A d o l e s c e n t H e a l t h C a re M a i n t e n a n c e in a Tee n Friendly Clinic Nicole Chaisson,
MD, MPH
a
, William B. Shore,
MD
b,
*
KEYWORDS Confidentiality Psychosocial screening tools Screening and prevention Health maintenance Teen-friendly clinic Immunizations KEY POINTS Primary care providers should be knowledgeable of confidentiality laws in their state and communities. Confidentiality practice guidelines should be reviewed with parents and adolescents. Adolescent psychosocial screening tools are effective in identifying adolescent strengths and high-risk behaviors. Every clinical encounter with adolescents is an opportunity to address screening and prevention.
CARING FOR TEENS IN THE PRIMARY CARE SETTING
Although access to primary care services is important for improving the health of adolescents, several decades of research within the United States and across the globe have documented the barriers that adolescents and young adults experience when trying to access these services.1 Both the World Health Organization and the Institute of Medicine have developed frameworks for the development of youth-friendly services to call attention to the need for improved access to adolescent health services.2,3 Primary care has the capacity to provide high-quality screening, assessment, and care management for teens in a confidential and supportive environment. Creating that environment is fundamental. Communication with Teens and Their Families
The role of families and caregivers is important in adolescent care. Families can be an asset through providing a thorough medical history, supporting teen development and Disclosures: None. a Department of Family and Community Medicine, University of Minnesota Medical Center, Family Medicine Residency, 2020 East 28th Street, Minneapolis, MN 55407, USA; b Department of Family and Community Medicine, University of California, San Francisco, 995 Potrero, Building 80, Ward 83, San Francisco, CA 94110, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 451–464 http://dx.doi.org/10.1016/j.pop.2014.05.001 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
452
Chaisson & Shore
independence, clarifying expectations and setting limits, and ensuring ongoing access to care. Although limited research has been performed on partnerships between parents of teens and health care professionals, recent qualitative data describe both direct and indirect strategies to strengthen parent/provider relationships to influence adolescent health outcomes.4 Direct strategies include efforts that create improved communication and partnership between the provider and the parent, and indirect strategies increase the provider’s influence on parent/teen communication within the context of clinic visits.4 This research is built on the concept of triadic relationships; a third person can often stabilize and improve the relationship between the other 2 people. These strategies could be particularly useful for family medicine clinics, where providers are seeing both adolescents and their parents as patients, creating an opportunity for growth of a strong triadic relationship.5 Before the onset of puberty, primary care providers should clearly lay the groundwork for health care visits during the adolescent years. Parents and their preteen children should be informed that issues discussed individually, with adolescents or parents, are confidential, and that adolescents may be examined without the parents present.6 It is important for providers to acknowledge that the adolescent is the patient; they should greet the adolescent first and then ask to be introduced to the family. Providers should take time to talk with both parents and teens to build trust, develop rapport, and support their relationship, but consider noting that it is “clinic policy” to talk with teens alone for some of the visit to allow for more open conversation. A qualitative study using focus groups with mother/son dyads showed that regular, routine inclusion of time alone during adolescent visits starting in early adolescence could lead to greater parental comfort with this process and increased disclosure by the adolescent.7 During the interview, providers should practice listening more than speaking; openended questions should be used to probe deeper, especially when asking about difficult subjects. If concerns arise, refrain from lecturing—teens do not need another parent—rather, practitioners should be open and honest and criticize the activity, not the adolescent.8,9 When performing the physical examination, providers should remember to wash their hands within the view of the adolescent; previous research noted that teens ranked providers washing hands as the most important item that affects their decision to seek health care.10 During the physical examination, providers should also respect their patients’ privacy and modesty by making sure they are appropriately gowned, discussing and explaining each part of the physical examination, and asking about any discomfort with the examination. Systems/Structure
