<\/p>\n
\u00a0<\/p>\n
\u00a0<\/pre>\nAlain Joffe<\/span> MD, MPH <\/strong><\/p>\n
\u00a0<\/p>\n
\n
\n<\/div>\nDepartment of Pediatrics,
\nJohns Hopkins Medical Institutions, Baltimore, Maryland<\/span><\/p>\n\n
\n<\/div>\nAddress
\nreprint requests to<\/span><\/em><\/p>\nAlain Joffe<\/span><\/strong>, MD, MPH<\/p>\n
Park 307<\/p>\n
Johns Hopkins Hospital<\/p>\n
600 North Wolfe Street<\/p>\n
Baltimore, MD 21287-2530<\/span><\/p>\n
<\/p>\n
<\/p>\n
BACKGROUND<\/h3>\n
Adolescents aged 11 to 21 years old
\nmade approximately 61.8 million office visits to physicians in 1994. Few of these
\nvisits were to internists. According to data from the 1994 National Ambulatory
\nMedical Care Survey, only 5.3% of visits by 12- to 17-year-olds and 7.4% of
\nvisits by 18- to 21-year-olds were to internists. [36<\/a>]<\/span><\/sup>
\nDespite the fact that adolescents comprise 15.4% of the U.S. population, they
\naccounted for only 9.1% of office visits in 1994. The opportunity for internists
\nand all other physicians to increase the numbers of adolescents in their
\npractices exists. This situation may be especially true if the 14.1% of
\nadolescents who were uninsured in 1995 receive coverage through federally
\nfunded state health insurance programs. Compared with adolescents with
\ninsurance, uninsured adolescents are five times as likely to lack a usual
\nsource of health care and twice as likely not to have had a physician contact
\nin the prior year. [23<\/a>]<\/span><\/sup><\/p>\nThe opportunity to incorporate more
\nadolescents into practice, if realized, could prove challenging for internists.
\nCurrent Residency Review Commitee (RRC) guidelines for internal medicine state
\nonly that “residents should be instructed in adolescent<\/span><\/strong>
\nmedicine<\/span><\/strong>, which may include the following
\ntopics: health promotion, family planning and human sexuality, sexually
\ntransmitted diseases (STDs), chemical dependency, sports medicine, and school
\nhealth issues.” Although structured patient care experiences directed by
\nfaculty experienced in the care of adolescents are desirable,<\/em> they are
\nnot required. Only 5% of the articles published in the Annals of Internal
\nMedicine<\/em> in 1998 indicated adolescence<\/em> as a key word for the
\narticle.<\/p>\n\u00a0<\/p>\n
RATIONALE FOR ADOLESCENT<\/span> MEDICINE<\/span><\/h3>\n
Except for the newborn and early
\ninfant years, no period of the human life span encompasses more dramatic
\nchanges than does adolescence. Regardless of how one designates the age limits
\nfor this period (e.g., ages 10 to 19, 12 to 21, 15 to 24 years), providing
\noptimal health care to individuals in this age group requires an in-depth
\nunderstanding of the biologic, cognitive, and sociocultural changes that occur,
\ntheir interrelatedness, and their potential impact on an adolescent’s health.
\nApplying this understanding to clinical practice defines the discipline of adolescent<\/span><\/strong> medicine<\/span><\/strong>.
\nA schematic representation of these changes is shown in Figure 1 (Figure Not
\nAvailable) . Throughout this article, the term puberty<\/em> is used to refer
\nto the biologic changes that teenagers undergo, primarily during the second
\ndecade of life. In contrast, the term adolescence<\/em> refers more broadly to
\nthe phase of human development encompassing the transition from childhood to
\nadulthood; this includes but is not limited to pubertal development.<\/p>\nFigure 1.<\/span><\/strong>
\n(Figure Not Available) The temporal relation between the biologic, psychologic,
\nand psychosocial events of adolescence. Age limits for the events and stages
\nare approximations and may differ from those used by other authors. The mean
\nage of onset of pubic hair development for boys (13.4 years) is likely too high
\nbecause of bias in the data collection method. These limits and the points indicating
\nthe attainment of individual stages of puberty were chosen for consistency and
\nto reflect the earlier maturation of American versus British adolescents. B2,
\nB3, B4, B5, breast stage 2, 3, and so forth; G2, G3, G4, G5 genital stage 2, 3,
\nand so forth; PH2, PH3, PH4, PH5, pubic hair stage 2, 3, and so forth; PHV,
\npeak height velocity. ( From <\/em><\/span>Joffe<\/span><\/em><\/strong>
\nA: Introduction to <\/span><\/em>adolescent<\/span><\/em><\/strong><\/em>medicine<\/span><\/em><\/strong>. In McMillan JA, DeAngelis CD, Feigen
\nRD, Warshaw J (eds): Oski’s Pediatrics. Principles and Practice, ed 2.
