A primary care approach to adolescent health care

Adolescents are generally thought to be healthy, but at least 20% of North American adolescents have a serious health problem.¹ Most adolescent morbidity and mortality are due to intentional and unintentional injuries; alcohol, tobacco, and other drug misuse; depression; unplanned pregnancies; and sexually transmitted infections.² These problems are often rooted in behaviors that are diagnosed not with a laboratory test or a physical examination but through open communication between the physician and the adolescent. In the past few years, several guidelines have been developed for the care of adolescents,^3,4,5,6 each emphasizing the importance of psychosocial screening.

Compared with other age groups and relative to their proportion of the population, adolescents in the United States underuse the health care system. Adolescent men are less likely than young women to visit physicians.^7,8,9 They also tend to use emergency departments, free clinics, and family planning clinics as their source of primary care. Adolescents are more likely to be uninsured than any other age group.^10,11,12,13 Physicians' visits with teens are typically short, with a mean duration of 16 minutes. Counseling or education is given to teens on only 50% of visits with their physicians. Adolescents report being more concerned about their physicians' characteristics than characteristics of the site or system. Teens prefer health care professionals who are honest, knowledgeable, and experienced and who wash their hands in the teens' presence. They want physicians who treat all patients equally, who emphasize confidentiality, and who relate well to teens.¹⁴

We describe the approach to adolescent care that we use in training residents and students who rotate through the Venice Family Clinic, Los Angeles, a free clinic with more than 70,000 total visits a year. We train nurse practitioners; pharmacy students; residents from internal medicine, pediatrics, family medicine, and obstetrics and gynecology; and third- and fourth-year medical students. Our goal is to provide trainees with the tools to enable them to feel comfortable and competent interviewing and examining teens. This approach is based on the training we provide, years of practice and teaching, and the literature cited.²

Summary points

• The encounter should begin with the teen and parents discussing the teen's past medical history and parents' concerns

• Parents should be asked to wait in the waiting room and be reassured that they will be invited back in to discuss any remaining issues

• Once alone with the teen, establish ground rules for confidentiality

• The teen's history yields far more information than the physical examination and results of diagnostic tests

APPROACH TO ADOLESCENTS

If adolescents do not trust their physicians, they will not feel comfortable discussing sensitive health concerns.^14,15 To earn this trust, the physician must be seen as an advocate for the teen. Issues of consent, confidentiality, and its limits are best discussed early in the visit.^14,15 A useful beginning is an initial introductory meeting with both the adolescent and parents. During this initial encounter, we establish what the parents' concerns are, obtain a family history, and ask about previous medical problems. This begins the transition from parent to teen as the medical historian. We next ask parents to wait in the waiting room so that we can speak privately with the adolescent. We interview the adolescent alone, perform a physical examination with a chaperone, and then invite the parents back into the room at the conclusion of the visit to discuss our findings.

It is important for teens to establish a separate relationship with the physician. On occasion, parents may express some resistance, and we then stress the importance of an adolescent having a physician with whom the teen can confide and discuss difficult issues that may arise in the future. We reassure parents that at the end of our encounter we will invite them back into the room to discuss any remaining issues.

If the parents are not present and have not given us explicit permission to treat their child, consent may be implied by virtue of the nature of the condition or the status of the teen (box). Laws about consent vary from state to state and practitioners should become familiar with the law in those states in which they provide care.

Once alone with the adolescent, we explain that our conversations are confidential, to the extent allowed by law.¹⁶ The law requires that only if we discover that an adolescent is in danger of hurting himself or herself or others does such a revelation need to be reported to the appropriate authorities.

During our discussion with the adolescent, we listen carefully to both what is said and what is not said. Conversation begins with a nonthreatening discussion of topics that may be of interest to the adolescent, such as inquiring about extracurricular activities or favorite music. The goal is to assist the adolescent in identifying potentially risky behaviors that may endanger their health and assessing their motivation to change those behaviors. We use the technique of motivational interviewing, which provides adolescents with feedback on risks and promotes a sense of responsibility for their health.¹⁷ Teens want factual information rather than authoritative instruction on what to do. Avoid using slang because most teens will be aware that this is not your customary language. In addition, by the time most physicians have heard of a purported teen expression, it is likely already outdated.

We use five premises that our trainees find useful when caring for adolescents (see shaded box).

The five “F”s

1. Explain Facts: adolescents should have a clear understanding of their illness.

2. Explore Fears adolescents may have concerning their illness or its effects on their life. They may also be worried about their body image, their identity, their peers, or other interpersonal relationships.