A clinic does not have to be a “teen clinic” to be teen-friendly; this goal can be accomplished in many ways. The Adolescent Health Working Group (www.ahwg.net) developed a Provider Toolkit Series that provides guidelines for teen-friendly services.11 First and foremost, providers and staff should enjoy working with adolescents. Structurally, it can be useful to create a space in the waiting area or another part of the clinic that includes posters, educational resources, and magazines geared toward teens. If financially possible, providing access to a computer space or guest wireless access may be appreciated by the more tech-savvy teens. When registering for clinic services, adolescents and their family should be presented with brochures describing the clinic’s policies regarding minor consent and access to confidential care. Clinics that care for adolescents should also advocate within their sponsoring institutions to ensure confidentiality is maintained after the clinic visit is complete. A qualitative study of clinician perspectives on adolescent care in urban
Adolescent Health Care Maintenance
primary care clinics found that, although clinicians were committed to offering preventive care during adolescents visits, systems issues must be developed that enhance consistency of delivery of confidential services that meet the recommended guidelines.8 Failure to meet those guidelines may contribute to skepticism among adolescent patients and their parents. Explanation of benefits notifications, patient satisfaction surveys, billing statements, or other forms of communication about the adolescent visits are often inadvertently sent to parents.12 Protection from these lapses should be paramount in teen care. MINOR CONSENT AND CONFIDENTIALITY
When working with adolescents in clinic, it is important to understand the state laws regarding minor consent for treatment and access to confidential care. The laws related to adolescent consent and confidentiality vary by state. Most states have up to 10 different minor consent rules and an equal number of potentially different confidentiality laws.13,14 Because of this complexity and the potential changes in these laws because of shifting political climates, it is important for providers to stay up to date. National organizations exist that monitor minor consent and confidentiality laws. The Center for Adolescent Health & the Law (www.cahl.org)13 and the Guttmacher Institute (www.guttmacher.org)14 are organizations that regularly monitor state laws regarding minor consent and access to confidential services. Both organizations provide updated state-by-state information. Generally, parental consent is required to provide medical care for patients younger than 18 years. However, many states allow for exceptions to parental consent. These exceptions may be defined by the status of the minor or the category of care that is needed. Teens living separately from their parents and managing their own financial affairs and those who are married and/or have borne a child are often considered emancipated minors and are given the legal status to consent for their own care.15 Some states also define mature minors as teens 15 years of age or older and allow them to assent to care and treatment for minor, low-risk illnesses such as evaluation of strep throat or a rash. Most states also allow for minors to consent for certain services related to pregnancy, sexually transmitted infections, contraceptive services, alcohol and drug treatment, emergency care (including evaluation for sexual assault), and mental health evaluation.15 These minor consent laws allow adolescents to access important medical services in circumstances in which they might otherwise forego care if a parent had to be involved.16,17 When providing health care to teens, confidentiality must be assured to gain their trust and allow space for them to be honest and feel safe disclosing personal information, especially information related to the sensitive topics noted within minor consent laws. Confidentiality laws ensure that care allowed by minor consent laws may only be accessed or released by the teen patient, giving control of certain aspects of the medical record to the adolescent. Studies have shown that for certain conditions, such as mental health problems or pregnancy, many minors will delay or not seek care if they think their parents may find out.16,17 Of course, if the teen is potentially at risk for harm to oneself or another, these laws do allow for parental notification to assure safety. Unfortunately, although states allow for protected rights to confidentiality of certain services, this is not always demonstrated in the real world. Providers should be aware of potential breaches of confidentiality, especially along administrative channels, including insurance notification of services (explanation of benefits), billing statements, and routine request of release of records to other health care providers or academic institutions.12 This area has been especially tricky with the new electronic
453
454
Chaisson & Shore