\nPhiladelphia, Lippincott Williams and Wilkins, 1999, p 528; with permission.)<\/span><\/em><\/p>\n\u00a0<\/p>\n
PUBERTY<\/h3>\n
Puberty starts well before any
\nphysical changes are apparent to the adolescent or his or her parents. Approximately
\n2 years before the appearance of secondary sexual characteristics, there is
\nincreased production of adrenal sex steroids. Higher levels of these hormones
\nare not, however, necessary for puberty to occur. In the earliest stages of
\npuberty, there is a sleep-associated increase in the pulsatile secretion (in
\nfrequency and in amplitude) of gonadotropin-releasing hormone (GnRH),
\nfollicle-stimulating hormone (FSH), and luteinizing hormone (LH). As puberty
\nprogresses, these increases are detectable throughout the day. Consequently, if
\nmeasurement of GnRH, FSH, or LH were necessary as part of the evaluation of an
\nadolescent with delayed onset of puberty, it would be important to obtain
\nspecimens during this early morning period.<\/p>\nParalleling increases in GnRH, FSH,
\nand LH, serum levels of testosterone and estrogen rise in boys and girls. The
\nrise in estrogens gradually reaches the level to induce menarche in girls, but
\nit is not for at least several years after menarche that the regular midcycle
\nsurge of estrogen leading to an LH surge and ovulation is established (positive
\nfeedback system). Accordingly, most young women ovulate infrequently for
\nseveral years after menarche and do not have significant dysmenorrhea.<\/p>\nThe control of the onset of puberty
\nis not well understood. Most experts agree that GnRH secretion increases as the
\nhypothalamus becomes less sensitive to circulating levels of testosterone and
\nestrogen, but the mechanism by which this occurs has yet to be elucidated.
\nBecause infants, even those born without functioning gonads, have relatively
\nelevated levels of gonadotropins that fall during early childhood, it is
\nhypothesized that puberty must also involve modulation of a direct inhibitory
\nprocess operating at the level of the central nervous system.<\/p>\nThe orderly appearance of secondary
\nsexual characteristics, changes in body composition, and increase in stature
\nall mirror the hormonal changes that are occurring. Documenting that these
\nchanges are occurring is as sensitive a measure of normal pubertal development
\nas would be repeated measures of testosterone or estrogen levels. The careful
\nrecords of Marshall and Tanner [20<\/a>]<\/span><\/sup>
\n[21<\/a>]<\/span><\/sup>
\nlaid the groundwork for describing the appearance of secondary sexual
\ncharacteristics and the assigning of sexual maturity ratings or Tanner stages.
\nThe various stages are assigned numbers from 1 to 5, with 1 representing no
\npubertal development and 5 signifying full adult development. Boys and girls
\nare assigned a rating based on the degree of pubic hair development (PH1 to
\nPH5). Girls receive a separate rating for their stage of breast development (B1
\nto B5), whereas boys are assessed based on the volume of their testicles (G1 to
\nG5). Because these ratings represent separate physical characteristics, it is
\ninappropriate to assign a mean Tanner stage<\/em> based on averaging the two
\n(e.g., a girl who has Tanner 2 breast development and Tanner 3 pubic hair does
\nnot have an overall Tanner stage of 2.5).<\/p>\nMost events that occur during
\npuberty correlate better with Tanner stage than with chronologic age. In fact,
\nknowledge of Tanner stage is essential to avoiding errors in diagnosis. For
\nexample, although gynecomastia is often associated with various diseases among
\nmen, it is normal (and usually self-limited) during puberty, especially at
\nTanner stage 2 or 3. Similarly, blood pressure levels correlate more closely
\nwith height age and Tanner stage than with chronologic age: A 13-year-old with
\na height age of 16 should be assessed according to normal blood pressure values
\nfor a 16-year-old. Finally, in that hemoglobin levels in boys rise
\nprogressively during puberty as testosterone levels increase, determination of
\nanemia should be based on sexual maturity rating, not age.<\/p>\nMarshall and Tanner’s studies
\ndocumented the orderly appearance of secondary sexual characteristics among
\npubertal adolescents. [20<\/a>]<\/span><\/sup>
\n[21<\/a>]<\/span><\/sup>
\nTypically, girls develop breast buds as the first sign of puberty (although
\nabout 15% develop pubic hair first). Approximately 1 year after breast budding,
\ngirls reach their peak height velocity, and 1 year later menarche ensues. After
\nmenarche, a girl usually grows only an additional 4 to 5 cm. Onset of puberty
\nin boys is heralded by an increase in testicular volume, followed by pubic hair
\ngrowth, then enlargement (length and circumference) of the penis. Peak height
\nvelocity occurs 2 years after the onset of testicular enlargement. Adolescents
\ngain about 15% to 25% of their final adult height during the pubertal growth
\nspurt. Genetic factors aside, boys generally wind up taller than girls because
\ntheir peak growth velocity occurs after a longer basal period of growth and
\nbecause their peak height velocity is greater than that of girls.<\/p>\nThis information can be used to
\ncounsel and reassure adolescents about what to expect during the pubertal years
\nas well as guide follow-up. For example, because peak height velocity occurs
\nearly in puberty and precedes menarche in girls, follow-up of a patient with
\n10\u00b0 of scoliosis (which worsens during the growth spurt) would be more frequent
\nbefore menarche than after. Similarly a young woman with Tanner stage 2 breast
\ndevelopment can be counseled that menarche is likely to occur in about 2 years.<\/p>\nGirls experience a drop in body
\nself-image as they progress through adolescence. This decreased self-image may,
\nin part, be due to the natural increase in percent body fat and widening of the
\nhips that occur during puberty. Against a backdrop of media images that
\nemphasize slimness as the sole standard for female beauty, girls may interpret
\nthese normal changes as evidence of their becoming fat. Discussions about these
\nnormal changes early in puberty may afford the physician an opportunity to
\ndiscuss body image concerns with the adolescent, to reassure her about her
\ndevelopment, and to help her achieve a realistic set of expectations and goals
\nregarding her physical development.<\/p>\nAlthough the sequence of pubertal
\nevents is generally invariable among boys and girls, the timing of onset and
\nprogression is not. This observation gives rise to the concept of early,
\naverage (or on-time), and late maturing adolescents. Typically, girls enter
\npuberty at approximately 11 years of age, but some, who are otherwise completely
\nnormal, may not do so until age 13. Boys usually begin puberty about 6 months
\nlater than girls, with the upper age limit of normal being 14. Recognizing this
\nbroad range of normal guides the clinician in determining at which point an
\nevaluation for delayed onset of puberty is indicated.<\/p>\nCompletion of breast development
\naverages 4 years, whereas pubic hair growth is completed in 2.5 years.