3. Address any Fables: adolescents may be misinformed about their illness or about adolescence; eg, the effects of masturbation.

4. Explore the adolescent's relationship with their Family. What are communication and trust like within the family unit? How does the teen settle conflicts that arise at home?

5. Ask how the adolescent views the Future. We make it clear that we are accessible, and the teen is given a contact phone number.

In offices or clinic settings with a variety of patients of different ages, scheduling times when only teens will be seen may be helpful. Teens feel more comfortable having other teens in the visiting area. This also provides an opportunity to play educational videotapes, have different devices or materials out for display, or provide educational brochures that may not be appropriate for younger age groups. Placing sensitive information in individual examination rooms rather than the waiting room gives teens the opportunity to take or read it unobserved by other teens.

We take advantage of an adolescent's visit to our clinic by offering a psychosocial screening examination. A psychosocial assessment tool has been developed to assess issues of home, education, activities, drugs, sexuality, suicide or depression, and safety (HEADSSS).¹⁸ This assessment tool provides an entree to discuss the major psychosocial issues of adolescents (table 1). Although these questions are personal, teens are reported to prefer to discuss these issues with physicians.^19,20 Assurances of confidentiality increase the number of adolescents who will discuss sensitive information about sexuality, substance misuse, and mental health and those who are willing to seek future health care. For this reason, we avoid administering written questionnaires in the waiting room.

Table 1.

Assessing issues of home, education, activities, drugs, sex, suicide or depression, and safety

Issue	Sample question
Home	Where do you live?
Who do you live with?
Do you share a bedroom? With whom?
How do you get along with the people you live with?
How much time do you spend at home?
What do you and your family argue about?
Can you go to your parents with problems?
Have you ever run away from home?
Education	What grade are you in?
What grades are you earning? Have they changed?
What are your best and your worst classes? Why?
Do you need extra help in school?
Do you work after school or on weekends?
Have you ever failed any classes or a grade?
Do you ever cut classes?
Activities	What do you do for fun?
What activities are you involved in during and after school?
Are you active in sports? Do you exercise?
Who do you do fun things with?
Do you have a best friend?
Who do you hang out with? Who are your friends?
Who do you go to with problems?
What do you do on weekends? Evenings?
Drugs	Do you drink coffee or tea?
Do you smoke cigarettes? Have you ever smoked one?
Have you ever tasted alcohol? When? What kind and how often?
Do any of your friends drink or use drugs?
What drugs have you tried? Have you ever injected drugs or steroids?
When? How often do you use them? How did you pay for the drugs?
Sexual activity or sexual identity	Have you ever had sex with men? Women? Both?
Have you ever had sex unwillingly?
How many sexual partners have you had?
How old were you when you first had sex?
Have you ever been pregnant?
Have you ever had an infection resulting from sex?
Do you use condoms or another form of contraception or sexually transmitted disease (STD) prevention? (use specific names for STDs).
Have you ever traded sex for money, drugs, clothes, or a place to stay?
Have you every been tested for the human immunodeficiency virus, or HIV? Do you think it would be a good idea to be tested?
Suicide or depression	How do you feel today on a scale of 0 to 10 (0 being very sad and 10 being very happy)?
Have you ever felt less than 5?
What made you feel that way?
Did you ever think about hurting yourself, that life wasn't worth living, or hope that when you went to sleep you wouldn't wake up again?
Safety	Do you regularly wear seat belts when riding or driving in a car?
Do you skateboard or rollerblade, and if so, do you wear protective gear?
Does anyone at home own a gun? If so, where is it kept? Does it have a safety latch on it?
Has anyone ever hurt you or intentionally destroyed something you value?
Do you ever feel unsafe at home, school, or at work or play?
How do you and your parents resolve conflicts? Have you ever been hit, pushed, or shoved?
	Has anyone ever touched you in a private place against your will?