health records, wherein advancements in technology have not always allowed for protected information to remain separate within the medical record. Ultimately, clinics and health organizations should develop policies and procedures to protect against these breaches in confidentiality, which are considered violations of the Health Insurance Portability and Accountability Act (HIPAA).18,19 As advocates for youth, providers can encourage teens to request alternate forms of communication (eg, personal cell phone numbers), promote efforts to allow teens to restrict access to their medical chart, and inform teens about their right to file complaints with health care organizations if they feel their rights are violated.18 STRENGTHS AND RESILIENCY
Recognizing a patient’s strengths can identify areas of resilience in teens. Several experts recommend that providers identify an adolescent’s strengths first to balance the rest of the behavioral screening.20,21 Studies confirm that the following can be protective factors for adolescents regardless of race, class, or gender:
An authoritative parenting style with consistent limit-setting A sense of connectedness with one caring adult Involvement with parents A positive body image Participation in extracurricular supervised activities Nonusing peer group Strong school affiliation22–24
Successful transition to adulthood is often bolstered by the connections that youth have with prosocial peers, schools, adult mentors, and the wider community. Much research in the past 3 decades has supported this idea that connectedness with others and within communities has been protective against several risky behaviors and supportive of healthy youth development. Identifying an adolescent’s strengths and interests and supporting prosocial connections may help families support their teen’s successful growth and development.22–24 ASSESSING RISK FACTORS
The leading causes of morbidity and mortality in adolescents continue to be the result of risky behaviors and poor decisions; these will be the health issues that physicians encounter in adolescent patients.25 Risk-taking behaviors (eg, alcohol, drugs, unsafe driving) and unhealthy decisions (eg, diet, inactivity) can have a dramatic and lasting impact on these teens and their future health. For this reason, adolescence is a prime time for clinicians to promote healthy behaviors with adolescent patients and to provide guidance for their families to intervene before the behaviors result in life long negative outcomes. Realizing that behaviors affect the health of teens and that those behaviors may change over the course of several months, many professional organizations have established guidelines for adolescent preventive care (Table 1). These guidelines include appropriate screening tools for asking adolescents about risk and protective factors in their lives. PSYCHOSOCIAL SCREENING TOOLS
Although discussing sensitive issues may be challenging for primary care providers, studies consistently confirm that adolescents and their parents want these sensitive issues to be addressed during both acute and preventive care visits.26,27 Several
Adolescent Health Care Maintenance
psychosocial screening tools have been developed to identify adolescent risks and strengths and to provide a nonthreatening mechanism to discuss sensitive issues with adolescents. The HEADSSS assessment is the most frequently used and effective screening tool to identify adolescent psychosocial risks, and has recently been updated to incorporate screening for eating behaviors and diet (HEEADSSS: Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety) (Table 2).28–30 During health maintenance visits, asking open-ended questions pertinent to each area can be helpful for identifying red flags in the history that can be further assessed with appropriate assessment tools and referred for additional care if necessary. Alternatively, the SSHADESS screen (Strengths, School, Home, Activities, Drugs/substance use, Emotions/depression, Sexuality, and Safety) was more recently developed to include inquiry about adolescent strengths and indentify features of resiliency.30 Regardless of the screening tool used, the following questions are essential to ask at every adolescent visit31: Have there been any significant changes/losses in your home/family/ community? Do you have someone who you can turn to if you are having a problem, worry, or bad day? These brief questions help identify the ways that a teen is connected to others, or not. Assessing for family conflict or stress and addressing family dysfunction play an important role in preventing high-risk behaviors in adolescence. Youth who have recently lost support or who cannot identify connections to others in their family or community may require further guidance and support from the clinical environment. HEALTH MAINTENANCE AND SCREENING