\nComparable figures for boys are 3 years for testicular growth and 1.5 years for
\npubic hair development. On average, puberty lasts 3 to 4 years; adolescents who
\nfail to progress through puberty should be thoroughly evaluated for the
\npresence of chronic illness, malnutrition, or other conditions that may affect
\nphysical development.<\/p>\nChanges in body composition that occur
\nduring puberty can have profound implications for adult health status.
\nAdolescents accrue 40% of their adult bone mass during puberty. Girls who
\ncomplete puberty having failed to develop adequate bone density, as can be seen
\nsecondary to anorexia nervosa or because of exercise-induced amenorrhea, may
\nnot subsequently be able to catch up. [34<\/a>]<\/span><\/sup>
\nIf so, these young women complete puberty being relatively osteopenic and may
\nbe at significant future risk for osteoporosis and hip fractures. Ensuring that
\nadolescents maintain regular menses and ingest at least 1300 mg of calcium per
\nday is essential for optimal bone development during adolescence and for
\nprevention of a common adult morbidity.<\/p>\nAdolescence is one of two critical
\nperiods for the development of obesity. During puberty, body fat increases in
\ngirls (from a baseline of about 16% to a peak of 26%), whereas it decreases in
\nboys. Because of differences in how adipose tissue is deposited, obese boys are
\nat greater risk for adult mortality, but obese girls are more likely to remain
\nobese as adults. The risk for being obese as an adult, with its known
\ncomplications, is increased for adolescents who remain obese at the completion
\nof puberty. [30<\/a>]<\/span><\/sup>
\nThese facts highlight the role of nutritional counseling during this period of
\ngrowth.<\/p>\n\u00a0<\/p>\n
COGNITIVE AND DEVELOPMENTAL CHANGES<\/h3>\n
Adolescence is characterized by an
\nemerging capacity to reason in an increasingly more sophisticated manner. [24<\/a>]<\/span><\/sup>
\nYounger teens are relatively concrete in their thinking and have difficulty
\nwith abstract concepts. They also tend to have little in the way of a future
\ntime orientation. During middle and late adolescence, the ability to reason
\nabstractly, to handle multiple concepts simultaneously, and to use a what if<\/em>
\napproach emerges. These older teens are capable of taking another person’s
\nperspective and are better able to project themselves into the future and
\nreflect about events that may be remote in time. This capacity to reason more
\nabstractly does not occur as an all-or-none process. Under periods of stress,
\nadolescents may revert to more concrete levels of thinking.<\/p>\nThese differences have significant
\nimplications for health care encounters. For example, counseling younger teens
\nabout smoking is more likely to have an impact if the focus is on the immediate
\nconsequences of smoking (bad breath, yellow teeth, and decreased exercise
\nperformance) rather than on long-term (and fairly abstract) conditions (lung
\ncancer or emphysema). Terms such as cancer or emphysema may be too abstract to
\nhave an impact on their decision regarding smoking.<\/p>\nEarly adolescents tend to be
\nself-centered in their thinking and preoccupied with their own needs. During
\nthe initial stages of puberty, this focus is on body changes (“am I
\nnormal?”) and may prompt physician visits largely for reassurance about
\ntheir development. A classic example is the adolescent boy with gynecomastia
\nwho presents to a physician for evaluation of chest pain. Adolescents do not
\nalways express concerns about their physical development. A teenager may be too
\nembarrassed to ask for acne therapy or to inquire whether her breast asymmetry
\n(a common finding in early puberty) is permanent.<\/p>\nBecause of their developmental
\nlevel, adolescents have a sense of uniqueness and personal invulnerability.
\nNegative health outcomes, such as unintended pregnancy, a serious injury, or a
\nsexually transmitted disease, happen to other teenagers but not to them. This
\nsense of personal invulnerability, coupled with a desire to test and master
\ntheir newly emerging physical and mental capabilities, may provide one
\nexplanation for the risk-taking behaviors observed during this age period.