Points to watch for in the HEADSSS assessment

If the adolescent has run away from home or spent long periods of time home alone, more attention needs to be directed to issues related to drug misuse, sexuality, and depression. A sudden, unexplained drop in grades or frequent absences should lead to further exploration of sexuality, drug misuse, family problems, or depression. School failure should be explored as a possible early indication of other risk behaviors in high school students.²¹ Questions about friends, the use of free time, and attendance at parties can provide indirect information about sexual activity, drug misuse, and mental health. We ask about self-image, including body building and associated steroid use and self-perception of weight. Reports suggest that anabolic steroid use is increasing in middle and high school students.²²

When discussing the topic of alcohol, tobacco, or other substance misuse, remain nonjudgmental. Those who care for adolescents should be familiar with the illicit drugs that are used in the community. Alcohol is still the most commonly misused substance in this age group. Aside from its direct toxic effects, alcohol misuse may lead to harmful effects such as impaired automobile, bike, or skateboard operation; depression; and other risky behaviors. More than two thirds of teens have had at least one sexual partner by age 18 years, and nearly one quarter have had more than four sexual partners.² The sexual partner of teen girls is usually an older man. In fact, in one study, two thirds of teenaged mothers had an adult partner more than four years older.³ It is useful to acknowledge that questions might be embarrassing but that their answers are confidential and that they are being asked to provide them with appropriate health care. We ask questions such as, “Other teenaged girls have told me that they feel pressured to have sex with their boyfriends. Have you ever felt this way?” A frank discussion of condom use, including a demonstration of how to use condoms, is an integral part of a discussion of safe sex. Studies have shown that when physicians take the time to discuss and demonstrate the appropriate use of condoms, teens are more likely to engage in safe sex than those teens who had not had such discussions or demonstrations.²³

By concentrating on risky sexual practices rather than sexual identity, physicians emphasize that the practice is risky, not the individual or their sexual preference. Gay or lesbian teens may not be in a stage of developing their sexual identity and may not feel comfortable being identified as gay or lesbian. Clinicians need to be aware that, in our society, being gay or bisexual is possibly associated with depression; an increased risk of suicide; social stigma; and physical, sexual, or emotional abuse.^24,25,26 Assess both past and current feelings of depression and risk for suicide.²⁷ The physician can also discuss other safety measures such as wearing seat belts, fighting with friends, domestic violence, and sexual abuse.²⁸

PHYSICAL EXAMINATION

A physical examination in an otherwise healthy teenager is unlikely to yield much useful information. Some indications for a pelvic examination include a direct request from the patient, the patient is sexually active, or the patient has abdominal or pelvic pain. It does not need to be done routinely on every adolescent woman. There is debate in the adolescent literature about whether urine screening in an asymptomatic adolescent can replace a routine yearly pelvic examination and Papanicolaou smear.^29,30,31 Most evidence-based guidelines recommend yearly Papanicolaou smears in sexually active teens.

A teen's first pelvic examination should be done by a physician who is comfortable and experienced in performing pelvic examinations. The examination is best explained to the teen while she is in her street clothes and carried out with a chaperone present, not a parent. We ask teens if they want their parent or someone else in the room for support. The examination should be scheduled with plenty of time for questions. We provide a mirror for the teen so that she may see what we are doing if she so wishes.

It is often more comfortable for a teen's first pelvic examination to perform the bimanual examination before the speculum examination. To minimize the patient's anxiety about the examination, begin by touching a neutral area before examining the genitalia, and avoid sudden motions. If a plastic speculum is being used, the teen should be warned that it might make a cracking or clicking sound when opened.

PREVENTION

Many issues related to prevention could be discussed (table 2). Diet, physical appearance, exercise, and anticipatory counseling are topics that have universal appeal. It can be helpful for physicians to discuss the physical and emotional changes that adolescents might expect to go through during the next several years (anticipatory guidance).

Table 2.