Health screening is the cornerstone of primary care. The wellness visit or preventive health checkup has become less about the actual physical examination and more about the conversation and guidance regarding healthy behaviors and screening for preventable or treatable illness. Although opinions differ regarding the frequency of adolescent wellness visits, The American Academy of Pediatrics’ Bright Futures guidelines and the American Medical Association’s Guidelines for Adolescent Preventive Services recommend annual preventive care services for patients aged 11 to 21 years, whereas the U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians recommend an individualized schedule (see Table 1).32–35 But what happens if the patients do not have these visits? Studies indicate that a minority, 38% or less, of adolescent patients have annual preventive care visits.36 and 70% have preventive visits an average of every 4 years.37 In these studies, the rates for preventive services were lower for patients from lower socioeconomic status and those who were uninsured. Additionally, providing anticipatory guidance was low during these visits, as low as 31% in some groups. Because adolescents visit primary care offices more often for nonpreventive care, these studies recommended that every contact with adolescent patients should be an opportunity to address preventive care and anticipatory guidance (or patient education). Clearly, screening must occur outside the traditional “well-teen visit” or it may not get done at all. Because of a lack of evidence-based research regarding preventive services, evidence-based guidelines that are universally accepted are difficult to develop. However, data are increasing from the field of public health that addresses social determinants of health in conjunction with Adolescent Health, focusing on a more holistic view
455
456
GAPS33
Bright Futures/AAP32
USPSTF34
AAFP35
Annually
Annually
One every 1–3 y as necessary
One every 1–3 y as necessary
Target Age Range
11–21 y
11–21 y
11–24 y
13–21 y
Vaccination
Follow ACIP schedule
Parental Involvement
At least once during early and middle adolescence
Three times during adolescence
No recommendation
Three times during adolescence Screen at each visit
Frequency of Visit
Health Guidance for Teens Normal Development
Screen at each visit
No recommendation
Injury Prevention
Screen/discuss at each visit
Insufficient evidence
Nutrition
Screen/discuss at each visit
Dental Health
No recommendation
Screen at each visit/no recommendation
No recommendation
Skin Protection
Discuss at each visit
Discuss at each visit
Counsel individuals with fair skin to minimize exposure to ultraviolet radiation
Testicular Self-Examination
No recommendation
Teach to patients after age 20 y
Recommends against testicular cancer self-screening
Consider selective counseling for at-risk youth
Recommends against testicular cancer self-screening
Screening and Counseling Obesity
Screen at each visit, discuss nutrition and exercise recommendations
Contraception
Assess risk and discuss at each visit
Tobacco Use Alcohol Use
Ask/counsel at each visit
Unclear benefit to screening; insufficient evidence
Screen at each visit
Insufficient evidence to screen ages
MD, MPH
a
, William B. Shore,
MD
b,
*
KEYWORDS Confidentiality Psychosocial screening tools Screening and prevention Health maintenance Teen-friendly clinic Immunizations KEY POINTS Primary care providers should be knowledgeable of confidentiality laws in their state and communities. Confidentiality practice guidelines should be reviewed with parents and adolescents. Adolescent psychosocial screening tools are effective in identifying adolescent strengths and high-risk behaviors. Every clinical encounter with adolescents is an opportunity to address screening and prevention.
CARING FOR TEENS IN THE PRIMARY CARE SETTING
Although access to primary care services is important for improving the health of adolescents, several decades of research within the United States and across the globe have documented the barriers that adolescents and young adults experience when trying to access these services.1 Both the World Health Organization and the Institute of Medicine have developed frameworks for the development of youth-friendly services to call attention to the need for improved access to adolescent health services.2,3 Primary care has the capacity to provide high-quality screening, assessment, and care management for teens in a confidential and supportive environment. Creating that environment is fundamental. Communication with Teens and Their Families
The role of families and caregivers is important in adolescent care. Families can be an asset through providing a thorough medical history, supporting teen development and Disclosures: None. a Department of Family and Community Medicine, University of Minnesota Medical Center, Family Medicine Residency, 2020 East 28th Street, Minneapolis, MN 55407, USA; b Department of Family and Community Medicine, University of California, San Francisco, 995 Potrero, Building 80, Ward 83, San Francisco, CA 94110, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 451–464 http://dx.doi.org/10.1016/j.pop.2014.05.001 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
452
Chaisson & Shore