\nViewed within this context, behaviors that are perceived as risky by adults can
\nbe seen as meeting important developmental needs for adolescents.<\/p>\nAdolescence is customarily divided
\ninto three stages: early (age 11 to 14 years), middle (age 14 to 17 years) and
\nlate (age 17 to 21 years). Early adolescence is characterized by a focus on the
\nphysical changes that accompany puberty and by concrete thinking. Separation
\nfrom parents and the rise in peer group influence begins during this stage but
\nis not prominent. During middle adolescence, peer group influence and conflicts
\nwith parents peak. Risk-taking behaviors, such as cigarette smoking, drinking,
\nand sexual intercourse become more common. Concerns about one’s developing sense
\nof self and autonomy become increasingly important. By late adolescence, the
\nfocus shifts to developing the capacity for intimacy in relationships and
\ndefining one’s career goals and place in society. Generally, peer group
\ninfluence lessens, and a rapprochement<\/em> with parents occurs. Older
\nadolescents are often idealistic and may be highly critical of traditional
\ninstitutions.<\/p>\n\u00a0<\/p>\n
SOCIOCULTURAL CHANGES<\/h3>\n
The development of adolescents
\ncannot be viewed in isolation from the world around them. Although adolescent<\/span><\/strong> medicine<\/span><\/strong>
\nrightly emphasizes the primacy of the adolescent, peers, parents (family),
\ncommunity, and culture all have a powerful impact on the adolescent’s behavior
\nand health status. For example, current societal expectations are that young
\npeople postpone marriage and the age of childbearing to complete the added
\nyears of schooling necessary to achieve economic self-sufficiency in today’s
\nmarketplace. Yet over the last 150 years, the age at which adolescents begin
\npuberty and are able to bear children has dropped substantially. Menarche
\ncurrently occurs at approximately 12.5 years, in contrast to 16 or 17 years in
\nthe 1860s. [22<\/a>]<\/span><\/sup>
\nTeenage pregnancy is of much greater concern now than it was in the 1800s.<\/p>\nEvidence continues to accumulate
\nconcerning the role of parents in promoting the health of adolescents. Results
\nfrom the National Longitudinal Study of Adolescent Health show that adolescents
\nwho feel connected to their families are at reduced risk for engaging in a wide
\nvariety of health-risking behaviors. [27<\/a>]<\/span><\/sup>
\nAdolescents who report satisfaction with their relationship with their mothers
\nand who perceive their mothers as having made clear statements against sexual activity
\nduring adolescence are more likely to be abstinent or to have sex less often
\nthan their peers; they are also more likely to use contraception if they choose
\nto have intercourse. [16<\/a>]<\/span><\/sup>
\nParental monitoring of adolescents (e.g., after school or at night) has been
\nassociated with a decreased risk for behaviors such as drug use and violence. [28<\/a>]<\/span><\/sup>
\n[30<\/a>]<\/span><\/sup>
\nAlthough parents are important in the lives of adolescents, fewer and fewer
\nparents, particularly single parents, are able to spend the necessary amount of
\ntime with their children. This situation may be one explanation for why parents
\ntend to underestimate the prevalence of risk behaviors among their adolescents.
\n[35<\/a>]<\/span><\/sup><\/p>\nResults from the National Health
\nand Nutrition Examination Survey (NHANES III) indicate that more than one fifth
\nof children and adolescents in the United States are obese; this represents an
\nincrease of more than 30% since 1980. Although the cause of this increase is
\nuncertain, it does not appear that changes in caloric intake alone can account
\nfor all the observed increase. The proportion of calories derived from fat
\namong adolescents in the United States has decreased over the last few decades.
\nIn contrast, a decrease in exercise, especially among girls, has been noted.
\nThroughout high school, approximately 50% of boys participate in vigorous
\nphysical activity. For girls, there is a 50% reduction in the proportion that
\nexercise, from 30% at entry to high school to 15% in twelfth grade. Other
\nstudies document the association between the number of hours of television
\nwatched per day and increased risk for obesity. [13<\/a>]<\/span><\/sup>
\nThe choices in electronic entertainment now available to adolescents (each of
\nwhich promotes a sedentary lifestyle) continue to expand. Television watching
\nmay contribute to adolescent obesity in other ways. Advertisements for food are
\nthe most common commercials on television, and the food promoted is often high
\nin calories, fat, or both; these foods are often consumed by adolescents while
\nwatching television.<\/p>\nTelevision and other forms of media
\nmay promote unhealthy lifestyles in a number of other ways. When adolescents
\nview images in which adolescents or adults smoke cigarettes, drink, engage in
\nsexual intercourse (usually without mention of contraception), and commit acts
\nof violence, they come to perceive these activities as being socially
\nacceptable or normative behaviors. These perceptions may, in turn, influence
\ntheir behavior. [3<\/a>]<\/span><\/sup>
\n[32<\/a>]<\/span><\/sup>
\nResearch studies have shown that to the extent teenagers perceive various
\nbehaviors as normative among their peers, the more likely they are to engage in
\nsimilar behaviors. [17<\/a>]<\/span><\/sup><\/p>\nAdvances in health care have
\nenabled many children with once fatal childhood diseases to survive into
\nadolescence and young adulthood. Other adolescents develop chronic illnesses,
\nsuch as inflammatory bowel disease, during the second decade of life. In both
\ncases, internists are likely to encounter a growing number of adolescents in
\ntheir practices with chronic illness. Some diseases, such as cystic fibrosis or
\ncertain forms of congenital heart disease, may be ones that internists have
\npreviously only rarely encountered.<\/p>\nThe impact of chronic disease on
\nadolescent development may be significant. Illnesses that result in visible
\ndeformity or limitations in activity are likely to be problematic for teens,
\nwho desire to fit in with peers. Compliance with drug regimens may also be
\ndifficult if side effects of medications result in physical changes, as is the
\ncase with prednisone therapy. Chronic illness may also interfere with the
