adolescent Health. JAMA 278:823, 1997
28. Richardson
JL, Radziszewska B, Dent CW, et al: Relationship between after-school care of
adolescents and substance use, risk taking, depressed mood, and academic
achievement. Pediatrics 92:32, 1993 Abstract
29. Serdula
MK, Ivery DI, Coates RJ, et al: Do obese children become obese adults? A review
of the literature. Prev Med 22:167, 1993 Abstract
30. Singer
MI, Miller DB, Guo S, et al: Contributors to violent behavior among elementary
and middle school children. Pediatrics 104:878, 1999 Abstract
31. Singh
S, Darroch JE: Trends in sexual activity among adolescent American women. Fam
Plann Perspect 31:212, 1999 Abstract
32. Strasburger
VC: “Sex, drugs, rock ‘n’ roll,” and the media–are the media
responsible for adolescent behavior? Adolesc Med 8:403, 1997
33. U.S.
Preventive Services Task Force: Guide to Clinical Preventive Services, ed 2.
Baltimore, Williams & Wilkins, 1996
34. Warren
MP, Stiehl AL: Exercise and female adolescents: Effects on the reproductive and
skeletal systems. J Am Med Womens Assoc 54:115, 1999
35. Young
TL, Zimmerman R: Clueless: Parental knowledge of risk behaviors of middle
school students. Arch Pediatr Adolesc Med 152:1137, 1998 Abstract
36. Ziv A,
Boulet JR, Slap GB: Utilization of physician offices by adolescents in the United
States. Pediatrics 104:35, 1999 Abstract
*CRAFFT is a mnemonic that
can prompt clinicians to survey adolescents for drug or alcohol related
problems in six areas. C refers to driving a Car after using drugs or
alcohol or riding with a driver who has done so. R refers to using drugs or
alcohol to Relax, feel better about oneself, or fit in. A refers to
using drugs or alcohol while Alone. The two “F’s” refer to Forgetting
things because of drugs or alcohol and having Family or Friends
indicate to the adolescent that he or she needs to cut down on the use of drugs
or alcohol. T is a marker for getting into Trouble because of drug or
alcohol use.