independence, clarifying expectations and setting limits, and ensuring ongoing access to care. Although limited research has been performed on partnerships between parents of teens and health care professionals, recent qualitative data describe both direct and indirect strategies to strengthen parent/provider relationships to influence adolescent health outcomes.4 Direct strategies include efforts that create improved communication and partnership between the provider and the parent, and indirect strategies increase the provider’s influence on parent/teen communication within the context of clinic visits.4 This research is built on the concept of triadic relationships; a third person can often stabilize and improve the relationship between the other 2 people. These strategies could be particularly useful for family medicine clinics, where providers are seeing both adolescents and their parents as patients, creating an opportunity for growth of a strong triadic relationship.5 Before the onset of puberty, primary care providers should clearly lay the groundwork for health care visits during the adolescent years. Parents and their preteen children should be informed that issues discussed individually, with adolescents or parents, are confidential, and that adolescents may be examined without the parents present.6 It is important for providers to acknowledge that the adolescent is the patient; they should greet the adolescent first and then ask to be introduced to the family. Providers should take time to talk with both parents and teens to build trust, develop rapport, and support their relationship, but consider noting that it is “clinic policy” to talk with teens alone for some of the visit to allow for more open conversation. A qualitative study using focus groups with mother/son dyads showed that regular, routine inclusion of time alone during adolescent visits starting in early adolescence could lead to greater parental comfort with this process and increased disclosure by the adolescent.7 During the interview, providers should practice listening more than speaking; openended questions should be used to probe deeper, especially when asking about difficult subjects. If concerns arise, refrain from lecturing—teens do not need another parent—rather, practitioners should be open and honest and criticize the activity, not the adolescent.8,9 When performing the physical examination, providers should remember to wash their hands within the view of the adolescent; previous research noted that teens ranked providers washing hands as the most important item that affects their decision to seek health care.10 During the physical examination, providers should also respect their patients’ privacy and modesty by making sure they are appropriately gowned, discussing and explaining each part of the physical examination, and asking about any discomfort with the examination. Systems/Structure
A clinic does not have to be a “teen clinic” to be teen-friendly; this goal can be accomplished in many ways. The Adolescent Health Working Group (www.ahwg.net) developed a Provider Toolkit Series that provides guidelines for teen-friendly services.11 First and foremost, providers and staff should enjoy working with adolescents. Structurally, it can be useful to create a space in the waiting area or another part of the clinic that includes posters, educational resources, and magazines geared toward teens. If financially possible, providing access to a computer space or guest wireless access may be appreciated by the more tech-savvy teens. When registering for clinic services, adolescents and their family should be presented with brochures describing the clinic’s policies regarding minor consent and access to confidential care. Clinics that care for adolescents should also advocate within their sponsoring institutions to ensure confidentiality is maintained after the clinic visit is complete. A qualitative study of clinician perspectives on adolescent care in urban
Adolescent Health Care Maintenance
primary care clinics found that, although clinicians were committed to offering preventive care during adolescents visits, systems issues must be developed that enhance consistency of delivery of confidential services that meet the recommended guidelines.8 Failure to meet those guidelines may contribute to skepticism among adolescent patients and their parents. Explanation of benefits notifications, patient satisfaction surveys, billing statements, or other forms of communication about the adolescent visits are often inadvertently sent to parents.12 Protection from these lapses should be paramount in teen care. MINOR CONSENT AND CONFIDENTIALITY
When working with adolescents in clinic, it is important to understand the state laws regarding minor consent for treatment and access to confidential care. The laws related to adolescent consent and confidentiality vary by state. Most states have up to 10 different minor consent rules and an equal number of potentially different confidentiality laws.13,14 Because of this complexity and the potential changes in these laws because of shifting political climates, it is important for providers to stay up to date. National organizations exist that monitor minor consent and confidentiality laws. The Center for Adolescent Health & the Law (www.cahl.org)13 and the Guttmacher Institute (www.guttmacher.org)14 are organizations that regularly monitor state laws regarding minor consent and access to confidential services. Both organizations provide updated state-by-state information. Generally, parental consent is required to provide medical care for patients younger than 18 years. However, many states allow for exceptions to