\nnormal separation from parents that occurs during adolescence. Parents may be
\nreluctant to grant autonomy to their child for fear that he or she will not
\nadequately manage the illness.<\/p>\nAlthough fewer adolescents with
\nchronic illnesses or disabling conditions may engage in risky behaviors than
\ntheir peers, a substantial number still do so. [2<\/a>]<\/span><\/sup>
\nBecause many of these adolescents suffer from social isolation and may lack
\ncredible sources of information about risky behaviors, it is essential that physicians
\nscreen all adolescents for these behaviors.<\/p>\n\u00a0<\/p>\n
HEALTH STATISTICS OF ADOLESCENCE<\/h3>\n
In the aggregate, health statistics
\nfor adolescents have improved in the 1990s. Nonetheless, significant numbers of
\nadolescents continue to engage in health-risking behaviors that result in
\nappreciable morbidity and mortality. Although each risk behavior is discussed
\nseparately, current research indicates that many adolescents who engage in one
\nsuch behavior often engage in others (co-vary).<\/p>\nIn contrast to adult mortality
\nfigures, the leading causes of death among adolescents are behavioral in
\norigin. In 1997, among 15- to 24-year-old males of all races, motor vehicle
\naccidents were the most common cause of death (38.1 per 100 000), followed by
\nhomicide (28.2) and suicide (18.9). For similarly aged females of all races,
\nleading causes of death were motor vehicle accidents (17.1), homicide (4.7),
\nand malignant neoplasms (3.7). Suicide is the second leading cause of death for
\n15- to 24-year-old white males (19.5), whereas homicide is the leading cause of
\ndeath for African-American males (113.3) and females (13.3) as well as for
\nHispanic males (42.7).<\/p>\nDrug use by adolescents has
\ndeclined in the last few years, after peaking in the mid-1990s. According to
\nthe 1998 Monitoring the Future Survey of more than 50,000 students across the
\nUnited States, use of any illicit drug in the 12 months before the survey
\ndeclined for the second year in a row among eighth graders and for the first
\ntime in the 1990s for tenth and twelfth graders (http:\/\/www.isr.umich.edu\/src\/mtf\/index.html).
\nDeclines in marijuana use accounted for much of the decrease, although 22% of
\neighth graders and 49% of twelfth graders reported having tried marijuana.
\nAlcohol use decreased for eighth graders for the second year in a row and
\ndeclined for the first time among tenth and twelfth graders. Nonetheless, 8.4%
\nof eighth graders, 21% of tenth graders, and 33% of twelfth graders reported
\nbeing drunk at least once in the 30 days preceding completion of the survey.<\/p>\nRates of cigarette smoking, which
\nhad shown a steady rise until 1996, began to decline in 1997; 19% of eighth
\ngraders, 27.6% of tenth graders, and 35% of twelfth graders reported smoking in
\nthe 30 days before the survey. Prevention of smoking during the adolescent
\nyears is essential and has both short-term and long-term payoffs. Among adults
\nwho smoke daily, 89% began any use of cigarettes and 71% began smoking
\nregularly by the age of 18. [19<\/a>]<\/span><\/sup>
\nPreventing adolescent smoking would reduce greatly the tobacco-related
\nmorbidity and mortality (emphysema, lung cancer, coronary artery disease) so
\nprevalent among adults.<\/p>\nIn the 1990s, rates of sexual
\nactivity among adolescents have stabilized and perhaps even begun to decrease,
\nwhereas use of condoms has increased. [31<\/a>]<\/span><\/sup>
\nIn combination, these two observations provide some explanation for the
\nsustained drop in adolescent pregnancy rates that has occurred since the
\nmid-1990s. Although these trends are encouraging, adolescents aged 15 to 19
\nyears have the highest rates of Neisseria gonorrhoeae<\/em> and Chlamydia
\ntrachomatis<\/em> infection of any other age group in the United States. [8<\/a>]<\/span><\/sup>
\nIt is estimated that one fourth of the 12 million cases of sexually transmitted
\ndiseases diagnosed annually in the United States occur among adolescents.<\/p>\nApproximately 5% of adolescents
\nhave a major depressive disorder, and nearly one fourth of students in a
\nnational survey reported having seriously considered killing themselves in the
\nlast year. In the same survey, 17.7% of students had made a plan, 8.7% had
\nattempted to do so, and almost 3% reported needing treatment from a physician
\nor nurse for the injury. Approximately 1% of white girls of middle to upper
\nsocioeconomic status have anorexia nervosa, and it is estimated that two to
\nfive times that many meet diagnostic criteria for bulimia nervosa.<\/p>\n\u00a0<\/p>\n
HEALTH VISITS FOR ADOLESCENTS<\/h3>\n
Given all the changes that occur
\nduring adolescence, the prevalence of risky behaviors among this population,
\nand the possibility for the internist to promote healthy lifestyles that can
\nprovide short-term and long-term benefits, health visits occurring during this
\nage period assume critical importance. The goals of the health visit are
\nthreefold: (1) to reassure the adolescent that his or her development is normal
\nor identify any problems that may require further evaluation or treatment; (2)
\nto assess the adolescent and his or her family for factors that may predispose
\nto or protect against the adolescent’s pursuit of health-risking behavior, and
\n(3) to promote a healthy lifestyle that will continue throughout adulthood.<\/p>\nIn a time of rapid and sweeping
\nchange in the health care industry, there is much discussion about how best to
\nachieve these goals in an efficient and cost-effective manner. In the 1990s, a
\nconsensus as to the scope and content of preventive services for adolescents
\nhas emerged. Five sets of comprehensive recommendations are now available,
\npromulgated by public and private national organizations. [7<\/a>]<\/span><\/sup>
\nAll five emphasize risk assessment and anticipatory health guidance as being as
\nimportant as physical examination and laboratory testing. Several sets
\nrecommend that although assessment and counseling occur annually, physical
\nexaminations need occur only every other year or less often. A health visit at
\n11 to 12 years of age, at which time immunizations can be updated, can serve as
\nthe inaugural adolescent visit. At this time, the physician can set the ground
\nrules for future visits so that the adolescent and parents know what to expect.