Prevention counseling

Condition	Background	Interventions
Alcohol and drug abuse	• Most adolescents experiment with alcohol.	• Deliver preventive messages at every routine visit.
• Alcohol and drugs can lead to or be a symbol of emotional problems.	• Ask about alcohol drug use without parents or guardians present.
• Adolescents are twice as likely as adults to drive under the influence of alcohol and are considerably more at risk to drive with someone who is under the influence of alcohol.	• Ask questions nonjudgmentally about substances used, frequency of use, and quantity of use as well as setting in which such use occurs.
• Most adolescents are willing to provide accurate information on substance abuse if time is taken to assure confidentiality and the clinician appears interested and non-judgmental.	• Reinforce that if teens do drink or use drugs, that they take preventive steps such as not driving while under the influence.
• Screening tests for drug use are of questionable value in the care of adolescents.	• Look for signs of substance abuse, such as aggressive behavior, recent change in personal appearance, personality changes, cutting classes, changes in school performance.
Dental diseases	• Dental and periodontal diseases are common and present long term risks.	• Provide counseling through discussion and printed material.
• Dental conditions can be disabling, disfiguring, and costly.	• Pay particular attention to high risk patients, such as those with diseases such as diabetes, smokers, and those with little access to conventional dental care.
• Dental caries, gingivitis, and periodontal disease, although primarily occurring in later life, are preventable.	• Counsel teens on preventive oral hygiene, including brushing with fluoride toothpaste, flossing, and limiting dietary intake of sugar.
• Encourage teens to be seen regularly by a dental care provider.
Injuries	• Accidents and unintentional injuries are the leading cause of death in adolescents, including motor vehicle accidents, head injuries, firearms, and drownings.	• Promoting behavior change.
• Discuss injury prevention at each visit to target in depth discussions to high-risk areas.
• Safe practices substantially reduce injuries including seatbelts, helmets (for use on motorcycles, bicycles, skateboards, and roller blades/skates), and the use of floatation devices when playing in water.	• Have printed information available.
• Encourage teens to learn to swim or at least learn about water safety.
• Alcohol and substance misuse often play a key role.	• Encourage teens to learn CPR and/or appropriate basic safety skills.
Tobacco use	• Most smokers begin to smoke as teenagers.	• Clinic and staff should regularly ask about smoking use.
• Once a teen begins to smoke he or she is likely to continue.	• Effective strategies include stickers on the chart, adding smoking to list of vital signs, and direct questioning.
• Nearly a quarter of male teens use smokeless tobacco.
• Smoking often occurs in the context of other risky behaviors.	• When patients do not use tobacco, provide positive reinforcement.
• Prevention programs have been effective in reducing smoking up to 4 years following the counseling.	• Enroll a teen who smokes in a smoking cessation program.
Sexual activity	• Teens are sexually active, and many will become pregnant.	• Begin discussion about pregnancy with teens well before they become sexually curious.
• Teen pregnancy poses significant problems, both physical and mental.	• Regularly discuss sexuality, the prevention of sexually transmitted diseases, sexual orientation.
• In teens who delay seeking effective prenatal care, pregnancies are at a particularly high risk.	• Adolescent women should be told about the risks and benefits of emergency contraception.
• Progesterone with condoms and oral contraceptives with condoms are equally effective is used as directed, and are well tolerated by teenage women.	• Condoms should be available, and staff should feel comfortable showing patients how to use them.
• Hormonal contraception (either medroxyprogesterone acetate or oral contraceptive pills) is safe and effective.
Physical activity	• Physical activity declines during adolescence.	• Ask all patients about their physical activity.
• Physical activity and fitness reduce the risk of mortality, morbidity, coronary artery disease, hypertension, obesity, diabetes, osteoporosis, depression, and anxiety.	• Provide positive reinforcement for those who are active.
• Emphasize lifetime sports, such as tennis, swimming, jogging.
• Encourage increased daily physical activity.
• Be alert for signs of excessive exercise, steroid use, or eating disorders.
		• Work to encourage health education programs and lifetime fitness skills.
CPR = cardiopulmonary resuscitation
Adapted from Guidelines for adolescent preventive services (GAPS). Chicago: Dept. of Adolescent Health, American Medical Association; 1993; 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.

Several issues need to be discussed before closing the interview. Before calling the parents back into the consultation room at the end of the visit, consult with the adolescent about what you will discuss and what will remain confidential. Both the adolescent and the parents should be offered a chance to ask questions. The parents may ask to see the physician alone. This can be accomplished most comfortably either while the adolescent is changing in preparation for their physical examination or before beginning the initial discussion with the adolescent. Remember that the teen, not the parent, is your patient.

The care of adolescent patients can be extremely rewarding. At times it can be frustrating and challenging, but following our guidelines, physicians and teens will be able to work together to improve the teens' health.

Figure 1.

Figure 2.

Table 1.

Types of minors' consent laws

Consent by nature of the condition:	Consent by virtue of the minor's status
Emergency	Emancipated by age
Sexually transmitted disease prevention, diagnosis and treatment; and/or reportable communicable or contagious disease	Emancipated by judicial decree
Living away from home and managing own financial affairs
AIDS treatment and/or HIV testing	Is or has been married
Pregnancy prevention, diagnosis and treatment (excluding sterilization)	Member of the armed forces
Abortion	A parent
Rape, incest, sexual abuse	A high school graduate
Alcohol and/or drug abuse treatment	Mature minor
Mental health (admission to hospital and/or outpatient treatment)
Reproduced with permission of Hofmann AE, Greydanus DE, eds. Adolescent medicine. Stamford CT: Appleton & Lange, 1997.