parental consent. These exceptions may be defined by the status of the minor or the category of care that is needed. Teens living separately from their parents and managing their own financial affairs and those who are married and/or have borne a child are often considered emancipated minors and are given the legal status to consent for their own care.15 Some states also define mature minors as teens 15 years of age or older and allow them to assent to care and treatment for minor, low-risk illnesses such as evaluation of strep throat or a rash. Most states also allow for minors to consent for certain services related to pregnancy, sexually transmitted infections, contraceptive services, alcohol and drug treatment, emergency care (including evaluation for sexual assault), and mental health evaluation.15 These minor consent laws allow adolescents to access important medical services in circumstances in which they might otherwise forego care if a parent had to be involved.16,17 When providing health care to teens, confidentiality must be assured to gain their trust and allow space for them to be honest and feel safe disclosing personal information, especially information related to the sensitive topics noted within minor consent laws. Confidentiality laws ensure that care allowed by minor consent laws may only be accessed or released by the teen patient, giving control of certain aspects of the medical record to the adolescent. Studies have shown that for certain conditions, such as mental health problems or pregnancy, many minors will delay or not seek care if they think their parents may find out.16,17 Of course, if the teen is potentially at risk for harm to oneself or another, these laws do allow for parental notification to assure safety. Unfortunately, although states allow for protected rights to confidentiality of certain services, this is not always demonstrated in the real world. Providers should be aware of potential breaches of confidentiality, especially along administrative channels, including insurance notification of services (explanation of benefits), billing statements, and routine request of release of records to other health care providers or academic institutions.12 This area has been especially tricky with the new electronic
453
454
Chaisson & Shore
health records, wherein advancements in technology have not always allowed for protected information to remain separate within the medical record. Ultimately, clinics and health organizations should develop policies and procedures to protect against these breaches in confidentiality, which are considered violations of the Health Insurance Portability and Accountability Act (HIPAA).18,19 As advocates for youth, providers can encourage teens to request alternate forms of communication (eg, personal cell phone numbers), promote efforts to allow teens to restrict access to their medical chart, and inform teens about their right to file complaints with health care organizations if they feel their rights are violated.18 STRENGTHS AND RESILIENCY
Recognizing a patient’s strengths can identify areas of resilience in teens. Several experts recommend that providers identify an adolescent’s strengths first to balance the rest of the behavioral screening.20,21 Studies confirm that the following can be protective factors for adolescents regardless of race, class, or gender:
An authoritative parenting style with consistent limit-setting A sense of connectedness with one caring adult Involvement with parents A positive body image Participation in extracurricular supervised activities Nonusing peer group Strong school affiliation22–24
Successful transition to adulthood is often bolstered by the connections that youth have with prosocial peers, schools, adult mentors, and the wider community. Much research in the past 3 decades has supported this idea that connectedness with others and within communities has been protective against several risky behaviors and supportive of healthy youth development. Identifying an adolescent’s strengths and interests and supporting prosocial connections may help families support their teen’s successful growth and development.22–24 ASSESSING RISK FACTORS
The leading causes of morbidity and mortality in adolescents continue to be the result of risky behaviors and poor decisions; these will be the health issues that physicians encounter in adolescent patients.25 Risk-taking behaviors (eg, alcohol, drugs, unsafe driving) and unhealthy decisions (eg, diet, inactivity) can have a dramatic and lasting impact on these teens and their future health. For this reason, adolescence is a prime time for clinicians to promote healthy behaviors with adolescent patients and to provide guidance for their families to intervene before the behaviors result in life long negative outcomes. Realizing that behaviors affect the health of teens and that those behaviors may change over the course of several months, many professional organizations have established guidelines for adolescent preventive care (Table 1). These guidelines include appropriate screening tools for asking adolescents about risk and protective factors in their lives. PSYCHOSOCIAL SCREENING TOOLS