\nThese rules center around the physician’s spending most of the visit with the
\nadolescent alone and issues of confidentiality.<\/p>\nThere is much confusion concerning
\nthe principles of consent and confidentiality as they pertain to adolescent
\nhealth care. Consent<\/em> is a function of the adolescent’s capacity to
\nunderstand treatment choices presented to him or her, including the risks and
\nbenefits, and to choose among them. Confidentiality<\/em> refers to the
\ncontrol and protection of health information shared between the adolescent and
\nthe physician. Beginning in the 1970s, states have generally granted
\nadolescents younger than 18 years of age the right to seek confidential health
\ncare services and to consent to treatment on their own in a number of
\nhealth-related areas. These are reproductive health care (including pregnancy
\ntesting and contraceptive services), diagnosis and treatment of sexually
\ntransmitted diseases, and assessment and treatment for drug and alcohol
\nproblems. Many states permit older adolescents to seek care for mental health
\nproblems on their own. Because the exact nature and wording of these statutes
\nvary from state to state, internists should become familiar with the statutes
\ngoverning care in their own state.<\/p>\nAn emerging body of research
\nunderscores the need for the clinician to discuss confidentiality with the
\nadolescent at the start of the visit. Many adolescents would forgo health care
\nif parents might find out; the proportion is highest among adolescents with
\nhealth concerns they wished to keep private. [4<\/a>]<\/span><\/sup>
\nIn a randomized trial, assurances of confidentiality increased the number of
\nadolescents who were willing to disclose sensitive personal information and
\nincreased their willingness to seek health care in the future. [10<\/a>]<\/span><\/sup>
\nConfidentiality, however, cannot be unconditional in that some information
\n(e.g., sexual abuse) must be disclosed by law and other information (e.g.,
\nsuicidality) is of sufficient potential harm to the adolescent that the
\nprinciple of first do no harm<\/em> supersedes the principle of
\nconfidentiality. The nature and limits of confidentiality should be explained
\nat the beginning of the visit. In one study of California physicians, 16.5% of
\ninternists did not discuss confidentiality at all with their adolescent
\npatients, and three fourths of the ones who did promised unconditional
\nconfidentiality. [9<\/a>]<\/span><\/sup><\/p>\nAlthough confidentiality is an
\nessential component of adolescent health care, most adolescents are part of a
\nfamily system. Teenagers, especially younger ones, are often accompanied to a
\nvisit by one or both parents or another adult guardian. Although it is
\nessential that the adolescent perceive that he or she is the central focus of
\nthe visit and that the physician is primarily focused on the adolescent’s
\nconcerns, some interaction with parents is desirable and necessary. Parents can
\nprovide important details about the adolescent’s prior medical history and the
\nfamily history. Parents should also be queried about their own health
\nbehaviors, such as seat belt use, personal use of drugs and alcohol, or mental
\nhealth problems, because these can have a significant impact on the
\nadolescent’s well-being. Parents can corroborate that things are going well for
\nthe adolescent or provide important clues when the adolescent’s level of
\nfunctioning has begun to deteriorate. This parental input may be particularly
\napplicable regarding substance abuse because denial that a problem exists is a
\nprominent component of the disease process. There are numerous ways to involve
\nparents during the visit. The author prefers, at new patient visits, to meet
\nwith the family together at the outset, then with the teenager alone for most
\nof the visit, then with the parents alone toward the end. At subsequent visits,
\nthe nature of the visit and the preference of the adolescent dictate the
\nnecessity for interaction with parents. At age 18, adolescents are entitled to
\nthe full legal protections due to any competent adult.<\/p>\nFigure 2 (Figure Not Available)
\ncontains recommended content for the well adolescent health maintenance visit.