Although discussing sensitive issues may be challenging for primary care providers, studies consistently confirm that adolescents and their parents want these sensitive issues to be addressed during both acute and preventive care visits.26,27 Several
Adolescent Health Care Maintenance
psychosocial screening tools have been developed to identify adolescent risks and strengths and to provide a nonthreatening mechanism to discuss sensitive issues with adolescents. The HEADSSS assessment is the most frequently used and effective screening tool to identify adolescent psychosocial risks, and has recently been updated to incorporate screening for eating behaviors and diet (HEEADSSS: Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety) (Table 2).28–30 During health maintenance visits, asking open-ended questions pertinent to each area can be helpful for identifying red flags in the history that can be further assessed with appropriate assessment tools and referred for additional care if necessary. Alternatively, the SSHADESS screen (Strengths, School, Home, Activities, Drugs/substance use, Emotions/depression, Sexuality, and Safety) was more recently developed to include inquiry about adolescent strengths and indentify features of resiliency.30 Regardless of the screening tool used, the following questions are essential to ask at every adolescent visit31: Have there been any significant changes/losses in your home/family/ community? Do you have someone who you can turn to if you are having a problem, worry, or bad day? These brief questions help identify the ways that a teen is connected to others, or not. Assessing for family conflict or stress and addressing family dysfunction play an important role in preventing high-risk behaviors in adolescence. Youth who have recently lost support or who cannot identify connections to others in their family or community may require further guidance and support from the clinical environment. HEALTH MAINTENANCE AND SCREENING
Health screening is the cornerstone of primary care. The wellness visit or preventive health checkup has become less about the actual physical examination and more about the conversation and guidance regarding healthy behaviors and screening for preventable or treatable illness. Although opinions differ regarding the frequency of adolescent wellness visits, The American Academy of Pediatrics’ Bright Futures guidelines and the American Medical Association’s Guidelines for Adolescent Preventive Services recommend annual preventive care services for patients aged 11 to 21 years, whereas the U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians recommend an individualized schedule (see Table 1).32–35 But what happens if the patients do not have these visits? Studies indicate that a minority, 38% or less, of adolescent patients have annual preventive care visits.36 and 70% have preventive visits an average of every 4 years.37 In these studies, the rates for preventive services were lower for patients from lower socioeconomic status and those who were uninsured. Additionally, providing anticipatory guidance was low during these visits, as low as 31% in some groups. Because adolescents visit primary care offices more often for nonpreventive care, these studies recommended that every contact with adolescent patients should be an opportunity to address preventive care and anticipatory guidance (or patient education). Clearly, screening must occur outside the traditional “well-teen visit” or it may not get done at all. Because of a lack of evidence-based research regarding preventive services, evidence-based guidelines that are universally accepted are difficult to develop. However, data are increasing from the field of public health that addresses social determinants of health in conjunction with Adolescent Health, focusing on a more holistic view
455
456
GAPS33
Bright Futures/AAP32
USPSTF34
AAFP35
Annually
Annually
One every 1–3 y as necessary
One every 1–3 y as necessary
Target Age Range
11–21 y
11–21 y
11–24 y
13–21 y
Vaccination
Follow ACIP schedule
Parental Involvement
At least once during early and middle adolescence
Three times during adolescence
No recommendation
Three times during adolescence Screen at each visit
Frequency of Visit
Health Guidance for Teens Normal Development
Screen at each visit
No recommendation
Injury Prevention
Screen/discuss at each visit
Insufficient evidence
Nutrition
Screen/discuss at each visit
Dental Health
No recommendation
Screen at each visit/no recommendation
No recommendation
Skin Protection
Discuss at each visit
Discuss at each visit
Counsel individuals with fair skin to minimize exposure to ultraviolet radiation
Testicular Self-Examination
No recommendation
Teach to patients after age 20 y
Recommends against testicular cancer self-screening
Consider selective counseling for at-risk youth
Recommends against testicular cancer self-screening
Screening and Counseling Obesity
Screen at each visit, discuss nutrition and exercise recommendations
Contraception
Assess risk and discuss at each visit
Tobacco Use Alcohol Use
Ask/counsel at each visit
Unclear benefit to screening; insufficient evidence
Screen at each visit
Insufficient evidence to screen ages