\nThe recommendations are derived and modified from a variety of sources,
\nincluding the preventive service guidelines highlighted by Elster. [7<\/a>]<\/span><\/sup>
\nIn an asymptomatic adolescent, the physical examination (excluding, perhaps,
\nthe pelvic examination in sexually active young women) is unlikely to detect
\nany significant abnormalities. Because much of the morbidity and mortality that
\noccur during adolescence and young adulthood is behavioral in origin, a
\nthorough and wide-ranging history is most likely to reveal pertinent positives,
\nand most of the time allotted for the visit should be devoted to this task.<\/p>\nFigure 2.<\/span><\/strong>
\n(Figure Not Available) Recommended content for routine adolescent visit. (
\nFrom <\/em><\/span>Joffe<\/span><\/em><\/strong> A: Introduction to <\/span><\/em>adolescent<\/span><\/em><\/strong><\/em>medicine<\/span><\/em><\/strong>. In McMillan JA, DeAngelis CD, Feigen
\nRD, Warshaw J (eds): Oski’s Pediatrics. Principles and Practice, ed 2.
\nPhiladelphia, Lippincott Williams and Wilkins, 1999, p 535; with permission.)<\/span><\/em><\/p>\nMany mnemonics have been developed
\nas a means to remind the physician to survey all of the pertinent aspects of an
\nadolescent’s level of functioning. One example is the HEADSS<\/em> assessment:
\nH<\/em>–homelife; E<\/em>–education; A<\/em>–activities; D<\/em>–drugs
\n(including alcohol); S<\/em>–sexuality; and S<\/em>–suicide (depression).
\nIn addition to a discussion of confidentiality, many other strategies can be
\nused to maximize the probability of obtaining accurate information.<\/p>\nThe interview is the essential
\ncomponent of the adolescent visit. It helps to build rapport and a sense of
\ntrust between the adolescent and the clinician and is the primary medium for
\ngathering information about the adolescent’s overall health. The interview must
\nbe conducted in a manner that maximizes the likelihood that all pertinent
\ninformation will be collected. Adolescents may not understand the need for
\nphysicians to ask questions pertaining to each of the aforementioned domains,
\nespecially if they have been previously accustomed to more narrowly focused
\nmedical interviews. Explaining that each domain relates to the adolescent’s
\noverall level of functioning and can affect the adolescent’s health helps place
\nthe questions in the proper context. “I ask these questions of all my
\npatients” reassures the adolescent that he or she is not being targeted
\nfor any particular reason of dress or hairstyle. Inquiries about personal
\nbehaviors may require different strategies and additional reassurance and explanation.
\nQuestions about drug abuse should first be directed toward ascertaining use of
\nnonprescription (but legal) and then prescription medications. These can be
\nfollowed by inquiring about friends’ use of illicit substances, then the
\nadolescent’s own use. Follow-up to positive responses with use of the CAGE (see
\nthe section on drugs in Fig. 2) (Figure Not Available) or CRAFFT *<\/a>
\n<\/span><\/sup>questionnaires helps keep the interview focused on the health
\nconsequences of drug use and avoids battles about how much drinking or drug use
\nis too much. [18<\/a>]<\/span><\/sup><\/p>\nQuestions about sexual behaviors
\nshould not suggest that any one standard of behavior is the norm. Prefacing
\ninquiries about sexual intercourse with the comment, “Some young people
\nyour age are having sex; others have chosen to be abstinent,” indicates
\nthat the clinician is open to either a yes or no response. Asking a boy if he
\nhas a girlfriend (or a girl about boyfriends) suggests that heterosexual
\nrelationships are the norm. A more open-ended line of questioning (“Have
\nyou ever had a sexual relationship with anyone?” followed by “Do you
\nhave sex with men, women, or both?”) signals to a gay or lesbian youth
\nthat he or she can be open about relationships.<\/p>\nDuring the interview, it is
\nimportant to elicit any negative consequences the adolescent may have
\nexperienced as a result of health-risking behaviors. These might include
\ncitations for driving while intoxicated, a decrease in exercise performance
\nafter initiation of smoking, a pregnancy scare, or an act of vandalism or
\nphysical violence that occurred while the adolescent was intoxicated. This
\ninformation can be useful in encouraging the adolescent to modify his or her
\nbehavior.<\/p>\nAdolescents may often use terms
\nthat are unfamiliar to the physician. It is better for the clinician to ask for
\nclarification rather than pursue a line of questioning based on an incorrect
\ninterpretation of a response. Conversely, physicians need not use slang in an
\nattempt to relate to adolescent patients. Although it may occasionally be
\nnecessary to use nonmedical terms to clarify a question, surveys of adolescents
\nindicate that the qualities they value most in a health care provider include
\nhonesty, being treated with respect, and the physician’s being knowledgeable. [12<\/a>]<\/span><\/sup><\/p>\nAlternatives to personal interviews
\ninclude questionnaires or computerized health assessments. Questionnaires for
\nadolescent visits have been developed by the Maternal and Child Health Bureau
\nas part of its Bright Futures Initiative (www.brightfutures.org) and as part of
\nthe Guidelines for Adolescent Preventive Services (GAPS) developed by the
\nDepartment of Adolescent Health at the American Medical Association. [8<\/a>]<\/span><\/sup>
\n[14<\/a>]<\/span><\/sup>
\nComputer-assisted visits can be cost-effective and are often preferred by
\nadolescents. [25<\/a>]<\/span><\/sup>
\n[26<\/a>]<\/span><\/sup><\/p>\nRelatively few routine laboratory
\ntests are indicated for the healthy adolescent (Fig. 2) (Figure Not Available)
\n. With the current availability of effective antiretroviral agents, screening
\nfor and early detection of human immunodeficiency virus (HIV) infection has
\nbecome increasingly important.<\/p>\nAt the end of the visit, physician
\ncounseling should focus on encouraging the adolescent to adopt health-promoting
\nbehaviors and to reduce identified risk behaviors. The nature and extent of the
\ncounseling is tailored to the individual adolescent, based on information
\nelicited during the history, physical examination, and, when indicated,
\nlaboratory testing. Health promotion focuses on such behaviors as wearing seat
\nbelts, using a bicycle helmet, establishing a regular exercise program, and
\nadopting a prudent diet that contains no more than 30% of calories from fat.
\nPromoting abstinence or, for sexually active adolescents, consistent use of
\ncondoms is important for prevention of sexually transmitted diseases.
\nDiscussions about effective means of contraception should occur with sexually
\nactive adolescents at risk for pregnancy or fathering a baby. Now that
\ncombination estrogen-progestin and progestin-only regimens have been approved
\nby the U.S. Food and Drug Administration for emergency contraception
\n(previously referred to as the morning-after pill<\/em>), women should
\nroutinely be counseled about and offered this additional method of pregnancy
\nprevention.<\/p>\nReduction of risky behaviors
\nincludes smoking cessation, avoiding drinking and driving (or driving after
\nsmoking marijuana), limiting one’s number of sexual partners, and not swimming
\nwhile intoxicated. The ideal method for promoting a reduction in risk behaviors
\nhas not been established. Motivational interviewing, used widely in the field
\nof substance abuse treatment, may be an effective means. [1<\/a>]<\/span><\/sup>
\nThis approach relies on direct feedback to the adolescent, based on information
\ngathered during the interview, regarding the negative health consequences he or
\nshe has experienced as a result of health-risking behaviors. For example, an
\nadolescent smoker can be reminded that the frequent colds he or she has had
\nover the last year are due to the deleterious effects cigarette smoke has on
\nthe protective mechanisms of the lungs. Reminding an adolescent that he or she
\nhas occasionally thought about needing to cut down on drinking may be enough
\nmotivation for the adolescent to try a period of abstinence. The motivational
\ninterviewing approach avoids physicians and patients from being locked in
\ndiscussions about whether risky behaviors are good<\/em> or bad.<\/em><\/p>\nEfforts to update immunizations
\nshould occur at each visit. Adolescents 11 years old and older should receive
\nan adult booster dose of diphtheria and tetanus toxoids (Td), depending on the
\ntime elapsed since their last one, and a second dose of measles-mumps-rubella
\nvaccine if they have not previously had one. Three doses of hepatitis B vaccine
\nshould be administered over a 6-month period. Adolescents without a clinical
\nhistory of varicella should receive one (if younger than age 13) or two (if age
\n13 or older) doses of varicella vaccine. The Advisory Committee on Immunization
\nPractices (ACIP) and the American College Health Association recommend that
\n“those who provide medical care to this group [college freshmen dormitory
\nresidents] give information to students and their parents about meningococcal
\ndisease and the benefits of vaccination.”<\/p>\nWhich components of preventive
\nservices for adolescents and young adults are effective and whether physician
\ncounseling can affect patient behavior are currently under study. [11<\/a>]<\/span><\/sup>
\nSome services, such as immunizations, screening for sexually transmitted
\ndiseases, Papanicolaou smears, smoking cessation counseling, and counseling to
\nwear seat belts, have been shown to be effective. Strategies such as framing
\nthe counseling to match a patient’s perceptions, being specific in the advice
\ngiven, suggesting small rather than large changes, and getting a commitment
\nfrom the patient can help increase the internist’s effectiveness. [33<\/a>]<\/span><\/sup>
\nAdolescents generally recognize physicians as reputable sources of health
\ninformation. Because the cause of health-risking behaviors is complex, no
\nsingle approach alone is likely to achieve this goal. Health promotion efforts
\nby physicians in conjunction with community-level interventions are most likely
\nto be successful. [5<\/a>]<\/span><\/sup><\/p>\n\u00a0<\/p>\n
CONCLUSION<\/h3>\n
Adolescence and young adulthood
\nrepresents a period of the human life span during which enormous change takes
\nplace. Most threats to the health of adolescents are behavioral in origin and
\nstem from the interaction among the biologic, psychologic, and sociocultural
\nchanges that occur. The specialty of adolescent<\/span><\/strong>
\nmedicine<\/span><\/strong> recognizes the significance of
\nthese changes and uses an understanding of the factors underlying them to
\npromote the optimal current and future physical and mental health of
\nadolescents.<\/p>\nReferences<\/h4>\n
\n1. <\/span>Bien TH,
\nMiller WR, Tonigan JS: Brief interventions for alcohol problems: A review.
\nAddiction 88:315, 1993<\/span> \u00a0 Abstract<\/span><\/a><\/p>\n<\/p>\n